Med Surg Respiratory NCLEX
A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."
"I am here to receive the yearly pneumonia shot again."
The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? "Handwashing is the best way to prevent transmission." "I should avoid kissing and shaking hands." "It is best to cough and sneeze into my upper sleeve." "The intranasal vaccine can be given to everybody in the family."
"The intranasal vaccine can be given to everybody in the family."
A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You will not spread the disease unless you stop taking your medication." "You will not pose an increased risk of disease to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."
"You will not pose an increased risk of disease to the people you have been living with."
When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? 1. Have trouble falling asleep? 2. Need to urinate during the night? 3. Awaken abruptly during the night? 4. Sleep more than 8 hours per night? 5. Need to sleep with the head elevated?
1. Have trouble falling asleep?; Awaken abruptly during the night?; Need to sleep with the head elevated? a. The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.
After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? 1. Decreased response to hypercapnia 2. Decreased number of functional alveoli 3. Increased calcification of costal cartilage 4. Decreased respiratory defense mechanisms
10. Decreased respiratory defense mechanisms a. These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.
The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? 1. Thoracentesis 2. Bronchoscopy 3. Arterial blood gases 4. Pulmonary function tests
11. Arterial blood gases a. Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? 1. Stridor 2. Rhonchi 3. Coarse crackles 4. Bronchovesicular
12. Coarse crackles a. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.
The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? 1. Cough sound, sputum production, pattern 2. Frequency, a family history, hematemesis 3. Smoking, medications, residence location 4. Weight loss, activity tolerance, orthopnea
13. Cough sound, sputum production, pattern a. The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.
During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? 1. Trachea moved to the left 2. Increased tactile fremitus 3. Decreased tactile fremitus 4. Diminished chest movement
14. Trachea moved to the left a. Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.
The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? 1. Motion 2. Anemia 3. Dark skin color 4. Thick acrylic nails
15. Motion a. Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question
In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? 1. Cyanosis 2. Tripod position 3. Kussmaul respirations 4. Accessory muscle use 5. Increased AP diameter
16. Tripod position; Accessory muscle use a. Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age.
The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? 1. Pain 2. Atelectasis 3. Pneumonia 4. Pleural effusion
2. Atelectasis a. Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.
What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? 1. Chest excursion 2. Spinal curvatures 3. Respiratory pattern 4. Fingernails and their base
2. Fingernails and their base a. Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? 1. 2 minutes 2. 5 minutes 3. 10 minutes 4. 15 minutes
3. 5 minutes a. After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? 1. Thoracentesis 2. Pulmonary angiogram 3. CT scan of the patient's chest 4. Positron emission tomography (PET)
4. Positron emission tomography (PET) a. ET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.
A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? 1. Monitor the patient for laryngeal edema. 2. Assess the patient's level of consciousness. 3. Monitor and manage the patient's level of pain. 4. Assess the patient's heart rate and blood pressure.
5. Monitor the patient for laryngeal edema. a. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? 1. Bronchospasm 2. Pneumothorax 3. Pulmonary edema 4. Respiratory acidosis
6. Pneumothorax a. Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.
The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? 1. Restlessness, tachypnea, tachycardia, and diaphoresis 2. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis 3. Combativeness, retractions with breathing, cyanosis, and decreased output 4. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue
8. Restlessness, tachypnea, tachycardia, and diaphoresis a. With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.
When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? 1. Vomiting 2. Increased urination 3. Decreased heart rate 4. Rapid respiratory rate
9. Rapid respiratory rate a. When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? A. 2 to 3 liters per minute B. 4 to 5 liters per minute C. 6 to 8 liters per minute D. 8 to 10 liters per minute
A In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen.
The home health care nurse is instructing a client diagnosed with chronic obstructive pulmonary disease (COPD) on how to perform breathing techniques that will assist in exhaling carbon dioxide and open the airways. Which statement by the client indicates that teaching has been effective? A. "Pursed-lip breathing helps keep the airways open." B. "Abdominal breathing is the best way to ease COPD." C. "Chest physical therapy helps increase expiratory volume." D. "Intercostal chest expansion can increase inspiratory volume."
A Pursed-lip breathing allows the client to slowly exhale carbon dioxide while keeping the airways open. Abdominal breathing is recommended for clients with dyspnea. Chest physical therapy and intercostal chest expansion are not breathing techniques.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client? A. Noting whether the client has visitors B. Instructing all staff members to not touch the client C. Giving the client a roommate with TB who persistently tries to talk D. Removing the calendar and clock in the room so that the client will not obsess about time
A The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply. A. Maintain the client in a position of comfort. B. Collect sputum specimens at the hour of sleep. C. Offer medication to suppress the cough as needed. D. Administer small, frequent meals with plenty of fluids. E. Have the client cough and breathe deeply 20 minutes after pain medication is given. F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.
A, D, E Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breath will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow
The client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? A. "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." B. "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." C. "Because your tongue may be blocking your throat, and you wake up because you are choking." D. "It isn't really that often. It just feels that way."
A. "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe."
A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion
A. Adventitious breath sounds
When suctioning a client with an endotracheal tube for the first time, what does the nurse do first? A. Briefly explains the procedure B. Preoxygenates the client C. Sets up a sterile field D. Suctions for 10 to 15 seconds
A. Briefly explains the procedure
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection with fever
A. Client with acute allergic reaction
The RN has received report about all of these clients. Which client needs the most immediate assessment? A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D. Client with pleural effusion who has decreased breath sounds at the right base
A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea
A. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93%
The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze
A. Crackles
A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis? A. Encourage client to ask questions and verbalize concerns. B. Leave client alone to deal with his own feelings. C. Medicate client with diazepam (Valium) for anxiety every 8 hours. D. Provide journals about cancer treatment.
A. Encourage client to ask questions and verbalize concerns.
In the older adult client, which respiratory change does not require further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production
A. Increased anteroposterior (AP) diameter
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90%
ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes
ANS: A Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.
ANS: A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.
ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.
After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
ANS: B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure
ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.
ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.
ANS: B Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
ANS: B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).
A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).
ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. "I will use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I should inhale deeply and blow out as hard as I can during the test." d. "My blood pressure and pulse will be checked every 15 minutes after the test."
ANS: C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
ANS: C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.
ANS: C The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases
ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patient's caregiver to be present during the teaching.
ANS: D Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the last year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."
ANS: D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowler's position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table
ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.
ANS: D To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? Arrange for a health care worker to observe the client take the medication. Give the client written instructions about how to take prescribed medications. Have the client repeat medication names and side effects. Instruct the client about the possible consequences of nonadherence.
Arrange for a health care worker to observe the client take the medication.
The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)? A. Chest x-ray B. Sputum culture C. Complete blood cell count D. Computed tomography scan of the chest
B Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB
The nurse is caring for a client with a tentative diagnosis of emphysema. The nurse monitors the client for which sign that distinguishes emphysema from chronic bronchitis? A. Minimal weight loss B. Pronounced dyspnea C. Copious sputum production D. Cough that began before the dyspnea
B Key features of pulmonary emphysema include dyspnea that is often pronounced, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and a milder severity of dyspnea.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status A. Decreased fat intake B. Decreased fluid intake C. Sleeping soundly during the night D. Anxiety about the upcoming pulmonologist visit
B The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. A. "All used dishes should be sterilized." B. "My close contacts should be tested for TB." C. "Soiled tissues should be disposed of properly." D. "House isolation is required for at least 8 months." E. "The mouth should always be covered when coughing."
B, C, E Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.
Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal
B. Bronchial breath sounds heard at the bases
In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO of 22. What action does the nurse need to take first? A. Call the physician. B. Encourage the client to slow his breathing rate. C. Nothing. These results are within the normal range. D. Provide oxygen support.
B. Encourage the client to slow his breathing rate.
The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement NPO (nothing by mouth) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy
B. Implement NPO (nothing by mouth) status.
People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply. A. Bakers B. Coal miners C. Electricians D. Furniture refinishers E. Plumbers F. Potters
Bakers Coal miners Furniture refinishers Potters
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic? A. "Well, I can see you never got to the stop smoking clinic." B. "Now that your secret is out, may we decide what you are going to do?" C. "Did you explore the stop smoking program at the senior citizens center?" D. "I wonder if you realize that by smoking you are slowly killing yourself."
C Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding? A. Loud wheezing B. Wheezing on expiration C. Noticeably diminished breath sounds D. Increased displays of emotional apprehension
C Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced
The nurse is planning care for a client newly diagnosed with active tuberculosis (TB). In addressing the psychosocial needs of the client, what would be a primary goal? A. The client will list all medications and explain when to use each. B. The client will verbalize ways to lessen the risk of transmitting the infection. C. The client will share with the nurse or other support person fears concerning the disease. D. The client will ask questions and actively seek information about the disease and its care.
C Providing psychosocial support means helping the client deal with her or his feelings. Goals for the client will focus on open expression of feelings and fears and the development of coping skills in dealing with the client's illness and care. Options 1, 2, and 4 identify important components of care but are unrelated to providing psychosocial support.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn? A. Holding a warm compress over the puncture site for 5 minutes B. Encouraging the client to open and close the hand rapidly for 2 minutes C. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
C. Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase 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 home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take? A. Determine the need to increase the oxygen. B. Reassure the client that there is no need to worry. C. Conduct further assessment of the client's respiratory status. D. Call emergency services to take the client to the emergency department.
C. With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is "no need to worry" is inappropriate. Calling emergency services is a premature action
You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection C. Administer oxygen. D. Notify the physician immediately.
C. Administer oxygen.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy
C. Computed tomography (CT) scan
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)? A. Administer bronchodilator medication on call. B. Encourage clear fluid intake 12 hours before the procedure. C. Ensure no smoking 6 hours before the test. D. Provide supplemental oxygen as testing begins.
C. Ensure no smoking 6 hours before the test.
A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink frothy sputum D. Yellow sputum
C. Pink frothy sputum
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism
C. Pneumothorax
An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? Check the resident's oxygen saturation. Do a complete neurologic assessment. Administer the prescribed PRN lorazepam. Perform a mini mental status exam.
Check the resident's oxygen saturation.
The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? Client with bacterial pneumonia and a cough productive of green sputum Client with neutropenia and pneumonia caused by Candida albicans Client with possible H5N1 influenza who currently has epistaxis Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)
Client with possible H5N1 influenza who currently has epistaxis
The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? Client with group A beta-hemolytic streptococcal pharyngitis who has stridor Client with pulmonary tuberculosis who is receiving multiple medications Client with sinusitis who has just arrived after having endoscopic sinus surgery Client with tonsillitis who has a thick-sounding voice and difficulty swallowing
Client with pulmonary tuberculosis who is receiving multiple medications
The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? Bradycardia Confusion Eupnea Pale skin
Confusion
The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? Completing the antibiotic medication regimen Taking pain medications every 4 to 6 hours Contacting the health care provider (HCP) if drooling occurs Using warm saline gargles and irrigations
Contacting the health care provider (HCP) if drooling occurs
The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern? A. Lack of knowledge about COPD B. Difficulty coping related with a situational crisis C. Negative self-image because of neurological deficit D. Restricted verbal communication because of a physical barrier
D A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options. (Focus on the subject, that the client is experiencing extreme dyspnea during an interview. Based on this, option 4 is the only option that addresses this subject.)
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? A. Cyanosis B. Hyperinflated chest C. Coarse crackles bilaterally D. Rapid, shallow respirations
D COPD is also known as chronic obstructive lung disease and chronic airflow limitation. It is a disease state characterized by airflow obstruction. An increase in the rate of respirations and a decrease in the depth of respirations indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present with some, but not all, clients. A hyperinflated chest (barrel-chest) and hypertrophy of the accessory muscles of the upper chest and neck may normally be found in clients with severe COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.
A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse should most importantly plan teaching strategies that are designed to do what? A. Promote membership in support groups. B. Encourage the client to become a more active person. C. Identify irritants in the home that interfere with breathing. D. Improve oxygenation and minimize carbon dioxide retention
D Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position? A. Sit bolt upright in bed with the arms crossed over the chest. B. Lie on the side with the head of the bed at a 45-degree angle. C. Sit in a reclining chair tilted slightly back with the feet elevated. D. Sit on the edge of the bed with the arms leaning on an overbed table.
D Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45 degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.
A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis? A. High fever and chest pain B. Increased appetite, dyspnea, and chills C. Weight gain, insomnia, and night sweats D. Low-grade fever, fatigue, and productive cough
D The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.
The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition? A. "I will rest a few minutes before I eat." B. "I will not eat as much cabbage as I once did." C."I will certainly try to drink 3 L of fluid every day." D. "It's best to eat three large meals a day, so that I will get all my nutrients."
D. Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client diagnosed with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gas-forming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps liquefy pulmonary secretions.
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action? A. Breathes in and then holds the breath for 30 seconds B. Loosens the abdominal muscles while breathing out C. Inhales with puckered lips and exhales with the mouth open wide D. Breathes so that expiration is two to three times as long as inspiration
D. COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.
The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test C. Client with sore throat and fever of 39° C oral D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? A. Client with allergic rhinitis scheduled for skin testing B. Client with emphysema who needs teaching about pulmonary function testing C. Client with pancreatitis who needs a preoperative chest x-ray D. Client with pleural effusion who has had 1200 mL removed by thoracentesis
D. Client with pleural effusion who has had 1200 mL removed by thoracentesis
The nurse answers the client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? A. Attempts to remove the obstruction B. Calls the Rapid Response Team to intubate immediately C. Calls the Rapid Response Team to perform an emergency cricothyroidotomy D. Determines the cause of obstruction
D. Determines the cause of obstruction
A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU? A. Assess breath sounds. B. Check gag reflex. C. Determine level of consciousness. D. Monitor blood pressure and pulse.
D. Monitor blood pressure and pulse.
An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN? A. Administer the purified protein derivative (PPD) for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.
D. Plan client and family teaching regarding upcoming pulmonary function testing.
Which clinical manifestation requires immediate action by the nurse for the client with laryngeal trauma? A. Aphonia B. Hemoptysis C. Hoarseness D. Tachypnea
D. Tachypnea
The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? Avoiding public gatherings at all times Early recognition and quarantine of affected persons Vaccinating community members with pneumonia vaccine Widespread distribution of antiviral drugs
Early recognition and quarantine of affected persons
The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? Hemoglobin A1C Culture and Sensitivity report Evaluating pneumonia vaccine status Ensuring education to cough into the upper sleeve
Evaluating pneumonia vaccine status
The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? Ensures that the client is wearing a mask Informs the visitor that the client cannot receive visitors at this time Provides a particulate air respirator to the visitor Provides the visitor with a surgical mask
Provides the visitor with a surgical mask
The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Severe coughing spasms
Severe coughing spasms
An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? Ensure that ED staff members receive oseltamivir (Tamiflu). Administer IM influenza vaccination. Place the client in a negative air pressure room. Start an IV line and begin intravenous hydration.
Start an IV line and begin intravenous hydration.
The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. Take a supplement containing B vitamins. Avoid alcohol containing beverages. Have kidney function tests monthly. Report changes in vision to the health care provider. Notify the health care provider for red-orange urine.
Take a supplement containing B vitamins. Avoid alcohol containing beverages. Report changes in vision to the health care provider.
The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. The client states she will complete the entire dose of antibiotic prescribed. The client reports fatigue and malaise. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). The client has been afebrile for 48 hours.
The client has been afebrile for 48 hours.
A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Combination medication therapy is effective in eliminating cough and fever. Combination medication therapy improves adherence. Combination medication therapy has fewer side effects, particularly liver damage. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.
The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.
The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. Breast cancer survivors Those in the local prison Homeless adults Recent immigrants to the United States Those who have received bacille Calmette-Guérin (BCG) vaccine
Those in the local prison Homeless adults Recent immigrants to the United States