Module 9 Study Quiz

After the nurse has provided teaching to a community group about how to prevent head and neck cancer, which statement by a group member indicates that more teaching is needed? A. "Chewing tobacco is better than smoking." B. "If you smoke, stop. If you don't, don't start." C. "Alcohol in moderation, but no alcohol is best." D. "Brush three times daily and floss at least once."

A. "Chewing tobacco is better than smoking." Rationale Both chewing and smoking tobacco cause head and neck cancer; this statement indicates the need for clarification by the nurse. The statement indicating that smokers should stop and others should not start smoking is accurate and shows understanding of the teaching. Since alcohol use increases risk for head and neck cancer, the statement that alcohol should be used in moderation or not at all shows that the teaching has been effective. The statement that good oral hygiene will decrease the risk for head and neck cancer is accurate and shows effective teaching.

While obtaining a health history for a patient with suspected tuberculosis (TB), the nurse expects which early signs or symptoms of the disease? Select all that apply. A. Anorexia B. Fatigue C. Dizziness D. Night sweats E. Chest tightness

A. Anorexia B. Fatigue D. Night sweats Rationale Symptoms of pulmonary TB usually do not develop until 2 to 3 weeks after infection or reactivation. The primary manifestation is an initial dry cough that often becomes productive with mucoid or mucopurulent sputum. Active TB disease may initially present with constitutional symptoms (e.g., fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, night sweats). Dyspnea is a late symptom that may signify considerable pulmonary disease or a pleural effusion. Hemoptysis, which occurs in less than 10% of patients with TB, is also a late sign. Dizziness and chest tightness are not symptoms associated with TB.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after surgery. Which symptoms would the nurse assess if this patient develops a pulmonary embolism (PE)? Select all that apply A. Dyspnea B. Tachypnea C. Tachycardia D. Coarse crackles E. Noisy respirations

A. Dyspnea B. Tachypnea C. Tachycardia Rationale PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Coarse crackles and noisy respirations may happen if thick secretions are present in the airway.

A healthy 70-year-old patient asks the nurse, "Which types of vaccinations are recommended for people my age?" Which vaccinations should the nurse suggest? Select all that apply. A. Influenza B. Pneumonia C. Meningococcal D. Hemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)

A. Influenza B. Pneumonia Rationale Older people are also more susceptible to infections (e.g., influenza, pneumonia) from pathogens that they were more immunocompetent against earlier in life. Bacterial pneumonia is the leading cause of death from infections in older adults. The patient should receive the shingles (herpes zoster), Pneumovax, and influenza vaccine. Meningococcal, Hib, and MMR vaccinations do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 generally are considered immune to measles and mumps. Hib vaccination is considered only for adults with selected conditions (e.g., sickle cell disease, leukemia, human immunodeficiency virus [HIV] infection, or for those who have anatomic or functional asplenia) if they have not been vaccinated previously.

Which patient conditions may cause recurrent episodes of epistaxis? Select all that apply. A. Nasal tumors B. Facial trauma C. High humidity D. Fever of unknown origin E. Foreign bodies inserted into the nares F. Overuse of nasal decongestant sprays

A. Nasal tumors B. Facial trauma E. Foreign bodies inserted into the nares F. Overuse of nasal decongestant sprays Rationale Nasal tumors, some anatomic malformations of the nose, foreign bodies inserted into the nose, and facial trauma can result in epistaxis. Using nasal decongestant sprays too frequently can also cause nose bleeds. Fever of unknown origin does not cause nasal bleeding. Low humidity, not high humidity, also can increase one's risk of epistaxis.

After noting that a patient's tracheostomy tube is dislodged, which action will the nurse take first? A. Observe for increased respiratory effort. B. Put the patient in the semi-Fowler's position. C. Ventilate the patient with a bag-valve-mask. D. Hold the stoma open with a sterile hemostat.

A. Observe for increased respiratory effort. Rationale The nurse will initially observe for signs of respiratory distress, such as increased respiratory rate, decreased oxygen saturation, or increased respiratory effort. If needed, the nurse may place the patient in the semi-Fowler's position, but this may not be necessary unless the patient is in respiratory distress. Manual ventilation may be needed if the patient is in respiratory distress, but this will not be necessary if the patient is breathing comfortably. The nurse may need to hold the stoma open with a sterile hemostat, but this will only be needed if assessments indicate respiratory distress.

Which action by the student nurse while performing chest percussion indicates the need for further teaching? A. Percussing with both hands simultaneously B. Placing a thin towel over the area being percussed C. Positioning the fingers and thumb in cup-like position D. Creating an air pocket between the patient's chest and the hand

A. Percussing with both hands simultaneously Rationale The hands are used in a rhythmic alternating fashion during chest percussion, not simultaneously. Placing a thin towel or cloth over the area of percussion will be more comfortable for the patient. During percussion, the thumb and fingers are cupped to create an air pocket between the hand and the patient's chest. The cup-like position of the hand on the patient's chest will create an air pocket, which will help loosen thick mucus during percussion.

Which process is stimulated by hypoxia? A. Hemolysis B. Erythropoiesis C. Hematopoiesis D. Thrombocytosis

B. Erythropoiesis Rationale Erythropoiesis is the production of red blood cells. A patient with a low red blood cell count will have low levels of oxygen, resulting in hypoxia. Therefore erythropoiesis is stimulated to increase the available oxygen. Hemolysis is degradation of red blood cells, which occurs due to bacterial infection or autoimmune disorders. Hematopoiesis is the formation of blood cell components and is not associated with hypoxia. Thrombocytosis is an increase in the platelet count, which is seen in response to bleeding.

Which nursing interventions are appropriate to help control bleeding for a patient with epistaxis? Select all that apply. A. Reassure the patient and keep him or her quiet. B. Administer saline nasal sprays to relieve congestion. C. Place the patient in a sitting position with the head tilted forward. D. Ask the patient to blow the nose to remove all the collected blood. E. Apply direct pressure by pinching the entire soft lower portion of the nose.

A. Reassure the patient and keep him or her quiet. C. Place the patient in a sitting position with the head tilted forward. E. Apply direct pressure by pinching the entire soft lower portion of the nose. Rationale To control epistaxis, the patient should be reassured and kept quiet. In epistaxis, approximately 90% of nosebleeds occur in the anterior portion of the nasal cavity and can be easily visualized. The patient should be made to sit, leaning slightly forward, with the head tilted forward. Direct pressure should be applied by pinching the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes. If bleeding does not stop within 15 to 20 minutes, consult the health care provider. Saline nasal sprays should not be used because these can dislodge the clot that is needed to stop the bleeding. Nose blowing will also remove the clot, which could lead to further bleeding.

Which cognitive changes are characteristic of a patient experiencing hypoxia? Select all that apply. A. Restlessness B. Apprehension C. Improved mood D. Memory changes E. Pursed lip breathing F. Improved concentration

A. Restlessness B. Apprehension D. Memory changes Rationale A patient who is hypoxic may have neurologic symptoms that include apprehension, restlessness, irritability, and memory changes. Mood will worsen rather than improve. Pursed lip breathing is not a cognitive symptom. Concentration will be poor with hypoxia rather than improved.

Which instruction will the nurse include when teaching a patient to use a hand-held nebulizer? A. Sit in an upright position during the treatment. B. Take short, shallow breaths while inhaling the medication. C. Rinse the nebulizer equipment under running water once a week. D. During the treatment, breathe in and hold the breath for 10 seconds.

A. Sit in an upright position during the treatment. Rationale The patient is placed in an upright position that allows for most efficient breathing to ensure adequate penetration and deposition of the aerosolized medication. Deep and slow breaths help ensure deposition of the medication throughout the lung. To reduce bacterial growth, the patient is asked to wash the nebulizer equipment daily in soap and water, rinse it with water, and soak it for 20 to 30 minutes in a 1:1 white vinegar-water solution, followed by a water rinse and air drying. The patient is taught to hold the breath for two to three seconds during nebulizer treatments.

An older adult may present with which respiratory assessment findings? Select all that apply. A. Thicker mucus B. Normal partial pressure of oxygen (PaO 2) and arterial oxygen saturation (SaO 2) C. Decreased chest wall movement D. Increased breath sounds in the lung apices E. Diminished breath sounds, particularly at lung bases

A. Thicker mucus C. Decreased chest wall movement E. Diminished breath sounds, particularly at lung bases Rationale Changes in the respiratory system in the older adult include thickened mucus, decreased chest wall movement, and diminished breath sounds, especially at the lung bases. The PaO 2 and SaO 2 levels are decreased.

Which patient assessment data indicate increased risk for head and neck cancer? Select all that apply. A. Tobacco use B. Female gender C. Poor oral hygiene D. Age 40 to 50 years E. Excessive alcohol consumption

A. Tobacco use C. Poor oral hygiene E. Excessive alcohol consumption Rationale Risk factors for head and neck cancer include tobacco use (the cause of 85% of the cases), excessive alcohol consumption (another major risk factor), poor oral hygiene, and male gender. Head and neck cancer occurs more frequently in men. Increased risk for head and neck cancer occurs after age 50.

Which assessment is most important to obtain for a patient with a radical neck dissection who is refusing any enteral feeding? A. Weight B. Pulse rate C. BP D. Respiratory rate

A. Weight Rationale Because this patient is at risk for inadequate nutrition, it will be important to monitor weight. Pulse rate will be assessed, but refusal of enteral feedings will not impact heart rate. BP will be monitored on all patients, but poor nutrition will not directly impact BP. Respiratory rate will be assessed, but the patient's refusal of enteral feeding will not directly affect respiratory rate.

The nurse is preparing a community education session related to the increased incidence of tuberculosis (TB) among the city's residents. The nurse identifies that which populations are most at risk for the disease? Select all that apply. A. Workers at a nearby prison B. Elderly adults who attend activities at a local senior center C. Adults who are homeless D. Children who attend a preschool three days a week E. Middle-aged adults who live in the inner-city neighborhood F. Immigrants from an underdeveloped country who live in temporary housing in the city

A. Workers at a nearby prison C. Adults who are homeless E. Middle-aged adults who live in the inner-city neighborhood F. Immigrants from an underdeveloped country who live in temporary housing in the city Rationale TB occurs disproportionately in the poor, underserved, and minorities. People most at risk include the homeless, residents of inner-city neighborhoods, foreign-born people, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV-injecting drug users, those with overcrowded living conditions and less-than-optimal sanitation, and those with poor access to health care. Immunosuppression from any cause (e.g., HIV infection, cancer, long-term corticosteroid use) increases the risk for active TB infection. Elderly adults who attend activities at a local senior center and children who attend a preschool three days a week do not have an increased risk of the disease.

A patient started treatment for sputum smear-positive tuberculosis (TB) 1 week prior to the home health nurse's visit. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Select all that apply. A. Increase the intake of foods that are high in vitamin C. B. Ensure that the home is well ventilated. C. Sleep alone. D. Spend as much time as possible outdoors. E. Minimize time in congregate settings. F. Minimize time on public transportation.

B. Ensure that the home is well ventilated. C. Sleep alone. D. Spend as much time as possible outdoors. E. Minimize time in congregate settings. F. Minimize time on public transportation. Rationale Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time spent in congregate settings or on public transportation. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others.

Which questions will the nurse ask when assessing the effects of a patient's respiratory diagnosis on activity-exercise patterns? Select all that apply. A. "Are you ever incontinent of urine when you cough?" B. "Do you have trouble walking due to shortness of breath?" C. "Does your spouse wake you in the middle of the night due to snoring?" D. "How many flights of stairs can you walk up before you are short of breath?" E. "Do you ever feel full very quickly when eating due to your breathing issues?"

B. "Do you have trouble walking due to shortness of breath?" D. How many flights of stairs can you walk up before you are short of breath?" Rationale When assessing the effects that a respiratory diagnosis has on activity-exercise patterns, the nurse will ask the patient if walking is impacted by dyspnea and how many flights of steps the patient can walk up before dyspnea occurs. Asking the patient about urinary incontinence with coughing is appropriate when assessing elimination patterns. Asking the patient if the spouse wakes him or her up in the middle of the night due to snoring will assess sleep-rest patterns. Asking the patient if he or she feels full quickly when eating assesses the patient's nutritional-metabolic pattern.

The nurse provides education for a patient about reducing the risk of atelectasis while undergoing chest tube drainage. Which statements made by the patient indicate effective learning? Select all that apply. A. "I should change positions slowly." B. "I should cough at regular intervals." C. "I should use my incentive spirometer." D. "I should reduce the intake of protein in my diet." E. "I should perform range-of-motion exercises."

B. "I should cough at regular intervals." C. "I should use my incentive spirometer." E. "I should perform range-of-motion exercises." Rationale Nursing care and patient teaching can minimize the risk of atelectasis. The nurse should encourage coughing, deep breathing, incentive spirometer use, and range-of-motion exercises. The nurse instructs the patient to change position slowly if he or she has hypotension. Protein is essential and does not reduce the risk of atelectasis.

Which actions will the nurse take when a patient first resumes eating after partial laryngectomy for laryngeal cancer? Select all that apply. A. Offer water at frequent intervals. B. Add gravy to meats, rice, and potatoes. C. Encourage oral nutritional supplements. D. Have oral suction available at the bedside. E. Lower the head of the bed while the patient is eating.

B. Add gravy to meats, rice, and potatoes. C. Encourage oral nutritional supplements. D. Have oral suction available at the bedside. Rationale Since patients with head and neck cancer and radical neck surgery frequently are poorly nourished before surgery and will have difficulty swallowing after surgery, the nurse will add gravy to foods to increase calories and to moisten foods for easier swallowing. Oral nutritional supplements are high in calories and nutrition to help with wound healing. Oral suction should be available because of the risk of aspiration after laryngeal surgery. Thin liquids such as water are more difficult to swallow and increase the risk for aspiration in the immediate postoperative period. To avoid aspiration risk, patients will be placed in the high Fowler's position or sit in a chair for meals.

Which intervention does the nurse perform 30 minutes before removing a chest tube from a patient? A. Prepare a sterile field that includes a petroleum dressing. B. Administer a pain medication to the patient. C. Clamp the chest tube. D. Ensure that the patient has nothing NPO.

B. Administer a pain medication to the patient. Rationale While removing the chest tube, the patient may have pain; therefore the nurse administers pain medication 30 to 60 minutes before the procedure. A sterile field should be prepared immediately before a sterile procedure. There is insufficient information to determine the status of the chest tube. It is highly unlikely that the chest tube is to be clamped because this increases pressure within the pleural space. The patient does not need to be NPO before the procedure.

Which assessment has the highest priority when the nurse is caring for a patient who is three hours postoperative laryngectomy? A. Patient pain B. Airway patency C. Incisional drainage D. BP and heart rate

B. Airway patency Rationale Because postoperative swelling may compress the trachea, assessing for airway patency has the highest priority after laryngectomy. Assessment and management of postoperative pain are also important but not as high of a priority as maintaining airway patency. There are large blood vessels in the neck, and frequent assessment of incisional drainage is essential, but changes in respiratory status have a higher priority. BP and heart rate will be frequently monitored but are not as important as assessment for respiratory compromise.

A patient presents with a lung abscess. The nurse expects that which intervention will be included in the patient's treatment plan? A. Postural drainage B. Antibiotic therapy C. Chest physiotherapy D. Fluid restriction

B. Antibiotic therapy Rationale Because there are mixed bacteria in a lung abscess, starting a broad-spectrum antibiotic is the appropriate treatment option. Postural drainage and chest physiotherapy are not recommended because they may cause spillage of the infection to other bronchi and spread the infection. Reducing fluid intake is not advisable; instead, adequate fluid intake is recommended.

The nurse must perform which intervention for a patient receiving a pulmonary function test? A. Schedule the test to occur after a meal. B. Assess the patient for respiratory distress. C. Provide a rest period before the procedure. D. Give a bronchodilator an hour before the test.

B. Assess the patient for respiratory distress. Rationale Continually assessing a patient for respiratory distress is the most important nursing intervention to perform for a patient receiving a pulmonary function test. The nurse should avoid scheduling the procedure after a meal and giving a bronchodilator an hour before the test. The nurse should also encourage rest after the test and not necessarily before it.

A patient recovering from thoracic surgery reports to the nurse feeling short of breath. Upon auscultation, which finding would confirm the nurse's suspicion of atelectasis? A. Loud squeaking sounds during inspiration B. Diminished breath sounds with dullness to percussion C. Crackling, wheezing, and accentuation of pulmonic breath sound D. Increased pulmonic heart sound and right-sided fourth heart sound

B. Diminished breath sounds with dullness to percussion Rationale Atelectasis is a condition where the lungs are collapsed as a result of closure of the pores of Kohn and airless alveoli. After thoracic surgery, a patient should take complete bed rest. The patient with atelectasis has diminished sounds or the absence of breath sounds, and there is a dullness upon percussion on the affected area. Loud breath sounds similar to the squeaking of a door can be heard in the patient with pleurisy during inspiration. Crackling, wheezing, and accentuation of pulmonic breath sound are heard in the patient with pulmonary embolism. The patient with secondary pulmonary arterial hypertension may have an increased pulmonic heart sound and right-sided fourth heart sound.

The nurse is caring for a patient with pneumonia and expects which interventions to be included in the treatment plan? Select all that apply. A. Reposition the patient at least once per hour. B. Monitor the patient's response to treatment. C. Provide adequate hydration by encouraging fluid intake. D. Administer analgesics on an around-the-clock basis for 24 hours. E. Provide postural drainage and chest percussion.

B. Monitor the patient's response to treatment. C. Provide adequate hydration by encouraging fluid intake. E. Provide postural drainage and chest percussion. Rationale Essential nursing care for patients with pneumonia includes monitoring physical assessment parameters, providing treatment, and monitoring the patient's response to treatment. Prompt collection of specimens and initiation of antibiotics are critical. O 2 therapy, hydration, nutritional support, breathing exercises, early ambulation, and therapeutic positioning are part of nursing care. Working with respiratory therapy to monitor the patient's condition and with physical therapy for postural drainage and chest percussion is essential. The nurse should turn and reposition patients at least every two hours to promote adequate lung expansion and the mobilization of secretions. There is not enough information to support the use of around-the-clock analgesic administration.

Which medication or therapy would the nurse administer to a patient who is having acute tachypnea, dyspnea, tachycardia, and decreased oxygen saturation following a major orthopedic procedure? Select all that apply A. Lidocaine B. Oxygen therapy C. Bronchodilators D. Anticoagulant therapy E. Skeletal muscle relaxant

B. Oxygen therapy D. Anticoagulant therapy Rationale Dyspnea associated with tachypnea, tachycardia, hypotension, and reduced oxygen saturation following a major orthopedic surgery indicates a pulmonary embolism. A pulmonary embolism could be a result of dislodgment of thrombus from the peripheral veins. Oxygen therapy helps improve oxygen saturation. Anticoagulant therapy prevents the blood from clotting further. Lidocaine, a local anesthetic, helps relieve laryngospasm but may not relieve pulmonary embolism. Bronchodilators help to dilate the airways but have no effect on embolism because it is associated with the compromised pulmonary circulation. IV skeletal muscle relaxants help relax the muscles to relieve laryngeal spasm but do not help relieve pulmonary embolism.

Following a bedside thoracentesis, the nurse will continue to assess the patient for signs and symptoms of which condition? A. Bronchospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis

B. Pneumothorax Rationale 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.

Which nursing action is the priority for a patient admitted to the hospital with cyanosis, dyspnea, and tachycardia and who is sweating and has cold, clammy skin? A. Start a glucose drip. B. Start oxygen therapy. C. Administer IV mannitol. D. Administer antihistamines.

B. Start oxygen therapy. Rationale The patient is showing signs and symptoms of inadequate oxygenation. Therefore the first thing that the nurse must do is start oxygen therapy immediately. All the other actions are secondary and performed only if required. Glucose drips are given to increase the intravascular volume. Mannitol should be administered if the intracranial pressure (ICP) is raised. Antihistamines are administered if there is an allergy.

A positron emission tomography (PET) scan is used for which respiratory assessment? A. To assess ventilation and perfusion of lungs B. To distinguish benign and malignant nodules C. To visualize pulmonary vasculature and locate obstruction D. To diagnose lesions difficult to see by CT scan

B. To distinguish benign and malignant nodules Rationale PET scans use an IV radioactive glucose preparation to demonstrate increased uptake of glucose in malignant lung cells. A ventilation/perfusion (VQ) scan is used to assess ventilation and perfusion of lungs. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction. An MRI test is used to diagnose lesions difficult to assess by CT scan.

Which chest palpation finding is a medical emergency? A. Increased tactile fremitus B. Trachea moved to the left C. Decreased tactile fremitus D. Diminished chest movement

B. Trachea moved to the left Rationale 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.

When caring for patients, which action does the nurse take to prevent health care-associated infections (HAIs)? A. Avoid direct contact with patients. B. Wash hands before and after patient care. C. Wear sterile gloves when working with patients. D. Treat all patients as if they are infected with mycobacterium tuberculosis.

B. Wash hands before and after patient care. Rationale Standard precautions should be instituted for all patients in the health care setting. These precautions include washing hands with soap and water or an alcohol-based rub before and after patient care. Wearing sterile gloves when working with patients is not always appropriate. Direct contact with patients is an aspect needed to deliver quality patient care. Precautions for care of patients with mycobacterium tuberculosis infection requires airborne precautions. Airborne precautions are instituted for patients with highly communicable respiratory diseases spread through the air over short distances.

Which postoperative patient is at the greatest risk for development of atelectasis? A. A patient after a hypoxic episode during an acute asthma attack B. An older adult patient who has undergone cardiothoracic surgery C. A patient not adherent with the pulmonary regimen after surgery D. A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

C. A patient not adherent with the pulmonary regimen after surgery Rationale Atelectasis is a common postoperative complication that is prevented by a pulmonary regimen of interventions such as deep breathing, coughing, turning, and using an incentive spirometer. Patients who have received general anesthesia and are noncompliant with a pulmonary regimen are at highest risk for atelectasis. Patients who have experienced a hypoxic episode during an acute asthma attack or with an acute exacerbation of chronic obstructive pulmonary disease are at lower risk for atelectasis than are postoperative patients. Postoperative older adults who have had cardiothoracic surgery are also at risk for atelectasis if they do not adhere to a pulmonary regimen.

A patient is admitted to a health care facility with a respiratory infection suspected to be caused by tuberculosis (TB). Which infection precaution does the nurse initiate? A. Contact precautions B. Droplet precautions until the presence of TB is confirmed C. Airborne precautions D. Standard precautions only, until a diagnosis is made

C. Airborne precautions Rationale Because TB is a respiratory infection that can easily be spread through the air and via respiratory secretions, airborne precautions are required until the presence or absence of infection is confirmed. Airborne precautions are used for infections spread in small particles in the air, such as chickenpox (varicella), measles, and TB. Contact precautions are used for infections spread by skin-to-skin contact or contact with other surfaces, such as C. difficile, methicillin-resistant S. aureus (MRSA), and vancomycin-resistant enterococci (VRE). Droplet precautions are used for infections spread in large droplets by coughing, talking, or sneezing, such as influenza and bacterial meningitis. Standard precautions are instituted for all patients to prevent the spread of health care-associated infections; this patient requires additional transmission-based precautions.

The registered nurse mentors a new graduate nurse. The new graduate provides care for a patient who has a chest tube in place after a partial lobectomy. Which action by the new graduate requires the mentor to intervene? A. Positions the patient in the semi-Fowler's position B. Encourages the patient to increase fluid intake C. Clamps the chest tube while the patient is ambulating D. Administers the patient's prescribed narcotic analgesic before activity

C. Clamps the chest tube while the patient is ambulating Rationale Clamping of chest tubes during transport or when the tube is accidentally disconnected is no longer advocated. The danger of rapid accumulation of air in the pleural space, causing a tension pneumothorax, is far greater than that of a small amount of atmospheric air that enters the pleural space. Patients with chest tubes are usually placed in the semi-Fowler's position for the sake of comfort and ease of breathing. Fluid intake is not a major concern in light of the information provided. Administering the patient's prescribed narcotic analgesic before activity is an expected standard of care for this patient.

A patient with a spontaneous pneumothorax has a chest tube in place that is attached to a chest drainage unit (CDU) with no suction being applied. The water level in the water-seal chamber is fluctuating. Which action does the nurse take? A. Notify the health care provider immediately. B. Decrease the amount of water in the water-seal chamber. C. Continue to monitor and document the respiratory status. D. Clamp the chest tube as close as possible to the insertion site.

C. Continue to monitor and document the respiratory status. Rationale In a CDU that is not attached to suction, the fluid in the water-seal chamber rises when the patient inhales and falls when the patient exhales. This is a normal finding. The absence of fluctuations may indicate an obstruction in the system. The nurse must continually check the function of the CDU and assess respiratory status at least every four hours. There is no need to notify the health care provider or decrease the amount of water in the water-seal chamber because the chest tube system is functioning normally. The chest tube should not be clamped; doing so could cause a tension pneumothorax.

Which side effect of radiation therapy will the nurse anticipate for a patient who has laryngeal cancer? A. Nausea B. Diarrhea C. Dry mouth D. Blistering burns

C. Dry mouth Rationale Dry mouth or xerostomia is a frequent and annoying side effect for patients receiving radiation therapy for head and neck cancer. Nausea might occur with chemotherapy but is not expected with head and neck radiation. Diarrhea may occur with chemotherapy or with radiation of the lower gastrointestinal tract but is not expected with head and neck radiation. Skin over the irradiated area may become red and sensitive, but blistering burns are not expected with radiation treatment for head and neck cancer.

Which action by the student nurse for a patient who has had epistaxis for 15 minutes after being admitted to the hospital indicates the need for further teaching? A. Applying anterior packing B. Elevating the head of the patient C. Laying the patient in a supine position D. Pinching the lower soft part of the nose

C. Laying the patient in a supine position Rationale While providing first aid measurement to a patient with epistaxis, the nurse should place the patient in a sitting position because it will reduce the blood pressure in the veins of the nose and reduce bleeding, thereby preventing the patient from swallowing blood. Anterior packing is used to prevent the flow of blood when the bleeding does not stop after 15 minutes. The nurse should elevate the head of the patient to prevent the flow of blood, and for the clear visualization of the nostrils. The nurse should pinch the lower soft part of the nose because this intervention helps to send the pressure back to the bleeding point in the nasal septum and stops the flow of blood.

Which action will the nurse include in the plan of care for a patient who had modified radical neck surgery for laryngeal cancer? A. Use of a shoulder immobilizer B. Assistance with putting on neck brace C. Neck and shoulder range of motion exercises D. Instructions to minimize turning the head from side to side

C. Neck and shoulder range of motion exercises Rationale Since nerve and muscle tissue is removed in radical neck surgery, the patient will need to begin physical therapy to prevent frozen shoulder and decreased neck range of motion after surgery. A shoulder immobilizer would limit shoulder movement and increase risk for frozen shoulder. A neck brace would decrease the patient's ability to turn the head and lead to decreased neck range of motion. Instructing the patient to minimize turning the head would limit patient recovery of neck range of motion.

Which assessments are the highest priority to obtain when caring for a patient who has a tracheostomy? A. Total protein level and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

C. Respiratory rate and oxygen saturation Rationale The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. The other assessments are also important but are not as high in priority as respiratory rate and oxygen saturation. Although total protein level and weight reflect nutritional status and will be monitored to ensure optimal nutrition, changes are not immediately life-threatening. An assessment of speech and swallowing is needed for the evaluation of communication and aspiration risk, but changes in these will not immediately affect oxygenation. Pain and mobility assessments are necessary but will not immediately threaten respiratory status.

One week after a thoracotomy, a patient with a chest tube attached to a chest drainage unit (CDU) experiences an air leak in the system. Which assessment finding warrants follow-up nursing interventions? A. The water-seal chamber contains 5 cm of sterile water. B. There is no new drainage in the collection chamber. C. The dressing over the chest tube insertion site is loose. D. The patient has a small pneumothorax.

C. The dressing over the chest tube insertion site is loose. Rationale If the dressing at the chest tube insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak; it should not be drained from the CDU. No new drainage does not indicate an air leak but may indicate that the chest tube is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

Which purpose would the nurse explain to the patient as the primary reason for continuous positive airway pressure (CPAP) therapy? A. To promote deep sleep B. To provide oxygenation C. To prevent airway collapse D. To assure rapid eye movement (REM) sleep

C. To prevent airway collapse Rationale The primary goal of CPAP therapy is to prevent airway collapse, which is the structural issue behind sleep apnea. Sleep apnea is primarily a ventilation problem, not an oxygenation problem. Promoting deep sleep and REM sleep are secondary goals of CPAP therapy that will result from improved airway patency.

The nurse collaborates with the health care team to arrange for home care for a patient with pulmonary tuberculosis (TB). Of the family members who live with the patient, which one is at the greatest risk for contracting the disease? A. A 15-year-old child who has a history of asthma B. A 25-year-old daughter who is seven months pregnant C. A 50-year-old spouse who is 20 pounds overweight D. A 75-year-old parent who takes prednisone

D. A 75-year-old parent who takes prednisone Rationale The patient's parent would be most susceptible to TB as a consequence of advanced age and immunosuppression by the corticosteroid. A history of asthma, obesity, and pregnancy do not increase the risk of contracting TB.

A patient presents with a pneumonia score of 5 on the Expanded CURB-65 scale. Which action does the nurse take? A. Advise no treatment. B. Advise treating in an outpatient setting. C. Consider admission to an inpatient medical-surgical unit. D. Consider admission to an intensive care unit.

D. Consider admission to an intensive care unit. Rationale The Expanded CURB-65 scale may be used as a supplement to clinical judgment to determine the severity of pneumonia and if patients need to be hospitalized. A patient score of 5 on the scale means the perceived risk is high and that placement in the intensive care unit is warranted. If the patient has symptoms of pneumonia, advising no treatment is not appropriate. Treatment in an outpatient setting is advised when the scores are 0 to 2 on the scale. Hospital admission is advised when the scores are 3 to 4 on the scale.

A patient is receiving enteral nutrition through a nasogastric tube. Which measure does the nurse take to reduce the risk for aspiration? A. Uses a high-fiber formula B. Labels or color-codes feeding tubes and connectors C. Marks the exit site of the feeding tube D. Elevates the head of bed to 45 degrees

D. Elevates the head of bed to 45 degrees Rationale Proper position of the patient reduces the risk for aspiration. The head of the bed should be elevated to a minimum of 45 degrees to prevent aspiration. Using a high-fiber formula helps to prevent constipation but does not protect from aspiration. Labeling or color-coding feeding tubes and connectors helps to decrease the risk for misconnections. Marking the exit site of the feeding tube is for observing a change in the external tube length during feedings.

Which immediate action does the nurse take when discovering that a patient's chest tube is disconnected from the chest drainage unit (CDU)? A. Apply a clamp to the distal end of the chest tube. B. Place the patient in a supine position. C. Wrap a petroleum (airtight) gauze over the end of the chest tube. D. Immerse the distal end of the chest tube in sterile water.

D. Immerse the distal end of the chest tube in sterile water. Rationale If the drainage system breaks, the nurse should place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal. This will reduce the risk of air entering the pleural space. Applying a clamp to the tube will accumulate fluid or air in the pleural space. There is no information given related to respiratory status to determine correct patient positioning. Wrapping a petroleum (airtight) gauze over the end of the chest tube will accumulate fluid or air in the pleural space.

The nurse provides education to a patient who is prescribed a metered dose inhaler (MDI). Which actions taken by the patient indicate the need for further teaching? Select all that apply A. Waits between puffs B. Activates the inhaler during inspiration C. Holds the breath for 10 seconds after a puff D. Inhales more than one puff with each inspiration E. Does not shake the MDI before use

D. Inhales more than one puff with each inspiration E. Does not shake the MDI before use Rationale The MDI has to be shaken before use, and the patient should only inhale one puff per inspiration. The patient using an MDI should wait between each puff. The MDI should be activated during inspiration. The patient should hold the breath for 10 seconds after each puff.

The nurse provides teaching for a patient who is scheduled for a bedside thoracentesis. Which does the nurse explain as the primary purpose of the procedure? A. Determining the stage of a lung tumor B. Directly inspecting and examining the pleural space C. Obtaining a specimen of pleural tissue for evaluation D. Relieving an abnormal accumulation of fluid in the pleural space

D. Relieving an abnormal accumulation of fluid in the pleural space Rationale Thoracentesis involves the insertion of a large-bore needle into the pleural space to relieve an abnormal accumulation of fluid in the pleural space. The procedure can significantly relieve symptoms related to this fluid accumulation, such as shortness of breath and discomfort. Thoracentesis cannot reveal the stage of lung cancer or permit direct inspection and examination of the pleural space. It may provide a pleural fluid specimen but not a pleural tissue specimen.

Which diagnostic test result will the nurse expect when a patient has respiratory failure as a result of a pulmonary embolism? A. Congestion on chest x-ray B. Increased PaO 2 on arterial blood gases C. Gram-positive organisms in the sputum specimen D. Ventilation-perfusion (V/Q) mismatch on lung scan

D. Ventilation-perfusion (V/Q) mismatch on lung scan Rationale Since pulmonary emboli will obstruct blood flow through the pulmonary capillaries, a mismatch between pulmonary perfusion and ventilation will occur and lead to hypoxemia. Pulmonary emboli do not cause alveolar congestion, and a chest x-ray will not show pulmonary congestion. PaO 2 will decrease with a pulmonary embolism because gas exchange will not occur in those alveoli where the pulmonary capillaries are obstructed by pulmonary emboli. Pulmonary embolism is not an infectious process, and sputum specimens will be negative for bacteria.

A patient underwent a radical neck dissection due to oral cancer and is receiving enteral nutrition at 50 mL/hour. The nurse reviews the patient's medical record and completes an assessment. Considering the patient's laboratory results, the nurse identifies that which assessment finding should be reported to the health care provider immediately? A. Tube feeding residual 10 mL B. Difficulty swallowing secretions C. Formed daily bowel movements D. Weight loss of 4 pounds in one week

D. Weight loss of 4 pounds in one week Rationale The patient has undergone a surgical procedure that has affected the ability to swallow and impedes nutrition. The patient has an albumin level that is greatly decreased, which reflects malnutrition. The fact the patient has lost 4 pounds in one week reflects the poor nutritional status and requires immediate health care provider notification. A tube feeding residual of 10 mL when receiving enteral feedings at 50 mL/hour indicates that the patient is handling the feedings. Difficulty swallowing secretions is a normal postoperative finding after this surgery. Formed daily bowel movements are normal.

The nurse is reviewing the assessment findings of four patients. Which patient should be evaluated for pleural effusion? PATIENT A: Pursed-lip breathing, use of accessory muscles for breathing, Increased (AP) diameter of chest, presence of wheezing PATIENT B: Decreased tactile fremitus, Unequal chest movement, Dullness on percussion, Absence of breath sounds PATIENT C: Tripod position, use of accessory muscles for breathing, Hyperresonance on percussion, Presence of coarse crackles PATIENT D: Increased (AP) diameter of the chest, Finger clubbing, Presence of rhonchi, Hx of repeated pulmonary infections

PATIENT B Rationale A pleural effusion involves the build-up of fluid in the pleural cavity around the lungs. Presence of fluid in the pleural cavity may result in decreased tactile fremitus, dullness on percussion, and absence of breath sounds. The patient may also have unequal chest movement due to fluid collection. Therefore Patient B is likely to have a pleural effusion. Patient A is likely to have asthma, as evidenced by pursed-lip breathing, use of accessory muscles for breathing, increased AP diameter of chest, and presence of wheezing. Patient C is likely to have chronic obstructive pulmonary disease (COPD), as evidenced by the tripod position, use of accessory muscles for breathing, hyperresonance on percussion, and presence of coarse crackles. Patient D is likely to have cystic fibrosis, as evidenced by an increased AP diameter of the chest, finger clubbing, presence of rhonchi, and a history of repeated pulmonary infections.