MS120 CH 29, 30, 31, 32, 33
Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours would alert the nurse to the possibility of oxygen toxicity?
A - Increased Dyspnea -An oxygen level higher than 50% when given continuously for more than 24 to 48 hours may damage the lungs. Initial symptoms include nonproductive cough, substernal chest pain, gastrointestinal upset, and dyspnea. Decreased rate and depth of respiration, wheezing on inhalation and exhalation, and increased excretion of thick, white, frothy sputum are not considered to be initial symptoms of oxygen toxicity.
The client with chronic obstructive pulmonary disease (COPD) states that he feels "full after eating a little food." What will the nurse teach the client?
A -"Avoid drinking fluids just before and during meals." -Early satiety makes it harder for clients with COPD to eat enough food to meet their energy requirements. Drinking fluids just before a meal or during a meal contributes to the sensation of fullness and clients stop eating sooner. Although it is recommended that clients with COPD use an inhaler before meals to increase ventilation and gas exchange (and to reduce coughing during meals), this practice does not affect early satiety and neither does diaphragmatic breathing. There is no evidence that changing the amount of protein and fat in the diet will change the client's feelings of satiety.
The nurse teaches the client about therapy to prevent asthma attacks. What statement by the nurse would best explain the purpose for daily asthma therapy?
A -"Frequent asthma attacks, even if they are halted relatively quickly, damage the bronchial tissues over time." -Because damage can occur with any asthma attack, the main focus of therapy should be on prevention rather than just on symptom management. Frequent asthma attacks will damage bronchial tissues but will not necessarily cause lung cancer, emphysema, or chronic bronchitis. There is no evidence that use of short-acting beta agonists will lead to drug resistance or that beta-agonist drugs will not affect the inflammatory aspects of the overall disease process.
Which discharge instructions will the nurse give to the client for laryngectomy stoma care?
A -"Gently wash the stoma with soap and water and then apply a water-based lubricant." -The client is taught to wash the stoma gently and prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection.
The home care nurse observes oral candidiasis in the client with severe, chronic, airflow limitation. What information will the nurse obtain from this client?
A -"How often are you using your steroid inhaler?" -Excessive use of steroid inhalers reduces local immune function and increases the client's risk for oral-pharyngeal infections, including candidiasis. There is no evidence that the common cold, long-term use of the same oxygen tank, or using a toothbrush for a longer period will increase the client's chances of developing candidiasis.
The nurse teaches the client about dietary changes necessary with chronic obstructive pulmonary disease (COPD). Which statement best indicates understanding?
A -"I will decrease calories from carbohydrates." -The client should decrease his ingestion of carbohydrates, since excess carbohydrate metabolism causes carbon dioxide production. There is no reason to decrease dairy products, decrease calories to 1000/day, or increase vegetables in the diet.
The nurse is teaching the client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube?
A -"I'm glad I will still be able to talk with this tube in place." -The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal chords. The tube still needs to be cleaned and suctioned. The tube may still become dislodged, and the client is able to swallow.
The client preparing to go home after a radical neck dissection for cancer is crying. When the nurse asks why he is crying, the client writes, "I know I shouldn't cry. This surgery may have saved my life, but I can't believe how much my appearance has changed." What is the nurse's best response?
A -"It's all right to cry. Mourning this loss is important in getting past this point." -The many changes resulting from a laryngectomy influence physical, social, and emotional functioning. Clients may perceive changes in their quality of life. The client needs to grieve. The nurse would never tell the client that her or his actions are "silly." Once the client moves through the grieving process, it may be appropriate for him or her to talk to someone who is further along in the grieving process.
How will the nurse teach the client to assess response to asthma therapy at home?
A -"Keep a daily symptom and intervention diary." -The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and responses to therapy in asthma. Chest circumference is not expected to change in clients with asthma. The client should not be instructed to discontinue medications. Teaching proper technique with inhalers is appropriate; however, this will not assist in assessing response to therapy.
The client scheduled to have a V/Q scan is worried about contaminating his grandchildren with radioactive materials. What is the nurse's best response?
A -"The material clears completely within 8 hours, so your grandchildren can visit then." -The radioactive materials used in this procedure are low emitters and have a short half-life. They are completely cleared from the body within 8 hours. It is incorrect to tell the client that he must wait 48 hours after the scan before having contact with other people or that there is no radioactivity during the scan or when the scanner is off.
The client with severe chronic bronchitis tells the nurse that eating is difficult because of his shortness of breath. What is the nurse's best response?
A -"Try using your bronchodilator inhaler about 30 minutes before you plan to eat." -When dyspnea is worsened by bronchoconstriction, using a bronchodilator before eating can decrease the shortness of breath long enough to allow the client more energy to eat. The client who is short of breath will need to conserve his energy to breathe and thus should avoid eating when he is experiencing dyspnea. There is no evidence that eating only pureed foods or a lack of solid foods will keep the client from tiring and therefore encourage his intake.
Which is the priority assessment for the client who has undergone posterior nasal packing 1 hour ago for a posterior nosebleed?
A -Assessing adequacy of the client's airway -The client's airway could be compromised by bleeding and is the highest priority assessment. If the client were to have posterior nasal bleeding, she or he could quickly loose a lot of blood. The second highest priority assessment would be assessing for evidence of bleeding. If the oral mucous membranes were dry, this would not indicate an emergency situation. Pain assessment is a priority, but not as high as an assessment of the airway.
The nurse assesses a client receiving 60% oxygen via a tracheostomy collar. Which assessment finding requires immediate action by the nurse?
A -Constant, nonproductive coughing -The causes and manifestations of lung injury from oxygen toxicity are the same as those for acute respiratory distress syndrome (ARDS). Initial symptoms include nonproductive cough, substernal chest pain, gastrointestinal (GI) upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated and the client's hydration status can be checked.
The client tells the nurse that she feels shy going out in public with her tracheostomy. Which of the following should be the highest priority action on the part of the nurse?
A -Helping the client drape attractive scarves so that the tracheostomy is hidden -The most effective intervention on the part of the nurse will be to help her learn to wear scarves attractively so that she can confidently go out in public. The client does not necessarily need counseling and does not need to avoid going out in public. The nurse's efforts should primarily involve the client.
What will the nurse teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture?
A -Keep wire cutters readily available at the bedside. -Instruct the client to keep wire cutters with him or her at all times in case this emergency arises. This is the only option that would be life-threatening if allowed to occur. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting occurs, this will not be as high a priority as having wire cutters available. The client will probably be ordered a liquid diet and may also be ordered an irrigating device for oral care, but these are not the priority interventions.
The nurse assesses the client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action?
A -Notify the physician immediately. -If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The physician should be notified immediately. Reapplying the ties, changing the inner cannula, or increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery
A client has a newly diagnosed lung disease and has been placed on 2 L of nasal oxygen while hospitalized. The client has only been on the oxygen for approximately 30 minutes when he suddenly seems even more short of breath than previously, although he is neither gray nor ashy in color. The nurse recognizes that the client is experiencing which of the following?
A -Oxygen-induced hypoventilation -Assess for oxygen-induced hypoventilation in the client whose main respiratory drive is hypoxia (hypoxic drive), such as in the client with chronic lung disease who also has carbon dioxide retention (hypercarbia). The symptoms listed are not characteristic of oxygen toxicity, absorption atelectasis, or hypocarbia.
The client has undergone a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which is the nurse's highest priority action?
A -Reinforcing the teaching by placing a chart in the client's room detailing the steps in the process -The client who is status post-partial laryngectomy should be taught alternate methods of swallowing and a chart to reinforce teaching should be placed in the client's room. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each week is not as effective as showing the client a chart. Having the client demonstrate swallowing will not verify that he or she understands supraglottic swallowing correctly.
When measuring the client's pulse oximetry, the nurse finds that the client has a reading of 85%, down from 92% 1 hour ago. What will the nurse do first?
A -Verify the assessment and apply nasal cannula oxygen. -A change in the reading of this extent should be verified before more extensive measures are applied, particularly if the client does not show accompanying symptoms. Coughing and deep breathing will not cause a significant change in pulse oximetry. If the measurement is valid, resting and rechecking the client will not increase his oxygen saturation. A code would only need to be called once the measurement has been verified.
The client has been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse is attempting to determine if the client's self-image has suffered as a result of his diagnosis. What is the nurse's priority line of questioning?
A -Whether the earning power of the client's household has decreased -Economic status may be affected by COPD through changes in income and health insurance coverage. If the client is the head of the household, severe COPD may require role changes that have a negative impact on self-image. If the client is experiencing difficulty in quitting smoking, his self-image will probably not be altered as much as it would be related to income. The client may be experiencing difficulty with his marital relationship, but it probably will not be causing changes in his self-image. Although the client may have had to change his hobbies to accommodate the disease, it probably will not have affected his self-image adversely.
Which statement indicates that the client understands side effects of methotrexate (Folex) therapy?
B - "I shouldn't drink wine for 48 hours after taking methotrexate." -Methotrexate induces some degree of liver damage when taken long term. Avoiding other liver-damaging agents, such as alcohol, near the time that the methotrexate is taken reduces the potential for enhancing the liver-damaging actions of methotrexate. There is no need to reduce the client's oxygen flow rate or eliminate caffeinated beverages while the client is on the medication. Fluids should be increased, not decreased, while taking this medication.
Which action is highest priority for the nurse to teach the client with a tracheostomy to decrease the risk for aspiration?
B - Thicken all liquids -Thickening liquids may assist the client in swallowing and help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration, and may actually put the client at a greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.
The client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. What is the nurse's first action?
B - Ventilates with resuscitation bag with mask -Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.
The client with asthma is scheduled to begin taking zafirlukast (Accolate). What will the nurse teach the client?
B -"Avoid aspirin for headaches and take acetaminophen instead." -Aspirin increases the plasma concentration of zafirlukast (Accolate). If the client must also take aspirin or aspirin-containing agents, the dose of zafirlukast must be reduced. There is no evidence that the fluid intake must be increased, that the drug should be taken before or after meals, or that sun exposure should be avoided while the client takes the drug.
A client with chronic obstructive pulmonary disease (COPD) tells the nurse that she cannot have sexual relations with her partner because of her fatigue. What will the nurse suggest to the client to help her relieve the fatigue associated with sexual intercourse?
B -"Consider intercourse in the morning or after a nap." -The client should consider timing intercourse for a time when she is well rested, such as the morning or after a rest period. Couples therapy will not help the client relieve fatigue. A decrease in the client's anxiety level will not make her better rested. An antidepressant medication will not decrease fatigue associated with sexual intercourse.
Part of the client's treatment involves paralysis of the cilia in the airways. Which statement by the nurse includes the highest priority teaching strategy regarding the drug?
B -"Cough every hour to help bring up mucus and secretions." -Coughing will be particularly important for this client because the cilia will not be able to move and bring up and distribute mucus. The client definitely should not take a cough suppressant. Although it will be important to increase the amount of water the client drinks, it will not be as high a priority as coughing frequently. Eating soft foods should not be necessary because swallowing should occur normally. The cilia move mucus up and away from the lower airway to the trachea, where the mucus is either spit out or swallowed.
The nurse observes that the middle-aged client's anteroposterior (AP) chest diameter is the same as her lateral chest diameter. What is the nurse's most important question for the client in response to this finding?
B -"Do you have any chronic breathing problems?" -The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, a barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked, but is not as indicative of underlying disease processes as an AP diameter exceeding the lateral diameter.
Which statement by the client's family member indicates an accurate understanding of the correct way to provide the client with mouth care while he has a tracheostomy?
B -"I can clean his mouth with water and a toothette." -The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash are all too irritating to the mucous membranes of the mouth.
Which client statement indicates potential obstructive sleep apnea?
B -"I wake up feeling just as tired as I did when I went to bed." -Clients are often unaware that they have sleep apnea. The disorder should be suspected for any person who has persistent daytime sleepiness or complains of waking up tired. Clients with this problem do not usually have trouble getting to sleep, nor do they remember waking up during the night. Although they may snore heavily, they do not usually complain of an inability to breathe while lying flat in bed.
Which statement indicates that the client does not understand teaching about radiation therapy for laryngeal cancer?
B -"I will purchase a wig so that my appearance will be close to normal." -Hair loss should not occur from undergoing radiation therapy for laryngeal cancer. The client should stay out of the sun during treatment, because the skin can become severely burned. Resting the voice is recommended during treatment. The client should also avoid shaving until redness and peeling of facial and neck skin are diminished.
Which statement indicates that the client needs more teaching regarding responses to rhinoplasty?
B -"I will wait until next month to have my photograph taken, after all the swelling is gone." -Explain that edema and bruising may last for weeks and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because there is less risk of bleeding than with aspirin. Fluids and stool softeners will decrease the risk of straining.
Which statement indicates that the client understands teaching about the correct use of a corticosteroid medication?
B -"This drug is effective in decreasing the frequency of my asthma attacks." -Corticosteroids decrease inflammatory and immune responses in many ways, including preventing the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they are not effective in reversing symptoms during an asthma attack and should not be used as rescue drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate intermittent asthma and are used on a short-term basis for moderate asthma.
What is the best instruction for the client who has step II asthma that is triggered by exercise?
B -"Use a short-acting beta agonist before you participate in exercise." -The most important information for the client with step II asthma is that the short-acting beta agonist should be used before participating in exercise. The client should not avoid exercise but should simply use the agonist before participation. Water-related activity is not restricted for this client. Systemic medications may decrease the frequency of attacks but do not have a rapid onset of action and will not prevent an attack if taken before exercise.
Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching?
B -"When I speak at all, I will whisper rather than use a normal tone of voice." -Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners
A client is being discharged with a tracheostomy and voices concern about appearance. What discharge teaching will assist the client with maintaining a positive body image?
B -"Your clothing can help hide the tracheostomy so it is not as noticeable." -The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about the illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy because airflow would be impaired. Ignoring comments will not help the client's self-image
What will the nurse teach the client about the relationship between smoking and the development of chronic lung disease?
B -"Your condition will not progress as rapidly if you stop smoking." -Cigarette smoking contributes to the continuing deterioration of lung tissue in chronic obstructive pulmonary disease (COPD). Stopping smoking cannot reverse the existing damage, but it can slow down disease progression. Cigarette smoking is a rare cause of asthma. Asthma does not disfigure the client's appearance.
The client who is scheduled to have a vertical laryngectomy asks the nurse what changes to expect in voice quality after the surgery. What is the nurse's best response?
B -"Your permanent voice will be hoarse and breathy." -The client's voice will be permanently affected after this type of a procedure. The client will be able to speak above a whisper. However, the voice will be hoarse. Speech will not be completely lost, but it will not be normal.
A client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What will the nurse do first?
B -Assess the client's pulse oximetry. -Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen. Although you would want to notify the physician of the change in the client's condition, the best action is first to assess pulse oximetry and then increase the oxygen. You would not just document the assessment finding without intervening. Lowering the head of the bed would not help the client oxygenate better.
The client is brought to the emergency department with severe facial trauma. Which is the nurse's highest priority in caring for this client?
B -Assessing for a patent airway -In prioritizing care, airway is the first priority. Assessments for fractures would be a secondary priority, as would controlling swelling. Although preserving vision will be an important concern, the only selection that involves airway, breathing, or circulation is assessment for a patent airway.
Which client requires immediate nursing intervention?
B -Client with sternal retraction -The client with sternal retraction is experiencing serious respiratory difficulty. Although the client may exhibit shortness of breath as well as bilateral crackles, neither of these symptoms shows the same degree of respiratory difficulty being experienced as sternal retraction. A pulse oximetry reading of 95% is within normal limits
Which observed action indicates that the client understands teaching on the correct way to perform diaphragmatic breathing?
B -Having hands on abdomen -To perform diaphragmatic breathing correctly, the client should put his hands on his abdomen to create resistance. This type of breathing cannot be effectively performed while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.
What intervention is essential in the care of a client post-radical neck dissection?
B -Keeping the carotid artery and the dressing wet with sterile saline -Wound breakdown is a common complication caused by poor nutrition, a long smoking history, alcohol use, wound contamination, and previous radiation therapy. Manage wound breakdown with packing and local care as prescribed to keep the wound clean and stimulate the growth of healthy granulation tissue. None of the other options are interventions applicable to a life-threatening situation such as a carotid artery rupture. Applying pressure to the carotid artery, maintaining the positioning of the laryngectomy tube, and assessing blood flow by Doppler will all be ineffective at preventing rupture of the carotid artery.
Which client can the nurse delegate to the LPN/LVN who has been pulled to the unit?
B -Older adult client with esophageal cancer who is awaiting gastric tube placement -The nurse can delegate stable clients to an LPN who has been pulled to the unit. The client who is 6 hours postoperative should not be delegated because he or she is not stable. The client who needs discharge teaching cannot be cared for by the LPN because the RN is the one responsible for the teaching and this cannot be delegated to an LPN. Similarly, the client who needs preoperative teaching needs to have this done by the RN.
The client is being weaned from his tracheostomy tube and has tolerated the tube being capped for 24 hours. Which of the following should be the highest priority action on the part of the nurse?
B -Placing a dry dressing over the stoma and secure it in place -The tube will be able to be removed after the client has tolerated it being capped for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. There should be adequate airflow around the capped tube. The physician will not likely insert the next smallest size tube but will instead remove the existing tube.
The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What is the nurse's highest priority action?
B -Question client regarding use of anti-arthritic medications. -Aspirin and other NSAIDs can trigger asthma in some people, although this response is not a true allergy. It results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways. This is a high priority considering the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention to review response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks, however, not the cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.
The client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?
B -Tachycardia -An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia.
Which is the nurse's best action to prevent aspiration in a client with open vocal cord paralysis?
B -Teach the client to tuck his or her chin down and forehead forward when swallowing. -The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.
Which intervention is the nurse's highest priority when encouraging self-care for a client with a closed fracture of the nose?
B -Teaching the client how to apply cold compresses to the area to reduce swelling -After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care.
The client with long-standing pulmonary problems is classified as having class III dyspnea. Based on this classification, what type of assistance will be highest priority as the nurse provides for activities of daily living (ADLs)?
B -The client may complete activities of daily living without assistance but requires rest periods during performance. -Class III dyspnea occurs during usual activities, such as showering, but the client does not require assistance from others.
The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client?
B -The nurse assesses the client's level of consciousness. -Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and breathe deeply frequently, raise the head of the bed, and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.
The nurse enters the room of a client who has a tracheostomy and finds a visitor in the room speaking loudly to the client. The client appears to be angry and frustrated. Which intervention should the nurse implement to address this problem?
B -The nurse should tactfully remind the visitor that the client's comprehension has not been affected, only his ability to speak. -Addressing psychological concerns is an important aspect of nursing care for clients recovering from a tracheostomy. While providing physical care, keep in mind the emotional impact of an artificial airway. Acknowledge the client's frustration with communication and allow time for communication. When speaking to the client, use a normal tone of voice. The tracheostomy tube does not alter hearing or comprehension.
The nurse assesses the client receiving oxygen via a partial rebreather mask. The nurse will intervene for which assessment finding?
C - The oxygen flow rate is 2 L/min. -Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.
What information is essential for the nurse to teach the client about diaphragmatic breathing?
C -"Have your abdomen rise on inhalation and fall on exhalation." -The technique of diaphragmatic breathing uses the diaphragm and the abdominal muscles actively during inhalation and exhalation. The abdomen rises on inhalation and falls on exhalation, indicating that the abdominal muscles are relaxed during inhalation and contracted during exhalation. The client does not need to keep muscles tense during the activity and should not lie prone.
Which statement by the client indicates that he has an accurate understanding of home self-care of his tracheostomy?
C -"I need to keep water from entering the airway." -The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.
What statement indicates that the client did not understand teaching regarding therapy with salmeterol (Serevent)?
C -"I will keep the inhaler with me always so that I can get the medicine in my lungs quickly." -Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. The client does not have to keep this inhaler with him or her always because it is not used as a rescue medication. Salmeterol (Serevent) has a slow onset of action; therefore it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.
Which statement indicates that the client understands teaching about the use of his long-acting beta2 agonist medication?
C -"I will take this medication daily to prevent an acute attack." -This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his daily medications.
Which statement indicates that the client needs additional teaching about a dry powder inhaler?
C -"I will wash the inhaler mouthpiece daily with soap and water." -Washing the dry powder inhaler (DPI) may cause the medication in the inhaler to clump together. This action reduces the precision of the delivery of the drug to the client. The other statements are all correct—the client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need to inhale more forcefully than with an aerosol inhaler.
A client with lung cancer refuses pain medications because he is "afraid of addiction." What is the nurse's best response?
C -"If you start taking the medication, it is unlikely you will become addicted." -Clients should be encouraged to take their pain medications, and addiction is usually not an issue. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used in addition to the pain medications. Although antidepressant medications are sometimes used as adjuvant therapy with traditional pain medications, this is not an appropriate suggestion for the nurse to make.
What is the highest priority concept for the nurse to teach about early symptoms of lung cancer?
C -"Symptoms are vague, such as cough and shortness of breath on moderate exertion." -The early symptoms of lung cancer are nonspecific (chronic cough, less endurance with heavy exercise, more easily becoming short of breath) and could be associated with almost any acute or chronic pulmonary problem. Pain, abnormal breath sounds, and bloody sputum are late manifestations of some types of lung cancer. Wheezing on exhalation is not considered an early symptom of lung cancer.
A client is to be discharged to home on oxygen therapy. What information will the nurse teach the client?
C -"The D or C cylinder can be carried." -The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should only be in a stand or rack.
Which client is at greatest risk for development of obstructive sleep apnea?
C -A middle-aged woman who is 50 pounds overweight -The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.
The nurse is caring for several clients on a respiratory unit. Which client will the nurse see first?
C -A young adult with an arterial oxygen level of 85% -The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to 100% is a normal level for this age group. The older adult with a pulse oxygen of 96% is within normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would also be seen as normal.
The client requires oxygen using a face mask but wants to remain as mobile as possible once he is discharged home. Which intervention by the home health nurse will best provide the client with maximal mobility?
C -Add extra connecting pieces of tubing to the client's existing oxygen setup. -To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. Strength training will not be effective when the main problem keeping the client from being mobile is the oxygen face mask. The nurse cannot decide to begin weaning the client from the mask nor change the face mask to a nasal cannula without a physician's order.
Which statement is correct concerning the development of cystic fibrosis (CF)?
C -Children of carriers do not carry the gene. -The development of CF depends on inheriting a pair of mutated CF gene alleles because the disorder is autosomal recessive. Both parents are carriers (heterozygous) with one normal CF gene allele and one mutated CF gene allele. If he is a carrier and has children with another carrier, there is a chance he could have a child with CF. He can be tested so that he knows his risk.
The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
C -Client has reduced breath sounds, nurse calls physician immediately -A potential serious complication after biopsy is pneumothorax, indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, there is no reason to withhold pain medication. A respiratory rate of 18/min is a normal finding and would not warrant changing the oxygen flow rate.
The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action?
C -Crackling sensation around the neck when skin is palpated -Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Although it is important to provide inner cannula care, it usually is performed every shift and PRN, not every 2 hours. Although the nurse may attempt recannulation of the airway, it will be difficult during the first 72 hours after surgery and will require the physician's intervention. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.
The nurse assesses a client receiving aminophylline. What assessment finding indicates a dangerous side effect of this medication?
C -Development of seizures -Methylxanthines, including aminophylline, stimulate the sympathetic nervous system, the cardiovascular system, and the kidneys. The development of a seizure would indicate central nervous system irritability. A bradycardiac heart rate would not be a side effect of the medication. Urinary output of 30 mL per hour is a normal assessment finding. A blood pressure of 100/60 is also considered within normal range.
How will the nurse most effectively intervene for the client who is experiencing social isolation related to his chronic obstructive pulmonary disease (COPD)?
C -Encourage the client to verbalize his thoughts and feelings. -Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They believe that these processes draw unnecessary attention in public and disgust their friends. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize his feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns would also not be an effective strategy to decrease social isolation
The nurse is calculating the client's smoking history in pack-years. The client has recently been diagnosed with lung cancer. Which will be the nurse's priority intervention during the interview?
C -Maintaining a nonjudgmental attitude to avoid encouraging the client to feel guilty -Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Ask the client whether any of these substances are used now or in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs a day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview.
The client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless sputum each day, mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information?
C -Monitors for an increase in sputum production or change in color -Sputum production is a normal function of the respiratory tract. Most healthy people produce about 90 mL of sputum/day. This sputum should be thin, clear, odorless, and have minimal or no color. The nurse's only action should be to monitor the client for an increase in sputum production or a change in color. It will not be necessary at this time to obtain a specimen for analysis or to prepare for a bronchoscopy.
The client is undergoing radiation therapy as treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client?
C -Omelet, untoasted whole wheat bread -Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too hard to swallow with this condition, and orange juice and other foods with citric acid are too caustic in this condition.
Which signs and symptoms are most indicative of hypercarbia?
C -PaCO2 = 60 mm Hg, unable to tolerate more than 2 L of oxygen -Assess for oxygen-induced hypoventilation in the client whose main respiratory drive is hypoxia (hypoxic drive), such as in the client with chronic lung disease who also has carbon dioxide retention (hypercarbia). The arterial carbon dioxide (PaCO2) level for these clients gradually rises over time. The central chemoreceptors in the brain (medulla) are normally sensitive to increased PaCO2 levels. When these receptors are active, they stimulate breathing and cause an increased respiratory rate. When the PaCO2 increases gradually to above 60 to 65 mm Hg, this normal mechanism no longer functions. The central chemoreceptors lose sensitivity to increased levels of PaCO2 and do not respond by increasing the rate and depth of respiration.
The client has undergone rhinoplasty. Which assessment finding would require immediate intervention on the part of the nurse?
C -Repeated swallowing -After rhinoplasty, repeated swallowing may indicate that the client is experiencing posterior nasal bleeding. Immediate intervention is necessary to prevent hemorrhaging. Swelling and bruising are common after the surgery and would not indicate nasal bleeding. The client cannot breathe through the nose after surgery because the nares are packed and taped. The client would also not be able to blow the nose.
Which clinical manifestation in a client 4 hours status post-nasoseptoplasty will the nurse report immediately to the surgeon?
C -Repeated swallowing -Repeated swallowing may indicate posterior nasal bleeding and should be reported immediately. The nurse should examine the back of the client's throat to confirm the presence of blood. The client would be expected to be breathing through the mouth because the nasal passages are packed with gauze. Bruising and swelling around the eyes would be expected. The packing in the nares would be expected to collect pink and serous drainage. Bright red drainage would be cause for concern.
Which assessment finding indicates the need for the nurse's immediate intervention?
C -Suprasternal retraction on inhalation -Inhalation that causes suprasternal retraction usually means that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. The asthma is not responding to the medication, and the regimen should be changed. A 10% decrease of peak expiratory flow rate is not significant. Bilateral tactile fremitus is a normal finding, as is a midline trachea.
Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration?
C -The client coughs immediately after swallowing. -The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for any number of reasons. A breathy and weak voice may indicate weak muscles and wheezing may indicate swelling or inflammation in the airways.
The nurse is evaluating a client's response to medication therapy for asthma. The client reports daily peak flowmeter readings in the yellow zone. How will the nurse interpret this information?
C -The client needs additional daily medication -The client who consistently has a reading in the yellow zone has a need for additional daily therapy to better control the symptoms because this is 50% to 80% of personal best. The client may need rescue drugs as prescribed but may not need them immediately. The peak flowmeter will not indicate that the client has an infection.
The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention?
C -Wheezes heard in central areas, administering inhaled bronchodilator -Wheezes are indicative of narrowed airways and bronchodilators will help open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions
The client is taking enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, for hypertension. Which assessment finding with this requires immediate intervention by the nurse?
D - Persistant dry cough -Approximately 80% of clients taking ACE inhibitors experience a persistent dry cough throughout the duration of therapy. Although it will be important for the nurse to note if the client is experiencing wheezing on exhalation or a heart rate of 100 beats/min, a blood pressure of 86/50 mm Hg is abnormally low and may result in a syncopal episode for the client.
The client is scheduled to have a bronchoscopy. Which preprocedural teaching is unique to the procedure?
D -"Don't eat or drink afterward until your gag reflex returns to prevent aspiration." -Aspiration is possible if vomiting occurs. Although the client should not smoke prior to the procedure and probably will not take most his oral medications prior to the procedure, the only instruction unique to the procedure is not eating or drinking afterward until return of the gag reflex is verified. Use of inhalers prior to the procedure will be by order of the physician.
Which statement indicates that the client understands teaching about the administration of omalizumab (Xolair) for her asthma?
D -"I will be given this drug subcutaneously in my doctor's office." -Immunomodulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. There is a high risk of anaphylaxis, so it is administered in the physician's office. The route is subcutaneous. It is not taken by mouth or injected intramuscularly.
Which statement indicates that the client needs more teaching about nasal continuous positive airway pressure therapy for obstructive sleep apnea?
D -"I will make certain that no one smokes in the room when I use the machine." -Having others in the room avoid smoking will not be of the same priority as the other instructions. It is much more accurate for the client to understand that continuous positive airway pressure therapy will assist in decreasing snoring and weight loss. The machine should be used whenever the client sleeps in bed, regardless of time of day.
The client tells the nurse that occasionally food seems to stick in his throat and makes it hard to breathe. What is the nurse's best response?
D -"Lumps of food can press into the trachea and block it. Drink water when this happens." -The cartilage rings of the trachea are C-shaped, with the open part next to the muscular tissue shared by the trachea and esophagus. This tissue can be moved outward from the esophagus and into the trachea when a bolus of firm food is in the esophagus. If this sensation is present whenever the client eats, it should be evaluated for other structural problems.
Which client would not be a candidate for a lung transplant?
D -A client with a systemic infection -Clients who receive a transplant must take immunosuppressive drugs for the rest of their lives to prevent transplant rejection. Such medications, when given to a person with a systemic infection, could lead to sepsis and death. Middle age, a latex allergy, or the presence of cystic fibrosis will not necessarily cause a client to be eliminated as a candidate for a lung transplant.
The nurse observes the nursing student suctioning the client. Which intervention on the student nurse's part has the greatest potential to cause tissue damage?
D -Applying suction when the catheter is inserted -Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroy cells. Oxygen saturation of 93% is acceptable postsuctioning. The client should be hyperoxygenated before and after suctioning. Intermittent suctioning as the catheter is withdrawn is standard procedure to prevent tissue damage.
The client with emphysema must learn how to use exercise conditioning for his pulmonary rehabilitation. What teaching strategy will have highest priority?
D -Breathe against a set resistance for 5 minutes 3 times/day. -Exercise conditioning for pulmonary rehabilitation focuses on strengthening the diaphragm and other respiratory muscles. Breathing against a set resistance increases the strength and endurance of respiratory muscles. Exercising only while in the standing position, holding breath between sets, and keeping arms above the head while exercising will not increase the strength and endurance of respiratory muscles.
The client expresses concern to the nurse regarding the development of mucositis as a result of chemotherapeutic agents administered to treat lung cancer. What is the priority instruction for the nurse to give the client?
D -Clean teeth using disposable mouth sponges; inspect mouth daily. -Frequent mouth assessment and oral hygiene are key in managing mucositis. Soft-bristled toothbrushes or disposable mouth sponges should be used to prevent trauma and bleeding. Preventive treatment should begin well before mouth sores develop.
The nurse is assessing a client after a thoracentesis. Which answer represents an accurate intervention by the nurse?
D -Crepitus felt at site, physician notified -Crepitus is usually an indicator of subcutaneous emphysema and is a significant complication that must be reported. Rating of pain as a 5, small amounts of drainage, and pulse oximetry measurements with their accompanying interventions are all important, but not unique to a thoracentesis nor as indicative of significant complications.
The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped?
D -Heart rate decreases from 78 to 40 beats/min -A decrease in the heart rate indicates that the client is not tolerating the procedure and the vasovagal reflex may be stimulated. An increase in the heart rate may be stimulated by the suctioning and is expected, as is a slight increase in blood pressure. The client will not be breathing during the procedure.
When assessing a client's respiratory status, which information is of highest priority for the nurse to obtain?
D -Occupation and hobbies -Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.
What assessment information could most directly relate to the adult client's diagnosis of new-onset asthma?
D -Occupation and usual hobbies -New-onset asthma could be directly related to a hobby that involves inhalation irritants. There is no evidence that previous history of pneumonia or tuberculosis, allergies, nutritional intake, or diet history is directly related to new-onset asthma.
Which laboratory value warrants immediate intervention by the nurse?
D -PaCO2 of 48 mm Hg -Although the nurse should note the results of all laboratory work carried out, only a PaCO2 of 48 mm Hg is likely to culminate in serious symptoms for the client. Neither the HCO3?, SpO2, nor pH levels assessed would be life-threatening nor indicative of serious complications that would override the importance of the PaCO2 level.
While suctioning the client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. What is the nurse's priority action?
D -Performs a more thorough assessment -A more thorough assessment must be performed so that additional data can be gathered before the nurse contacts the physician for orders. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own, nor should the nurse decide to make the client NPO without a physician's order. Additional nursing interventions are required other than documentation alone.
What is highest priority for the nurse to teach the client who is to undergo pulmonary surgery?
D -Postoperative pulmonary hygiene -The two nursing priorities before surgery are teaching the client the expected regimen of pulmonary hygiene to be used in the period immediately after surgery and assisting the client in a pulmonary muscle strengthening/conditioning regimen as postoperative pulmonary hygiene. The surgeon instructs the client on surgical complications, explains the purpose of intubation, and discusses the potential need for cardiopulmonary bypass.
The client is becoming frustrated because of his inability to communicate while he has a tracheostomy. Which intervention by the nurse will most effectively enhance his ability to communicate?
D -Providing the client with a communication board and keeping the call bell within reach -A communication board and the call light will reassure the client that his needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he uses. Ordering a sedative for the client is merely an evasive response on the nurse's part. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate.
The client has been placed on 6 L of humidified oxygen via nasal cannula. What will be the highest priority action of the nurse?
D -Removing condensation in tubing by disconnecting and emptying into trash can -Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so that the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or nebulizer. If a closed system is maintained, there should be no reason for bacterial analysis of the condensation. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.
The nurse is assessing a client with chronic lung disease on 6 L/min oxygen via nasal cannula. Which finding indicates a potentially acute problem?
D -Respiratory rate of 6/min -The client with chronic lung disease is driven by the hypoxic drive to breathe. If the client receives too much oxygen, the respiratory rate will slow. The nurse should decrease the oxygen flow. Respiratory failure could result. Wheezes are not an acute problem. A pulse oximetry of 93% is acceptable, as is a pH of 7.35.
The nurse is teaching a family member how to suction the client's tracheostomy at home. Which of the following should be the highest priority action on the part of the nurse to teach the family member?
D -Suction using clean technique. -The family member can suction using clean technique because there are fewer organisms in the home in comparison to the hospital. Never suction the mouth first because the airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate tube except in an emergency.
The client arrives in the emergency department experiencing difficulty breathing. Which assessment finding requires immediate action by the nurse?
D -Use of accessory muscles to breathe -The use of accessory muscles to breathe is characteristic of status asthmaticus—a severe, life-threatening, acute episode of airway obstruction. Use of accessory muscles for breathing and distention of neck veins are observed. Whereas wheezing is characteristic of status asthmaticus, crackles typically do not develop. Although crackles indicate atelectasis or fluid buildup, they do not indicate a more critical situation than the use of accessory muscles to breathe. Cyanosis may develop as the condition progresses, rather than a flushed appearance, and the client may have difficulty speaking. White sputum is not a cause for concern.
The client is scheduled to undergo a thoracentesis. What will be the nurse's priority intervention?
D -Verification that informed consent has been given by the client -A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.