Med Surg - Exam 3 (ATI, EOC, NCLEX)

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The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? 1.Positive 2.Negative 3.Uncertain 4.Borderline

2 A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. The remaining options are incorrect interpretations.

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties? 1.Venting to the outside and ultraviolet light 2.Ultraviolet light and 3 air exchanges per hour 3.Ten air exchanges per hour and venting to the outside 4.Venting to the outside, 6 air exchanges per hour, and ultraviolet light

4 A client suspected of having TB is admitted to a private room that has at least 6 air exchanges per hour and negative pressure in relation to surrounding areas. The room should be vented to the outside and should have ultraviolet lights installed.

The early stage of incomplete breakdown of glucose occurs whenever cells metabolize under anaerobic conditions to form lactic acid. Based on this knowledge of pathophysiology, which conditions could cause the client to develop acidosis? Select all that apply: A. Sepsis B. Hypovolemic shock C. Use of a mechanical ventilator D. Prolonged nasogastric suctioning E. Hypoventilation

A,B,E

After several weeks of "not feeling well", a patient is seen in the physician's office for possible TB. If TB is present, which assessment findings does the nurse expect to observe? Select all that apply: A. Fatigue B. Weight gain C. Night sweats D. Chest soreness E. Low-grade fever

A,C,E

A pt. with COPD is admitted to the hospital with an exacerbation. ABG results are: pH 7.30, PaCO2 51, HCO3 25 A.Respiratory acidosis, uncompensated B.Respiratory alkalosis partially compensated C.Respiratory acidosis, compensated D.Metabolic acidosis, compensated

A. Respiratory acidosis, uncompensated.Rationale: pH is low (acidosis), CO2 is high, HCO3 is normal (uncompensated). The person has COPD which is r/t respiratory acidosis.

A patient is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of this drug. What does the nurse monitor in relation to the heparin therapy? A. Lab values for any elevation of PT or PTT value B. PTT values for greater than 2.5 times the control and/or the patient for bleeding C. Occurrence of a pulmonary infarction by blood in the sputum D. PT values for INR for a therapeutic range of 2 to 3 and/or the patient for bleeding

Common causes of Metabolic Alkalosis are oral ingestion of? A) Diary products B) Antacids C) Antidiarrheals

The nursing student is assisting in the care of a patient on a mechanical ventilator. Which action by the student contributes to the prevention of ventilator-assisted pneumonia? A. Suctions the patient frequently B. Performs oral cares every 2 hours C. Encourages visitors to wear a mask D. Obtains a sputum culture

What is the safest way to administer oxygen to a client with chronic respiratory acidosis? A. High-volume intermittent positive pressure B. Low-flow oxygen (2 L per minute) via nasal cannula C. High-flow 40% oxygen via facemask D. Positive-end expiratory pressure

Which of the following ABG's would the nurse expect to see when a client has apnea and develops acidosis? A. pH 7.45, PaCO2 48, HCO3 25 B. pH 7.29, PaCO2 62, HCO3 23 C. pH 7.36, PaCO2 42, HCO3 26 D. pH 7.49, PaCO2 30, HCO3 35

B. pH 7.29, PaCO2 62 mmHg, HCO3- 23 mEq/LRationale: Letter B would show the patient is in acidosis, respiratory acidosis in particular. This is because the pH is low (Normal Range: 7.35-7.45) and the PaCO2 is really high (Normal Range: 35-45). This is also metabolically uncompensated because the HCO3- is WNL (Normal Range 22-26). Another indicator that it is respiratory is that the patient has apnea which is correlated with the respiratory system as well.

A family member of a patient with COPD asks the nurse, "What is the purpose of making him cough on a routine basis?" What is the nurse's best response? A. "We have to check the color and consistency of his sputum." B. "We don't want him to feel embarrassed when coughing in public, so we actively encourage it." C. "It improves air exchange by increasing airflow in the larger airways." D. "If he cannot cough, the physician may elect to do a tracheostomy."

A patient is admitted after a near-drowning and develops ARDS which is confirmed by the physician. The nurse prepares equipment for which treatment? A. Oxygen therapy via CPAP B. Mechanical ventilation and endotracheal tube placement C. High-flow oxygen via facemask D. Tracheostomy tube

Upon observation of a chest tube set-up, the nurse reports to the physician that there is a leak in the chest tube and system. How has the nurse identified the problem? A. Drainage in the collection chamber has decreased B. The bubbling in the suction chamber has suddenly increased C. Fluctuation in the water seal chamber has stopped D. There was onset of vigorous bubbling in the water seal chamber

5. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

5. A. CORRECT: The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. An elevated sedimentation rate is not a contraindication to receiving heparin. C. An incident of exercise-induced asthma is not a contraindication to receiving heparin. D. An elevated platelet count is not a contraindication to receiving heparin.

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? 1."My nails may become clubbed." 2."My nails may have multiple small pits." 3."I may develop flattening of the nail plate." 4."I may develop horizontal depressions on my nails."

1 A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1."I will lie on the affected side for an hour." 2."I can expect a chest x-ray exam to be done shortly." 3."I will let you know at once if I have trouble breathing." 4."I will notify you if I feel a crackling sensation in my chest."

1 After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

1 Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse? 1.Stop the TPN solution. 2.Place the client in the high-Fowler's position. 3.Notify the primary health care provider (PHCP). 4.Place the client on the left side in the Trendelenburg's position.

1 Although stopping the TPN solution will not treat the problem, it will prevent it from worsening and is a quick action that can be completed first. Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The high-Fowler's position is not helpful at this time. The PHCP should be notified, but this is not the first action.

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement? 1."I should use disposable plates, forks, and knives." 2."I should cough into tissues and throw them away carefully." 3."It's important to cover my mouth if I laugh, sneeze, or cough." 4."It's very important to wash my hands after I touch my mask, tissues, or body fluids."

1 Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and should dispose of tissues carefully. The client also may need to wear a mask as advised by the primary health care provider. It is important to perform proper hand washing after contact with body substances, tissues, or face masks.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? 1.Fall 2.Rise 3.Double 4.Remain unchanged

1 CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1.Stridor 2.Occasional pink-tinged sputum 3.Respiratory rate of 24 breaths/minute 4.A few basilar lung crackles on the right

1 Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the primary health care provider (PHCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the PHCP.

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1.Grasp the retention sutures to spread the opening. 2.Call the primary health care provider to reinsert the tube. 3.Call the respiratory therapy department to reinsert the tracheotomy. 4.Cover the tracheostomy site with a sterile dressing to prevent infection.

1 If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts to replace the tube immediately. Calling ancillary services or the primary health care provider will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? 1.Notify the primary health care provider (PHCP). 2.Increase the frequency of suctioning. 3.Add moisture to the oxygen delivery system. 4.Document the character and amount of drainage.

1 Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the PHCP is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the PHCP places the client at risk.

The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1.Elevate the head of the bed. 2.Monitor oxygen saturation levels every 4 hours. 3.Encourage coughing and deep breathing every 4 hours. 4.Assess respiratory rate and breath sounds every 4 hours.

1 Nursing interventions for the client with an inhalation burn injury include assessing the respiratory rate every hour, monitoring oxygen saturation levels every hour, and assisting the client in coughing and deep breathing every hour. The head of the bed is elevated to facilitate lung expansion.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the primary health care provider (PHCP). 4.Measure oxygen saturation by oximetry.

1 Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the PHCP, but these would not be the first actions in this situation.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome

1 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1.Respiratory acidosis from inadequate ventilation 2.Respiratory alkalosis from anxiety and hyperventilation 3.Metabolic acidosis from calcium loss due to broken bones 4.Metabolic alkalosis from taking analgesics containing base products

1 Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1.Air embolism 2.Hyperglycemia 3.Catheter-related sepsis 4.Allergic reaction to the catheter

1 Signs and symptoms of air embolism include decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of impending doom, chest pain, cyanosis, and hypotension. The signs and symptoms in the question do not indicate hyperglycemia, an infection (catheter-related sepsis), or an allergic reaction.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission? 1.The disease is transmitted by droplet nuclei. 2.Clothing and sheets should be bleached after each use to kill the TB nuclei. 3.Deep pile carpet collects TB bacteria and should be removed from the home. 4.The client should specifically maintain enteric precautions to prevent transmission.

1 TB is spread by droplet nuclei or via the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. It is unnecessary to remove carpeting from the home. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1.Just under the left clavicle 2.Midsternum, 1 inch to the left 3.Over the fifth intercostal space 4.Midsternum, 1 inch to the right

1 The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1.Absence of dyspnea 2.Increased severity of cough 3.Dull percussion notes over lung tissue 4.Decreased tactile fremitus over lung tissue

1 The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing

1 The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1.Dyspnea 2.Bradypnea 3.Bradycardia 4.Decreased respirations

1 The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving theophylline. The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted? 1.5 mg/mL (20 mcmol/L) 2.10 mg/mL (40 mcmol/L) 3.15 mg/mL (60 mcmol/L) 4.20 mg/mL (79 mcmol/L)

1 Theophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and monitors for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL (40 to 79 mcmol/L). If the laboratory result indicated a level of 5 mg/mL (20 mcmol/L), the dosage of the medication would need to be increased.

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? 1.Directly observed therapy 2.More medication instructions 3.Involvement of the family in teaching 4.Reinforcement by the primary health care provider

1 Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? 1."I will discard used tissues in a plastic bag." 2."I need to wash my hands at least 4 times a day." 3."I will brush my teeth and rinse my mouth once a day." 4."I will turn my head to the side if I need to cough or sneeze."

1 Used tissues are discarded in a plastic bag. The client with TB should wash the hands carefully after each contact with respiratory secretions. Oral care should be done more frequently than once a day. The client should not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The primary health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. 1.Administer oxygen. 2.Assess the blood pressure. 3.Start an intravenous (IV) line. 4.Prepare to administer warfarin sodium. 5.Prepare to administer morphine sulfate. 6.Place the client on bed rest in a supine position.

1,2,3,5 If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply. 1.Signs of hepatitis 2.Flu-like syndrome 3.Low neutrophil count 4.Vitamin B6 deficiency 5.Ocular pain or blurred vision 6.Tingling and numbness of the fingers

1,2,3,5 Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side and adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin? Select all that apply. 1.Signs of hepatitis 2.Flu-like syndrome 3.Low neutrophil count 4.Vitamin B6 deficiency 5.Ocular pain or blurred vision 6.Tingling and numbness of the fingers

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. 1.Dyspnea at rest 2.Clubbed fingers 3.Muscle retractions 4.Decreased respiratory rate 5.Increased body temperature 6.Prolonged expiratory breathing phase

1,2,3,6 The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Lying supine with the feet elevated 4.Sitting up with the elbows resting on knees 5.Lying on the back in a low-Fowler's position

1,2,4 The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply. 1.Fatigue 2.Lethargy 3.Chest pain 4.Morning cough 5.Low-grade fever 6.Labored breathing

1,2,4,5 The symptoms of tuberculosis include a slight morning cough, fatigue, lethargy, and low-grade fever. The other symptoms listed are advanced (not initial) signs and symptoms.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

1,2,5 The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

1,3,4 If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air embolus is in the right side of the heart, notify the PHCP and Rapid Response Team, and administer oxygen as needed. Slowing the dialysis treatment or giving an intravenous bolus will not correct the air embolism or prevent complications.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1,3,4,5 The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary, because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1,3,4,5 The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary, because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. 1.Dyspnea 2.Headache 3.Night sweats 4.A bloody, productive cough 5.A cough with the expectoration of mucoid sputum

1,3,4,5 Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

1. A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my heart rate while taking this medication." D. "I can have mouth sores while taking this medication."

1. A. Anti-inflammatory agents, such as corticosteroids, can cause hyperglycemia. B. Anti-inflammatory agents can decrease the immune response. C. CORRECT: Bronchodilators, such as albuterol, can cause tachycardia. D. Anti-inflammatory agents can cause mouth sores. NCLEX® Connection: Pharmacological and Parenteral Therapies,

1. A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

1. A. CORRECT: The client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. B. A female who is postmenopausal has decreased estrogen levels. Increased estrogen levels are a risk factor for developing a pulmonary embolism. C. CORRECT: The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. E. CORRECT: The client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

1. A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

1. A. CORRECT: The client who has a pneumothorax can experience tachypnea related to respiratory distress caused by the injury. B. CORRECT: The client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. C. The client who has a pneumothorax can experience tachycardia related to respiratory distress and pain. D. The client who has a pneumothorax can experience an increase in the use of accessory muscles as respiratory distress occurs. E. CORRECT: The client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

1. A home health nurse is teaching a client who has active tuberculosis and is following a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicate understanding? (Select all that apply.) A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."

1. A. Medications should not be replaced for one another. It is important that the client adhere to the multimedication regimen prescribed to treat tuberculosis. B. CORRECT: The client should wash their hands each time they cough to prevent spreading the infection. C. CORRECT: The client should wear a mask while in public areas to prevent spreading the infection. The client has active TB, which is transmitted through the airborne route. D. The client will need to collect sputum cultures every 2 to 4 weeks until three consecutive sputum cultures have come back negative. E. The client should continue to avoid crowded areas if possible and take preventative measures, such as wearing a mask when going out.

1. A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

1. A. PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis. B. CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. C. PSV does not guarantee minimal minute ventilation because no ventilator breaths are delivered. D. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client.

10 (10) A patient being mechanically ventilated after a severe chest wall injury and flail chest complains of dizziness, tingling around the mouth, and anxiety. What should the nurse do first? Notify the physician. Obtain arterial blood gases. Administer prescribed analgesic. Contact respiratory therapy to evaluate ventilator settings.

10. Correct answer: B Rationale: The patient is demonstrating classic manifestations of respiratory alkalosis, a potential complication of mechanical ventilation when the rate or volume of ventilations is too high. Arterial blood gases (ABGs) provide the data necessary to confirm and treat this problem. The nurse should obtain recent ABG values before contacting the physician. An analgesic is not going to reduce the patient's symptoms because the respiratory rate on the ventilator is set too high. The nurse should obtain an ABG to validate the patient's manifestations before contacting the respiratory therapist to change or evaluate the ventilator settings.

10 (35) The nurse is teaching a patient about caring for a tracheostomy after discharge. What information should the nurse include? (Select all that apply.) Use sterile technique when changing dressings. Water sports are contraindicated. Recommend bathing rather than showering. Keep the area around the stoma clean and dry. Increase fluid intake.

10. Correct answer: B, D, E Rationale: Water sports are contraindicated due to the possibility of taking water in through the stoma. The area around the stoma should be kept clean and dry to prevent excoriation of the skin. Increased fluid intake helps to maintain mucosal moisture and loosen secretions. Clean technique is used for dressing changes in the home. Baths or showers may be used as long as the head is not submerged and water does not enter the stoma.

10 (36) The nurse is planning care for a patient with a tension pneumothorax. The nurse should identify which interventions to achieve which goal as the highest priority for this patient? Manage acute pain Reduce risk for aspiration or other injury Promote effective gas exchange Prevent ineffective breathing pattern

10. Correct answer: C Rationale: Maintaining or restoring adequate alveolar ventilation and gas exchange is of highest priority for the patient with a pneumothorax. Loss of negative pressure in the pleural cavity and the resulting collapse of lung tissue can cause poor chest expansion and loss of alveolar ventilation. Pain, aspiration and other injury, and establishing effective breathing patterns are important concerns, but are not the highest priority for this patient.

10 (37) The nurse is caring for a patient undergoing mechanical ventilation for acute respiratory failure. Which measure should the nurse use to help maintain effective alveolar ventilation? Keep the patient in the supine position. Maintain ordered oxygen concentration. Increase the tidal volume on the ventilator. Perform endotracheal suctioning as indicated.

10. Correct answer: D Rationale: A patent airway is necessary to maintain effective alveolar ventilation and gas exchange. Endotracheal suctioning as needed will ensure a patent airway for the patient. The supine position will not ensure effective alveolar ventilation. Providing oxygen as prescribed will not ensure effective alveolar ventilation. Increasing the tidal volume on the ventilator could cause lung tissue trauma.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1.pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2.pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3.pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4.pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

2 A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2 acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1.Palpation and clubbing 2.Percussion and vibration 3.Hyperoxygenation and suctioning 4.Administer a bronchodilator and monitor peak flow

2 Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

A client with tuberculosis receiving cycloserine orally twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by providing which information to the client? 1.Withhold the morning dose on the day of the scheduled blood test. 2.Take the morning dose, and have the blood drawn 2 hours after taking the dose. 3.Withhold the evening dose before the test and the dose scheduled for the morning of the test. 4.Double the dose the evening before the test, and withhold the morning dose on the day of the test.

2 Cycloserine is an antituberculosis medication that requires weekly serum medication level determinations to monitor for neurotoxicity and other adverse effects. Peak concentrations are measured 2 hours after dosing and should be between 25 and 35 mcg/mL.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1.Do nothing because this is an expected finding. 2.Check for an air leak because the bubbling should be intermittent. 3.Increase the suction pressure so that the bubbling becomes vigorous. 4.Clamp the chest tube and notify the primary health care provider immediately.

2 Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a primary health care provider's prescription.

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? 1.Osmosis 2.Diffusion 3.Ionization 4.Active transport

2 Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1."It will enter the left main bronchus if inserted too far." 2."It will enter the right main bronchus if inserted too far." 3."It may enter the left main bronchus if not inserted far enough." 4."It may enter the right main bronchus if not inserted far enough."

2 If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1.Edema 2.Dyspnea 3.Frothy sputum 4.Diminished breath sounds

2 In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? 1.Hypercalcemia 2.Peripheral neuritis 3.Small blood vessel spasm 4.Impaired peripheral circulation

2 Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are not associated with the information in the question.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action? 1.Use alcohol in small amounts only. 2.Report yellow eyes or skin immediately. 3.Increase intake of Swiss or aged cheeses. 4.Avoid vitamin supplements during therapy.

2 Isoniazid is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine, because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.

A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching? 1."It is transmitted by the airborne route." 2."It is a fast-growing infectious disease." 3."People who have been in constant close contact with the infected person will need to be tested and treated if necessary." 4."The risk for transmission is reduced after the infectious person has received proper medication therapy for 2 to 3 weeks and clinical improvement occurs."

2 Mycobacterium tuberculosis is a nonmoving, slow-growing (not fast-growing), acid-fast rod transmitted via the airborne route. The other options are accurate statements.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? 1.Increase to 3 L/min and titrate until the SpO2 is 95%. 2.Increase to 3 L/min and titrate until the SpO2 is 88%. 3.Place the client on a non-rebreather mask on 100% FiO2. 4.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

2 Oxygen is used cautiously and should be titrated to the lowest amount needed; however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and the current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%. An SpO2 of 95% is the recommended level for a healthy individual; therefore, option 1 is incorrect. A non-rebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar

2 The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs? 1.Five sputum cultures are negative. 2.Three sputum cultures are negative. 3.A sputum culture and a chest x-ray are negative. 4.A sputum culture and a tuberculin skin test are negative.

2 The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of 3 sputum cultures are negative because the client is considered noninfectious at that point. Therefore, the remaining options are incorrect. A negative chest x-ray does not mean that the client is noninfectious. A positive tuberculin skin test never reverts to negative.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? 1.This is expected and will last for at least 1 year. 2.This is expected, and the client should gradually increase activity as tolerated. 3.This is an unexpected finding with TB, but it should resolve within 1 month or so. 4.This is a short-lived problem that should be gone within 1 week after beginning medication therapy.

2 The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 3, and 4 are incorrect information.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside? 1.Code cart 2.Intubation tray 3.Thoracentesis tray 4.Chest tube and drainage system

2 The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1.Five blood cultures are negative. 2.Three sputum cultures are negative. 3.A blood culture and a chest x-ray are negative. 4.A sputum culture and a tuberculin skin test are negative.

2 The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? 1.Pallor 2.Low arterial PaO2 3.Elevated arterial PaO2 4.Decreased respiratory rate

2 The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear

2 The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition? 1.Asthma 2.Pleurisy 3.Emphysema 4.Pulmonary edema

2 The sound that the nurse hears is a pleural friction rub. A pleural friction rub is the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is a superficial, low-pitched, coarse rubbing or grating sound that sounds like 2 rough surfaces rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface. It is not cleared by a cough. Disorders that cause airflow obstruction, such as emphysema or asthma, would produce high- or low-pitched wheezes (musical sounds similar to a squeak). Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? 1.The client needs to have the test repeated. 2.Client results are within the therapeutic range. 3.Client results are higher than the therapeutic range. 4.Client results are lower than the needed therapeutic level.

2 The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury

2 This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1.Sitting position 2.Tripod position 3.Supine position 4.High-Fowler's position

2 Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? Rationale:The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high-Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1.A low arterial PCO2 level 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

2,3 Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

he nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1.A low arterial PCo2 level 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1.Reduce fluid intake to less than 1500 mL/day. 2.Teach diaphragmatic and pursed-lip breathing. 3.Encourage alternating activity with rest periods. 4.Teach the client techniques of chest physiotherapy. 5.Keep the client in a supine position as much as possible.

2,3,4 Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

Which are possible causes of upper airway obstruction? Select all that apply. 1.Thin secretions 2.Laryngeal edema 3.Head and neck cancer 4.Foreign body aspiration 5.Lymph node enlargement

2,3,4,5 Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. 1.Purified air 2.Cigarette smoking 3.Genetic risk factor 4.Environmental factors 5.Eating plenty of fruits and vegetables 6.Alpha-1 antitrypsin (AAT) deficiency

2,3,4,6 Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

What early signs and symptoms should the nurse assess for in a client with a suspected pulmonary embolism? Select all that apply. 1.Orthopnea 2.Tachypnea 3.Restlessness 4.Normal oxygen saturation 5.Feeling of impending doom

2,3,5 Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial oxygen saturation. If suspected, the nurse immediately notifies the Rapid Response Team and primary health care provider. The nurse stays with the client, reassures the client, and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital signs and checks lung sounds. The nurse continues to monitor the client closely, prepares the client for tests prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas. When prescribed, the client is prepared for the administration of heparin therapy or other therapies such as embolectomy or placement of a vena cava filter if necessary. Finally, the nurse documents the event, the interventions taken, and the client's response to treatment.

2. A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.

2. A. Assessing the client's pain and administer pain medication is important. However, another action is the priority. B. CORRECT: The priority action when using the airway, breathing, circulation (ABC) approach to client care is to establish and maintain the client's respiratory function. Obtaining a large-bore IV needle for decompression is the priority action by the nurse. C. Administering a benzodiazepine will treat the client's anxiety. However, another action is the priority. D. Gathering supplies to prepare for chest tube insertion is important. However, another action is the priority.

2. A nurse is preparing to administer an initial dose of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools

2. A. CORRECT: Observe for hypokalemia. This is an adverse effect of prednisone. B. Tachycardia is an adverse effect of a bronchodilator. C. CORRECT: Observe for fluid retention. This is an adverse effect of prednisone. D. Nausea is an adverse effect of a bronchodilator. E. CORRECT: Monitor for black, tarry stools. This is an adverse effect of prednisone. NCLEX® Connection: Pharmacological and

2. A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

2. A. Confusion is a late manifestation of hypoxemia. B. CORRECT: Pale skin is an early manifestation of hypoxemia. C. Bradycardia is a late manifestation of hypoxemia. D. Hypotension is a late manifestation of hypoxemia. E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia.

2. A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

2. A. Expect the client to have tachypnea. B. CORRECT: Expect the client to have a pleural friction rub. C. Expect the client to have hypotension. D. CORRECT: Expect the client to have petechiae. E. CORRECT: Expect the client to have tachycardia

2. A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include? A. "You will need to continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."

2. A. The client who has tuberculosis needs to continue taking the multimedication regimen for 6 to 12 months. B. CORRECT: The client who has tuberculosis needs to provide sputum samples every 2 to 4 weeks to monitor the effectiveness of the medication. C. The client who has tuberculosis is often treated in the home setting. D. The client who has tuberculosis needs to wear a mask when in public areas.

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? 1.Systemic tuberculosis 2.Pulmonary tuberculosis 3.Exposure to tuberculosis 4.No evidence of tuberculosis

3 A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Options 1, 2, and 4 are incorrect interpretations of the data presented in the question.

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? 1.Encourage intake of fluids. 2.Shave the anticipated entry site. 3.Ask the client about allergies and previous reactions. 4.Contact the operating room regarding the need for the procedure.

3 A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is not necessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1.Cyanosis 2.Hyperinflated chest 3.Rapid, shallow respirations 4.Coarse crackles auscultated bilaterally

3 An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? 1.Holding a warm compress over the puncture site for 5 minutes 2.Encouraging the client to open and close the hand rapidly for 2 minutes 3.Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes 4.Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

3 Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which assessment finding should the nurse expect to note? 1.Continuous rapid regular breathing 2.Periods of apnea followed by bradypnea 3.Periods of apnea followed by deep rapid breathing 4.Periods of bradypnea followed by periods of tachypnea

3 Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. The descriptions in the remaining options are incorrect.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

3 Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a primary health care provider's prescription.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? 1.An uninsured man who is homeless 2.A newly immigrated woman from Korea 3.A man who is an inspector for the U.S. Postal Service 4.An older woman admitted from a long-term care facility

3 Clients at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus infection or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1.A 25-year-old woman with diabetic ketoacidosis 2.A 65-year-old man out of bed 1 day after prostate resection 3.A 73-year-old woman who has just had pinning of a hip fracture 4.A 38-year-old man with pulmonary contusion sustained in an automobile crash

3 Clients frequently at risk for pulmonary embolism include those who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation

3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Replace the chest tube system. 2.Obtain a pulse oximetry reading. 3.Call the primary health care provider. 4.Place the client in a Trendelenburg's position.

3 If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the primary health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? 1.Electrolyte levels 2.Coagulation times 3.Liver enzyme levels 4.Serum creatinine level

3 Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years or abuses alcohol. The laboratory tests in options 1, 2, and 4 are not necessary.

A client with tuberculosis is starting antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? 1.Electrolyte levels 2.Coagulation times 3.Liver enzyme levels 4.Serum creatinine level

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3 The normal pH is 7.35 to 7.45. Normal PaCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and PaCO2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1.Suctioning is required frequently. 2.The client's skin and mucous membranes are light pink. 3.Aspiration of gastric contents occurs during suctioning. 4.Excessive secretions are suctioned from the tube and stoma.

3 Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? 1.Pneumonia 2.Pulmonary edema 3.Pulmonary embolism 4.Myocardial infarction

3 Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom; it is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. The conditions in the remaining options are not associated with thrombophlebitis.

A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action? 1.Repeat arterial blood gas testing. 2.Maintain continuous pulse oximetry. 3.Notify the primary health care provider (PHCP). 4.Decrease the amount of oxygen administered.

3 Respiratory failure is defined as a PaO2 of 60 mm Hg or lower. The nurse should notify the PHCP for further prescriptions. Common causes of hypoxemic respiratory failure are pneumonia, pulmonary embolism, and shock. This client should be receiving oxygen. Repeating the arterial blood gases and maintaining continuous pulse oximetry do nothing to correct the problem.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? 1.PaO2 58 mm Hg, PaCO2 32 mm Hg 2.PaO2 60 mm Hg, PaCO2 45 mm Hg 3.PaO2 49 mm Hg, PaCO2 52 mm Hg 4.PaO2 73 mm Hg, PaCO2 62 mm Hg

3 Respiratory failure is described as a PaO2 of 60 mm Hg or lower and a PaCO2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (PaCO2) from the client's baseline are considered diagnostic.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1.Administration of plasma expanders, low-flow oxygen, and suctioning 2.Administration of bronchodilators, intubation, and mechanical ventilation 3.Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4.Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask

3 Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. The remaining options are incorrect.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? 1.Should always be taken with food or antacids 2.Should be double-dosed if 1 dose is forgotten 3.Causes orange discoloration of sweat, tears, urine, and feces 4.May be discontinued independently if symptoms are gone in 3 months

3 Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a primary health care provider. It is best to administer the medication on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication.

A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin for treatment. The nurse teaches the client to perform which action? 1.Report any change in urine color. 2.Take both medications with food. 3.Take both medications together once a day. 4.Expect to take the medications for 2 to 3 weeks.

3 Rifampin in combination with isoniazid prevents the emergence of medication-resistant organisms. This combination, taken together daily, eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and should be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness, and the therapeutic effect may be evident in 2 to 3 weeks.

A client with tuberculosis (TB) has a prescription for rifampin. What instruction should the nurse include in the client's teaching plan? 1.Yellow-colored skin is common with this medication. 2.The medication must always be taken on an empty stomach. 3.Wearing glasses instead of soft contact lenses will be necessary. 4.As soon as the cultures come back negative, the medication may be stopped.

3 Soft contact lenses may be permanently damaged by the orange discoloration in body fluids caused by rifampin. Any sign of possible jaundice (yellow-colored skin) should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures give negative results.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1."Strapping is useful only if the ribs are fractured in several places at once." 2."That's a good idea. I'll ask the primary health care provider for a prescription for the needed supplies." 3."That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4."That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

3 Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? 1.Atelectasis and viral infection 2.Bronchoconstriction and stridor 3.Collapse of alveoli and decreased compliance 4.Decreased ciliary action and retained secretions

3 Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The primary health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect? 1.Atelectasis and viral infection 2.Bronchoconstriction and stridor 3.Collapse of alveoli and decreased compliance 4.Decreased ciliary action and retained secretions

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse? 1.Osteoarthritis 2.Hypothyroidism 3.Diabetes mellitus 4.Polycystic disease

3 Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Lying on the back in a low-Fowler's position 4.Sitting up with the elbows resting on the knees

3 The client should not lie on the back because this reduces movement of a large area of the client's chest wall. The client should use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? 1."I need to protect the stoma from water." 2."Soaps should be avoided near the stoma." 3."I should use diluted alcohol on the stoma to clean it." 4."I should apply a non-oil-based ointment to the skin surrounding the stoma."

3 The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? 1.Pain with deep breathing 2.Increased chest tube drainage 3.Lung crackles in the remaining lung 4.Respiratory rate of 20 breaths/minute

3 The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1.Fat embolism 2.Mediastinal shift 3.Mediastinal flutter 4.Hypovolemic shock

3 The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? 1.Increased oxygen saturation with ambulation 2.A widened diaphragm documented by chest x-ray 3.Hyperinflation of lungs documented by chest x-ray 4.A shortened expiratory phase of the respiratory cycle

3 The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken

3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? 1.Wash hands and don a surgical mask. 2.Wash hands and wear a gown and gloves. 3.Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. 4.The nurse needs no precautions. The client is instructed to cover the mouth and nose when coughing.

3 The nurse wears a HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. In addition, a surgical mask will not protect against Mycobacterium tuberculosis.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? 1.Document the finding in the client's record. 2.Call the employee health service department. 3.Contact the primary health care provider (PHCP). 4.Call the radiology department for a chest radiographic study to be done.

3 The nurse who obtains a positive test reading should call the PHCP immediately. The PHCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided.

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client with obstructive pulmonary disease receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value? 1.8 mcg/mL (44 mcmol/L) 2.9 mcg/mL (50 mcmol/L) 3.18 mcg/mL (100 mcmol/L) 4.26 mcg/mL (144 mcmol/L)

3 The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 mcmol/L). If the level is less than the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Values of 8 and 9 mcg/dL (44 and 50 mcmol/L) indicate low values, while 26 mcg/dL (144 mcmol/L) indicates an elevated value.

The nurse should report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1.Adventitious breath sounds 2.Temperature of 99.4° F (37.4° C) orally 3.Blood pressure of 198/110 mm Hg 4.Respiratory rate of 28 breaths per minute

3 Thrombolytic therapy is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the PHCP before initiating therapy.

The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1.Sims' position, with the head of the bed flat 2.Prone, with the head turned to the side supported by a pillow 3.Left side-lying position, with the head of the bed elevated 45 degrees 4.Right side-lying position, with the head of the bed elevated 45 degrees

3 To facilitate removal of fluid from the pleural space, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table, with the feet supported on a stool. The other position is lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area easily removed with thoracentesis.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1.Chest x-ray 2.Bronchoscopy 3.Sputum culture 4.Tuberculin skin test

3 Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? 1."Do you have shallow breathing?" 2."Do you feel like you have a lot of energy?" 3."Do you have a headache or become confused?" 4."Do you feel dizzy or have tingling sensations?"

3 When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, along with hyperkalemia, a rapid irregular pulse, and dysrhythmias.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias

3 When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 1.Bradypnea 2.Flattened neck veins 3.Decreased cardiac output 4.Hyperresonance to percussion 5.Tracheal deviation to the opposite side

3,4,5 Tension pneumothorax is the rapid accumulation of air in the pleural space. This causes extremely high intrapleural pressures, resulting in tension on the heart and great vessels. This can cause decreased cardiac output (tachycardia, hypotension), hyperresonance on percussion, and a tracheal shift away from the affected side. Bradypnea and flattened neck veins are incorrect because the client would have tachypnea and distended neck veins.

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3,4,5,6, The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

3. A nurse is discharging a client who has COPD. The client is concerned about not being able to leave the house due to the need for staying on continuous oxygen. Which of the following responses should the nurse make? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you so you will not need to get out."

3. A. CORRECT: Inform the client that there are portable oxygen systems that can be used to leave the house. This should alleviate the client's anxiety. B. Tell the client to use oxygen at all times to prevent becoming hypoxic. C. Encourage the client to return to a daily routine, but include periods of rest. D. Encourage the client to return to a daily routine. Home health services promote a client's independence.

3. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2°F), and blood pressure 100/54mmHg. Which of the following nursing actions is the priority? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a CT scan.

3. A. Notify the provider about the condition to obtain guidance on treatment. However, another action is the priority. B. Administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority. C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, determine that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action. D. Obtain a CT scan to detect the presence and location of the blood clot. However, another action is the priority.

3. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."

3. A. The client who is receiving rifampin should expect to see his urine turn a dark orange. B. The client who is taking ethambutol does not have an adverse effect resulting in changes to the sclera of the eyes. C. CORRECT: The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication. D. The client who is taking isoniazid should take vitaminB6 daily and observe for signs of hepatotoxicity.

3. A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 4 hr.

3. A. The nurse should apply soft wrist restraints to prevent self-extubation or according to facility policy. B. The nurse should monitor ventilator settings hourly. C. The nurse should document tube placement in centimeters at the client's teeth or lips. D. CORRECT: The nurse should assess the breath sounds of a client receiving mechanical ventilation every 4 hr.

3. A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough."

3. A. Weakness is an expected finding following recovery from a pneumothorax. B. The client should expect a lengthy recovery following a pneumothorax. C. It is not necessary to wear a mask following a pneumothorax, unless the client has another condition, such as immunosuppression. D. CORRECT: The client should notify the provider of a productive or persistent cough. This can indicate that the client might need treatment of a respiratory infection.

3 (36) The nurse evaluating an intradermal PPD tuberculin test notes large erythemic area surrounding the test site. What additional information indicates to the nurse that this is a positive result? The erythemic area is greater than 9 mm in size. The test was administered 24 hours ago. There is a 5 mm hardened area at the injection site. The patient resides in a long-term care facility.

3. Correct answer: C Rationale: The intradermal PPD is read by measuring the area of induration or hardness at the injection site. Redness or erythema at the site does not indicate a positive test. The test is read at 48 and 72 hours. Residing in a long-term care facility is not a relevant factor.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? 1.Allow the client to deal with the disease in an individual fashion. 2.Ask family members whether they wish a psychiatric consultation. 3.Encourage the client to visit with the pastoral care department's chaplain. 4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4 A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1.Pain 2.Fear 3.Anxiety 4.Hypoxia

4 After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after an inhalation injury and also may occur after an electrical injury. Although anxiety, fear, and pain may occur, confusion and combativeness are most likely associated with hypoxia.

A client with a documented exposure to tuberculosis is on medication therapy with isoniazid. The nurse is monitoring laboratory results and determines that which laboratory value indicates the need for follow-up? 1.Platelet count 325,000 mm3 (325 × 109/L) 2.Serum creatinine 1.0 mg/dL (88.3 mcmol/L) 3.Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L) 4.Aspartate aminotransferase (AST) 55 U/L (55 U/L)

4 Because isoniazid therapy can cause elevated hepatic enzymes and hepatitis, liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years of age or who abuses alcohol. The normal AST level is 0 to 35 U/L (0 to 30 U/L). The other options are not monitored routinely and are also normal.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action? 1.Prepare the client for intubation and mechanical ventilation. 2.Talk to the family about the client's right to change his mind. 3.Administer an antianxiety medication to the client to ease his breathing. 4.Notify the primary health care provider (PHCP) that the client is rescinding the DNR prescription.

4 COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the PHCP to reverse the DNR prescription on the chart. The PHCP also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the PHCP. Option 2 is incorrect because the PHCP should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions. Some states offer DNR Comfort Care and DNR Comfort Care Arrest protocols. Protocols in these instances list specific actions that health care providers will take when providing cardiopulmonary resuscitation.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? 1.Low cardiac output secondary to cor pulmonale 2.Gas exchange alteration related to ventilation-perfusion mismatch 3.Altered breathing pattern secondary to increased work of breathing 4.Inability to clear the airway related to inability to expectorate sputum

4 COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? 1."I need to avoid alcohol and sedative medications." 2."I have to cut down on the percentage of carbohydrates in my diet." 3."Besides smoking, I can't be around second- or thirdhand smoke." 4."I have to keep my nasal cannula oxygen levels between 4 and 6 L/min."

4 Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per primary health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems.

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? 1.Fear and anxiety 2.Complaints of pain 3.Clear breath sounds 4.Use of accessory muscles for breathing

4 Clinical indicators of respiratory injury in a burn-injured client include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would be more likely to indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values also would be noted.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How should the nurse interpret this finding? 1.The drainage chamber is full. 2.The pneumothorax is resolving. 3.The suction chamber system is shut off. 4.There is an air leak somewhere in the system.

4 Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

The clinic nurse develops a plan of care for a client with emphysema who will be started on long-term corticosteroid therapy. Which specific instruction should the nurse include in the plan of care? 1.Instruct the client to maintain a low-potassium diet. 2.Encourage the client to consume a fluid intake of 3000 mL/day. 3.Encourage the client to increase the amount of sodium intake in the diet. 4.Instruct the client to return to the clinic for monitoring of blood glucose levels.

4 Corticosteroid therapy can cause calcium and potassium depletion, sodium retention, and glucose intolerance. The client should be monitored for hyperglycemia. Also, an increase in potassium and a decrease in sodium intake are recommended to prevent potassium depletion and sodium retention while taking the corticosteroid. Although increased fluids are important for the client with emphysema to maintain thin respiratory secretions, this action is not specific to the use of corticosteroids.

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first? 1.Request a cardiopulmonary consult. 2.Teach the client to splint the incision. 3.Teach the proper technique for huff coughing. 4.Ensure that the client is experiencing adequate pain control.

4 Coughing is 1 of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse should first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it should follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which finding? 1.Impaired sense of hearing 2.Gastrointestinal side effects 3.Orange-red discoloration of body secretions 4.Difficulty in discriminating the color red from green

4 Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? 1.The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2.The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3.The family will be treated prophylactically, and the client will not be contagious after 1 continuous week of medication therapy. 4.The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

4 Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1.Assist the victim to sit up. 2.Remove the victim's shirt. 3.Turn the victim onto the side opposite the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment.

4 If flail chest is present, the nurse applies firm but gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim's respiratory status. The nurse does not move an injured client for fear of worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured clients should be kept warm until help arrives at the scene.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1.Initiate an intravenous line. 2.Assess the client's blood pressure. 3.Prepare to administer morphine sulfate. 4.Administer oxygen, 8 to 10 L/minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Encourage the client to sleep until arterial blood gas results improve. 3.Ask the primary health care provider for a prescription for succinylcholine. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4 Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds? 1.Effectiveness of medication therapy 2.The deep breaths that the client is taking 3.Decreased inflammatory reaction at the site 4.Accumulation of pleural fluid in the inflamed area

4 Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. The remaining options are incorrect interpretations.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder? 1.The stretch receptors in the lungs are irritated. 2.The diaphragm is weak and is difficult to move. 3.This condition causes nerve endings to be especially sensitive. 4.The inflamed pleurae cannot glide against each other as they normally do.

4 Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. The remaining options are incorrect.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1.Sitting up in bed 2.Side-lying in bed 3.Sitting in a recliner chair 4.Sitting up and leaning on an overbed table

4 Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1.Promote oxygen intake. 2.Strengthen the diaphragm. 3.Strengthen the intercostal muscles. 4.Promote carbon dioxide elimination.

4 Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1.Slow, deep respirations 2.Rapid, deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration

4 Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? 1.The client has no risk of acquiring TB and needs no further workup. 2.The client is at increased risk for acquiring TB and needs immediate medication therapy. 3.The client's test result will be negative, and a sputum culture will be required for diagnosis. 4.The client's test result will be positive, and a chest x-ray study will be required for evaluation.

4 The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is currently being weaned to triamcinolone by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms? 1.Chills, fever, and generalized rash 2.Vomiting, diarrhea, and increased thirst 3.Blurred vision, headache, and insomnia 4.Anorexia, nausea, weakness, and fatigue

4 The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other signs that can be detected and are objective include hypotension and hypoglycemia.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1."I need to continue medication therapy for 1 month." 2."I can't shop at the mall for the next 6 months." 3."I can return to work if a sputum culture comes back negative." 4."I should not be contagious after 2 to 3 weeks of medication therapy."

4 The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Sitting up with elbows resting on knees 4.Lying on the back in a low-Fowler's position

4 The client should use the positions outlined in options 1, 2, and 3. These allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? 1.1 or 2 days 2.1 to 2 weeks 3.Almost 1 week 4.Several weeks to months

4 The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? 1.High fever 2.Flushed skin 3.Complaints of weight gain 4.Complaints of night sweats

4 The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate

4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear? 1.Gloves only 2.Fluid shield mask 3.Gown, mask, and gloves 4.High-efficiency particulate air (HEPA) filter mask

4 The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved.

The nurse is teaching a client with tuberculosis about nutrition and foods that should be increased in the diet. The nurse should suggest that the client increase which food items? 1.Potatoes and fish 2.Eggs and spinach 3.Grains and broccoli 4.Meats and citrus fruits

4 The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables.

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? 1.Obstruction of the bronchus 2.Inflammation of the pleural surfaces 3.Passage of air through a narrowed airway 4.Opening of small airways that contain fluid

4 The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched, discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low-snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial, low-pitched, coarse rubbing or grating sound) is heard when the pleural surfaces are inflamed. Passage of air through a narrowed airway is associated with wheezes (a high-pitched musical sound similar to a squeak).

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? 1.6 to 12 hours 2.12 to 24 hours 3.24 to 28 hours 4.48 to 72 hours

4 The tuberculin skin test is an accurate and reliable test that will provide information to the primary health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result should be done 48 to 72 hours after the injection.

A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate? 1."Inhaled glucocorticoids cure the condition." 2."Inhaled glucocorticoids treat this condition more effectively." 3."Inhaled glucocorticoids decrease the symptoms more quickly." 4."Inhaled glucocorticoids are preferred because of decreased adverse effects."

4 Triamcinolone is an adrenocorticosteroid. Inhaled glucocorticoids are preferable for long-term management because there is a decreased incidence of adverse effects since the medication is not absorbed systemically. COPD is a progressive condition and cannot be cured. Options 2 and 3 are incorrect.

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1.Pain medication 2.Endotracheal intubation 3.Oxygen via nasal cannula 4.100% humidified oxygen by face mask

4 With a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. This method provides a greater concentration of oxygen than oxygen delivered via nasal cannula. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Pain medication may be needed but would not be the initial intervention.

4. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

4. A. A nonrebreather mask delivers an approximated amount of oxygen. B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered. C. A nasal cannula delivers an approximated amount of oxygen. D. A simple face mask delivers an approximated amount of oxygen.

4. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day for my ulcer." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

4. A. Document the client's allergy to morphine to manage the client's discomfort due to a blood clot. However, another action is the priority. B. CORRECT: The greatest risk to the client is the possibility of bleeding from a peptic ulcer. The priority intervention is to notify the provider of the finding. C. Document the client's history of a blood clot to provide preventative measures. However, another action is the priority. D. Expect the client to report pain with breathing. However, another action is the priority.

4. A nurse in the emergency department is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxical chest movement

4. A. The client can have tachycardia as a manifestation when experiencing a flail chest due to inadequate oxygenation. B. CORRECT: The client can have cyanosis as a manifestation when experiencing a flail chest due to inadequate oxygenation. C. CORRECT: The client can have hypotension as a manifestation when experiencing a flail chest. D. CORRECT: The client can have dyspnea as a manifestation when experiencing a flail chest due to injury and the client's inability to effectively inhale and exhale. E. CORRECT: The client can have paradoxical chest movement as a manifestation when experiencing a flail chest due to injury to the chest and the inability to inhale and exhale.

4. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."

4. A. The client should place an adapter on a finger to read the blood oxygen saturation level while performing a pulse oximetry reading. B. The client who practices diaphragmatic or abdominal breathing should lie supine with knees bent. C. The client who practices diaphragmatic or abdominal breathing should rest a hand over the abdomen to determine if the breathing is done correctly. D. CORRECT: The client who is using the spirometer should take in as deep a breath as possible before exhaling. As the client exhales, the needle of the spirometer rises. This promotes lung expansion.

4. A nurse is preparing to administer a new prescription for isoniazid (INH) to a light-skinned client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints." C. "You might notice tingling of your hands." D. "You might experience a loss of appetite."

4. A. Yellowing of the skin can be an adverse effect of rifampin or pyrazinamide in a client who has light skin. B. Experiencing pain in the joints can be an adverse effect of rifampin. C. CORRECT: Tingling of the hands can be an adverse effect of isoniazid. D. Loss of appetite can be an adverse effect of rifampin.

4 (36) The nurse is teaching a patient who is prescribed prophylactic daily isoniazid (INH) for conversion of a tuberculin test. What should the nurse include in this patient's teaching? (Select all that apply.) This drug turns the urine red-orange, which is harmless. Periodic eye examinations are required during treatment. Report numbness and tingling of extremities to the physician. Do not use aspirin while taking this drug because abnormal bleeding may occur. Expect to have liver function studies done periodically during treatment.

4. Correct answer: C, E Rationale: When teaching a patient who is taking INH, the nurse needs to include information on adverse effects such as numbness and tingling of extremities and how these effects need to be reported to the physician. The patient should also be made aware that periodic liver function studies are required. Rifampin may cause an orange-red coloration of saliva and urine. Ethambutol may affect red-green color discrimination and visual acuity. Periodic eye examinations are recommended. Aspirin may interfere with rifampin absorption and should not be taken concurrently.

4 (37) The nurse is assessing a patient with chronic obstructive airway disease. Which finding would be expected when conducting the physical examination of this patient? (Select all that apply.) Mental confusion and lethargy Oxygen saturation readings of 85% or less 3+ pitting edema of ankles and lower legs AP chest diameter equal to or greater than lateral chest diameter Use of accessory muscles of respiration

4. Correct answer: D, E Rationale: In the patient with chronic obstructive airway disease, air trapping and hyperinflation increase the anterior-posterior chest diameter, causing barrel chest. Accessory muscles of respiration are prominently used. Mental confusion, oxygen saturation levels below 85%, and 3+ pitting edema of the ankles and lower legs are not expected assessment findings and should be reported to the healthcare provider.

5. A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

5. A. Assist-control mode takes over the work of breathing. B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths. D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths. E. Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually

5. A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

5. A. CORRECT: A persistent cough is a manifestation of tuberculosis. B. Weight loss is a manifestation of tuberculosis. C. CORRECT: Fatigue is a manifestation of tuberculosis. D. CORRECT: Night sweats is a manifestation of tuberculosis. E. CORRECT: Purulent sputum is a manifestation of tuberculosis.

5. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include? A. "Take quick breaths upon inhalation." B. "Place your hand over your stomach." C. "Take a deep breath in through your nose." D. "Puff your cheeks upon exhalation."

5. A. The client should take a slow deep breath upon inhalation. This improves breathing and allows oxygen into lungs. B. The client should place a hand on the stomach while performing diaphragmatic or abdominal breathing. This allows resistance to be met and serves as a guide that the client is inhaling and exhaling correctly. C. CORRECT: The client should take a deep breath in through the nose while performing pursed-lip breathing. This controls the client's breathing. D. The client should not puff their cheeks upon exhalation. This does not allow the client to optimally exhale the carbon dioxide from the lungs. NCLEX® Connection: Physiological Adaptation,

5 (37) The nurse is determining goals of care for a patient with chronic obstructive pulmonary disease. Which would be an appropriate goal for this patient? Will maintain SaO2 of 90% or higher. Will verbalize self-care measures to regain lost lung function. Arterial blood gases will be within normal limits by discharge. Will identify strategies to help reduce number of cigarettes smoked per day.

5. Correct answer: A Rationale: During an acute exacerbation of COPD, keeping the SaO2 above 90% is an appropriate goal. This goal must be individualized as some patients may no longer be able to obtain 90% saturation. However, this is the best of the goals listed. Lung function that has been lost from chronic obstructive pulmonary disease cannot be regained. Arterial blood gases will not be normal because the patient's oxygen and carbon dioxide levels are altered due to lung changes. The nurse should help the patient develop a smoking cessation plan to preserve remaining lung functioning.

6 (35) The nurse suspects that a patient is experiencing obstructive sleep apnea. What did the nurse most likely assess in this patient? (Select all that apply.) Loud cyclic snoring Elevated blood pressure Complaints of morning headache Complaints of daytime sleepiness Decreased oxygen saturation levels while awake

6. Correct answer: A, B, C, D Rationale: The manifestations of sleep apnea include loud, cyclic snoring, hypertension, morning headache, and daytime fatigue and sleepiness. Decreased oxygen saturation while awake is not a manifestation of obstructive sleep apnea.

6 (36) The nurse caring for a patient following a lobectomy notes 100 mL of red drainage in the chest drainage container since checking it 30 minutes previously. What should the nurse do to help this patient? (Select all that apply.) Notify the surgeon. Empty the chest tube drainage system. Assess vital signs and level of consciousness. Apply pressure to the chest tube insertion site. Note the finding and reevaluate drainage in 30 minutes.

6. Correct answer: A, C Rationale: Chest tube drainage that is red, free flowing, and exceeds 70 mL/h indicates hemorrhage and must be reported. Vital signs and level of consciousness are measured to evaluate cardiac output and hemodynamic stability. The drainage should not be emptied and pressure should not be applied to the chest tube insertion site. The nurse needs to notify the surgeon now and not wait for 30 minutes to reevaluate the patient's drainage.

6 (37) The nurse is planning care for a patient with chronic obstructive pulmonary disease. Which information should the nurse consider when determining if the patient should have supplemental oxygen? Oxygen is used only at night for patients with COPD. Because oxygen is flammable, the patient should not smoke when using oxygen. The patient needs to be closely monitored for signs of respiratory depression. Oxygen is never used for patients with COPD because they may become dependent on it.

6. Correct answer: C Rationale: Administering oxygen to patients with chronic elevated carbon dioxide levels in the blood can actually increase the PaCO2, leading to increased somnolence and even respiratory failure. Close monitoring of level of consciousness and arterial blood gases during oxygen therapy is vital. Long-term oxygen therapy is used for severe and progressive hypoxemia. It also reduces the rate of hospitalization and increases length of survival. Oxygen may be used intermittently, at night, or continuously. For severely hypoxemic patients, the greatest benefit is seen with continuous oxygen. The patient with chronic obstructive pulmonary disease should be working on a smoking cessation plan.

7 (10) A patient's arterial blood gas results are pH 7.21, PaO2 98 mmHg, PaCO2 32 mmHg, and HCO3− 17 mEq/L. Which acid-base imbalance do these results indicate to the nurse? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

7. Correct answer: A Rationale: pH of less than 7.35 indicates acidosis. The bicarbonate level is less than 22 mEq/L, which indicates a metabolic component. The PaCO2 of 32 is less than 35 mmHg. This indicates respiratory compensation for the excess acid. None of these blood gas values supports respiratory acidosis or metabolic or respiratory alkalosis.

7 (36) A patient is scheduled for a thoracentesis. What should the nurse do to assist the patient for this procedure? (Select all that apply.) Encourage to cough as the fluid is withdrawn. Coach to breathe deeply as the needle is inserted. Help to sit upright and lean forward during the procedure. Remind to remain on quiet bedrest for 4 hours following the procedure. Advise patient that a feeling of pressure will occur during insertion.

7. Correct answer: C, E Rationale: The patient having a thoracentesis needs to sit upright, leaning forward during the procedure to spread the rib cage for easier placement of the needle. Local anesthesia will prevent pain, but a feeling of pressure will occur during insertion. The patient should not cough as fluid is withdrawn. The patient does not need to breathe deeply when the needle is inserted. The patient only needs to remain positioned on the unaffected side for 1 hour after the procedure to allow the pleural puncture to heal.

8 (36) The nurse is providing discharge teaching to a patient with a fractured rib. What should the nurse instruct the patient to do? Use a small pillow to splint the area when coughing. Avoid using pain medications to prevent respiratory depression. Remain on bedrest for a week to allow the fracture to stabilize. Use elastic roller bandages like ACE wraps to stabilize the chest wall and promote comfort.

8. Correct answer: A Rationale: A patient with a fractured rib should be urged to use a small pillow to splint the area when coughing to reduce the movement of rib cage and pain. Providing adequate analgesia to promote breathing, coughing, and movement is the primary intervention. Bedrest is not required with a rib fracture. Rib belts, binders, and taping to stabilize the rib cage are not recommended because they may interfere with ventilation and lead to atelectasis.

8 (10) A patient diagnosed with a suspected heroin overdose has a respiratory rate of 5 to 6 per minute. Which additional data should the nurse expect to collect on this patient? (Select all that apply.) pH 7.29 PaCO2 54 mmHg HCO3− 32 mEq/L Alert and oriented Skin warm and flushed

8. Correct answer: A, B, E Rationale: The slow respiratory rate leads to inadequate alveolar ventilation. As a result, carbon dioxide is not effectively eliminated from the blood, causing it to accumulate. This increases carbonic acid levels, leading to respiratory acidosis, as indicated by the low pH and high PaCO2. Excess carbon dioxide causes vasodilation, leading to warm, flushed skin, particularly in acute respiratory acidosis. The bicarbonate level is initially unchanged in acute respiratory acidosis because the compensatory response of the kidneys occurs over hours to days. The increased carbon dioxide level will affect neurologic function and the patient will not be alert and oriented.

8 (37) A patient in skeletal traction suddenly develops right-sided chest pain and shortness of breath. What should the nurse do? (Select all that apply.) Check for Homans sign. Start oxygen per nasal cannula. Place in the high-Fowler position. Administer the prescribed analgesic. Auscultate heart sounds every 2 to 4 hours.

8. Correct answer: B, C, E Rationale: These manifestations may indicate pulmonary embolism. Oxygen should be administered to support gas exchange and tissue oxygenation. The high-Fowler position facilitates oxygenation. Auscultating heart sounds can help detect cardiac compromise. Checking for Homans' sign would not be beneficial at this time. Pain medication should not be provided until a pain assessment is completed.

9 (10)The nurse is caring for a patient undergoing gastric decompression. This patient is at risk for which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

9. Correct answer: B Rationale: Gastric suctioning removes highly acidic gastric secretions, increasing the risk of metabolic alkalosis. Gastric suctioning will not cause metabolic or respiratory acidosis. Respiratory alkalosis is caused by hyperventilation.

9 (37) The nurse caring for a patient with COPD is concerned that the patient is developing respiratory failure. What did the nurse assess as an early sign of possible respiratory failure? Deep coma Decreased urine output Restlessness and tachypnea Hypotension and tachycardia

9. Correct answer: C Rationale: The manifestations of respiratory failure are caused by hypoxemia and hypercapnia, as well as the underlying disease process. Dyspnea and headache are early signs. Hypoxemia causes dyspnea and neurologic symptoms such as restlessness, apprehension, impaired judgment, and motor impairment. Tachycardia and hypertension develop as the cardiac output increases in an effort to bring more oxygen to the tissues. As hypoxemia progresses, dysrhythmias, hypotension, and decreased cardiac output may develop. Increased carbon dioxide levels depress CNS function and cause vasodilation.

A client who has a decreased amount of hydrogen ions and a decreased amount of carbon dioxide in the body will have what response? A. Decreased rate and depth of respirations B. Decreased renal absorption of hydrogen ions C. Increased rate and depth of respirations D. Decreased renal excretion of bicarbonates

A client with bilateral lower lobe pneumonia is diagnosed to have respiratory acidosis based on arterial blood gas results. What is this client's likely cause of respiratory acidosis? A. Under elimination of carbon dioxide from the lungs B. Buffering of extracellular fluid by ammonium C. Over elimination of carbon dioxide from the lungs D. An increased bicarbonate level due to respiratory elimination of acid

A patient in respiratory failure is diagnosed with a flail chest. After the patient is intubated, which treatment does the nurse expect to be implemented? A. PEEP B. SIMV C. BiPap D. PIP

The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggests a tension pneumothorax? A. Tracheal deviation to the unaffected side B. Inspiratory stridor and respiratory distress C. Diminished breath sounds over the affected hemothorax D. Hyperresonant percussion note over the affected side

The nurse suspects a patient has a PE and notifies the physician who orders an arterial blood gas. The physician is en route to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test? A. Spiral CT scan B. Pulmonary angiography C. 12-lead ECG D. Ventilation and perfusion scan

Which test result indicates a patient has clinically active TB? A. Induration of 12 mm PPD and positive sputum B. Positive chest x-ray for TB C. Positive chest x-ray and clinical symptoms D. Sputum tests positive for blood

The nurse assesses a client with uncontrolled type 1 diabetes mellitus for which of the following acid-base imbalances? A. Metabolic alkalosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic acidosis

The nurse is caring for a patient who was recently extubated. What is an expected assessment finding for this patient? A. Stridor B. Dyspnea C. Restlessness D. Hoarseness

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