N618 - Exam 2 - Resp

The nurse is assessing the client diagnosed with a lung abscess. Which information supports this diagnosis of lung abscess? 1. Tympanic sounds elicited by percussion over the site. 2. Inspiratory and expiratory wheezes heard over the upper lobes. 3. Decreased breath sounds with a pleural friction rub. 4. Asymmetric movement of the chest wall with inspiration.

1. Dull sounds would be heard over the site of a lung abscess as a result of the solid mass. 2. Crackles may be heard, but wheezes indicate a narrowing of airways, not exudate-filled airways. 3. Diminished or absent sounds are heard with intermittent pleural friction rubs. A lung abscess is the accumulation of pus in an area where pneumonia was present that becomes encapsulated and can extend to the bronchus or pleural space. 4. Even with a lung abscess, the chest should move symmetrically.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. 4. The stem does not state the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment, and "check" (option "3") is a word that can be used synonymously for "assess." Monitoring (option "4") is also assessing, but the test taker should not check a diagnostic test result before caring for the client.

The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse.

1. A child with asthma can eat a regular diet if the child is not allergic to the components of the diet. 2.Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack. 3. The stem did not indicate the child is developmentally delayed. 4. The child does not require a home health nurse solely on the basis of asthma; the school nurse or any child-care provider should be informed of the child's diagnosis, and the parents must know the individual caring for the child is prepared to intervene during an attack. TEST-TAKING HINT: The test taker must be aware of the disease process, determine causes, and then make a decision based on interventions required.

Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply. 1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake.

1. A client with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate. 2. The client's lung sounds should be assessed to determine how much air is being exchanged in the lungs. 3. Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree. 4. The pulse oximeter evaluates how much oxygen is reaching the periphery. 5. Increasing fluids will help thin secretions, making them easier to expectorate.

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

1. A complete blood count determines the oxygen-carrying capacity of the hemoglobin in the body, but it will not identify the immediate problem. 2.Pulmonary function test are completed to determine the forced vital capacity (FVC), the forced expiratory capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicates respiratory compromise. 3.Allergy skin testing will be done to determine triggers for allergic asthma, but it is not done during an attack. 4.Drug cortisol levels do not relate to asthma. TEST-TAKING HINT: If the test taker is unsure about the correct response, it is helpful to choose the option that directly relates to the topic. Asthma is a pulmonary problem, and only one (1) option has the word "pulmonary" in it.

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

1. A large amount of thick sputum is a common symptom of COPD. There is no cause for immediate intervention. 2.The nurse should decrease the oxygen rate to two (2) to three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. 3. It is common for clients with COPD to use accessory muscles when inhaling. These clients tend to lean forward. 4. In clients with COPD, there is a characteristic barrel chest from chronic hyperinflation, and dyspnea is common. TEST-TAKING HINT: This question requires interpreting the data to determine which are abnormal or unexpected and require intervention. Options "1," "3," and "4" are expected for the client's disease process.

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest.

1. A person with a viral infection should not return to work until the virus has run its course because the antibiotics help prevent complications of the virus, but they do not make the client feel better faster. 2.Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection. 3.Antibiotics will not prevent the flu. Only the flu vaccine will prevent the flu. 4.When people take portions of the antibiotic prescription and stop taking the remainder, an antibiotic-resistant strain of bacteria may develop, and the client may experience a return of symptoms—but this time, the antibiotics will not be effective. TEST-TAKING HINT: Knowing drug classifications and how the drugs within the classification work would assist the test taker to determine the correct answer. Antibiotics work to destroy bacterial invasions of the body.

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.

1. A purple flat area indicates that the client became bruised when the intradermal injection was given, but it has no bearing on whether the test is positive. 2. A positive skin test is 10 mm or greater with induration, not redness. 3.If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. 4. These are negative findings and do not indicate the need to have x-ray determination of disease. TEST-TAKING HINT: The test taker should note descriptive terms such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never," and absolutes usually indicate incorrect answers.

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C, 2,000 mg daily. 2. Strict bedrest. 3. Humidification of the air. 4. Decongestant therapy.

1. Alternative therapies are therapies not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's functions. 2.Bedrest is accepted standard advice for a client with a cold. 3.Humidifying the air helps to relieve congestion and is a standard practice. 4.Decongestant therapy is standard therapy for a cold. TEST-TAKING HINT: Only one of the answer options is not common advice for a client with a cold. When all options but one (1) match each other, then the odd option should be selected as the correct answer.

The client diagnosed with a cold is taking an antihistamine. Which statement indicates to the nurse the client needs more teaching concerning the medication? 1. "If my mouth gets dry I will suck on hard candy." 2. "I will not drink beer or any type of alcohol." 3. "I need to be careful when I drive my car." 4. "This medication will make me sleepy."

1. Antihistamines dry respiratory secretions through an anticholinergic effect; therefore, the client will have a dry mouth. 2. Antihistamines cause drowsiness; therefore, the client should not drink any type of alcohol. 3. Antihistamines cause drowsiness, so the client should not drive or operate any type of machinery. 4. Antihistamines cause drowsiness; therefore, the client understands the teaching.

The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective? 1. A decrease in the white blood cells in the sputum. 2. The client's symptoms are improving. 3. No change in the chest x-ray. 4. The skin test is now negative.

1. Antitubercular medications target the tubercular bacilli, not white blood cells. 2. As the bacilli are being destroyed, the client should begin to feel better and have fewer symptoms. 3. At six (6) weeks, the chest x-ray may not have changes. 4. The skin test will always be positive.

The nurse is planning the care of a client diagnosed with asthma and has written a problem of "anxiety." Which nursing intervention should be implemented? 1. Remain with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

1. Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and the client is not alone. 2. Because anxiety is an expected occurrence with asthma, it is not necessary to notify the health-care provider. 3. An anxiolytic medication could decrease respiratory drive and increase the respiratory distress. Also, the medication will require a delayed time period to begin to work. 4. Drinking fluids will not treat an asthma attack or anxiety. TEST-TAKING HINT: Before choosing an answer option that directs the test taker to notify a health-care provider, the test taker should determine if the option is describing an expected event or data for the disease process being discussed. If it is expected, then notifying the health-care provider would not be the correct answer.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1. Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted. 2. This should be done to ensure the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention. TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the ordered oral antibiotic STAT. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed assistive personnel weigh the client.

1. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medications only after several days of IVPB therapy. 2.Meal trays are not priority over cultures. 3.To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibi- otics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. 4.Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection. TEST-TAKING HINT: Option "1" has a medication classification and a route, and the test taker should question if the route is appropriate for the client being admitted. Clients will not die from a delayed meal, but a client could die from delayed IV antibiotic therapy

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water-seal compartment. The chest tube is never stripped, which creates a negative air pressure and could suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1. Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. 2. The pneumococcal vaccine should be ad- ministered every five (5) to seven (7) years. 3. Reducing the number of cigarettes smoked does not stop the progression of COPD, and the client will continue to experience signs and symptoms such as shortness of breath or dyspnea on exertion. 4. Clients diagnosed with COPD should increase their fluid intake unless contraindicated for another health condition. The increased fluid assists the client in expectorating the thick sputum. TEST-TAKING HINT: Nurses are expected to serve as community resources. The nurse should be knowledgeable about health promotion activities such as immunizations. One (1) option describes a desired goal, but the other three (3) do no

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. 2.This would be a goal for self-care deficit but not for impaired gas exchange. 3.This would be a goal for the problem of activity intolerance. 4.Impaired gas exchange results in hypoxia, the earliest sign/symptom of which is a change in the level of consciousness. TEST-TAKING HINT: The test taker should match the answer option to the listed nursing problem. Option "1" is a staff goal to accomplish. When writing goals for the client, it is important to remember they are written in terms of what is expected of the client. Options "2" and "3" are appropriately written client goals, but they do not evaluate gas exchange.

The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the "Right to Know" law. Which information should the nurse include in the presentation? Select all that apply. 1. A client who smokes cigarettes has a drastically increased risk for lung cancer. 2. Floors need to be clean and dust needs to be wet to prevent transfer of dust. 3. The air needs to be monitored at specific times to evaluate for exposure. 4. Surface areas need to be painted every year to prevent the accumulation of dust. 5. Employees should wear the appropriate personal protective equipment.

1. Clients who smoke cigarettes and work with toxic substances have increased risk of lung cancer because many of the substances are carcinogenic. 2. When floors and surfaces are kept clean, toxic dust particles, such as asbestos and silica, are controlled and this decreases exposure. Covering areas with water controls dust. 3. The quality of air is monitored to determine what toxic substances are present and in what amount. The information is then used in efforts to minimize the amount of exposure. 4. Applying paint to a surface does not eliminate or minimize exposure and can trap more dust. 5.Employees must wear protective coverings, goggles, and other equipment needed to eliminate exposure to the toxic substances.

The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? 1. Close the door and discuss the UAP's action after coming out of the room. 2. Make the UAP come back outside the room and then reenter, closing the door. 3. Say nothing to the UAP but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the UAP immediately.

1. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner. 2. The employee is an adult and as such should be treated with respect and corrected accordingly. 3. Problems should be taken care of at the lowest level possible. The nurse is responsible for any task delegated, including the appropriate handling of isolation. 4. Correcting staff should never be done in the presence of the client. This undermines the UAP and creates doubt of the staff's competency in the client's mind. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correcting the UAP in this manner has the greatest chance of creating a win-win situation.

Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough

1. Clubbing of the fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. 2. These clients have frequent respiratory infections. 3.Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD. 4. These clients have a productive cough, not a nonproductive cough. TEST-TAKING HINT: The test taker must be observant of terms such as "recently diagnosed," which help to rule out incorrect answers such as option "1." Option "2" has the word "infrequent." The test taker must notice these words.

Which intervention should the nurse implement for the client experiencing bronchospasms? 1. Administer intravenous epinephrine, a bronchodilator. 2. Administer Albuterol, a bronchodilator, via nebulizer. 3. Request a STAT portable chest x-ray at the bedside. 4. Insert a small nasal trumpet in the right nostril.

1. Epinephrine is administered intravenously during an arrest in a code situation, but it is not a treatment of choice for bronchospasms. 2. Albuterol given via nebulizer is administered to stop the bronchospasms. If the client continues to have the bronchospasms, intubation may be needed. 3. A STAT portable x-ray will be ordered, but the goal is to prevent respiratory arrest. 4. Nasal trumpet airways would not be helpful in stopping the bronchospasm and respiratory arrest.

The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea.

1. Fever is a sign of infection, and crepitus is air trapped in the layers of the skin. 2.Rales indicate fluid in the lung, and hives are a skin reaction to a stimulus such as occurs with an allergy to a specific substance. 3.During an asthma attack, the muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces, and dyspnea. 4. During an attack, the chest will be expanded from air being trapped and not being exhaled. A chest x-ray will reveal a lowered diaphragm and hyperinflated lungs. TEST-TAKING HINT: The test taker must have a basic knowledge of common medical terms to answer this question. Dyspnea, wheezing, and rales are common terms used when describing respiratory function and lung sounds. Crepitus and eupnea are not as commonly used, but they are also terms that describe respiratory processes and problems.

Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack? 1. Administer glucocorticoids intravenously. 2. Administer oxygen 5 L per nasal cannula. 3. Establish and maintain a 20-gauge saline lock. 4. Assess breath sounds every 15 minutes.

1. Glucocorticoids are a treatment of choice, but they are not the first intervention. 2.The client is in distress so the nurse must do something for the client's airway. 3. A saline lock is needed for intravenous fluids, but it is not the first intervention. 4.Assessment is the first step of the nursing process but in distress do not assess.

The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that children current with immunizations will not get a cold. 3. Tell the children they should go to the doctor if they get a cold. 4. Demonstrate to the students how to wash hands correctly.

1. It is not feasible for a child to always have a tissue or handkerchief available. 2.There is no immunization for the common cold. Colds are actually caused by at least 200 separate viruses and the viruses mutate frequently. 3. Colds are caused by a virus and antibiotics do not treat a virus; therefore, there is no need to go to a health-care provider. 4.Hand washing is the single most useful technique for prevention of disease. TEST-TAKING HINT: Option "1" contains the word "always," an absolute word, and in most questions, absolutes such as "always," "never," and "only" make that answer option incorrect.

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. 2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP. 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than staying in the bed, so no action would be needed. TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should correct the action, demonstrate a skill, or somehow intervene with the UAP's behavior.

. The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 4. Assess level of conscious. 5. Auscultate breath sounds.

1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated. 2. Encouraging breathing exercises can be delegated. 3. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse. 4.Assessment cannot be delegated. Confusion is one of the first symptoms of hypoxia. 5. Auscultation is a technique of assessment and cannot be delegated.

Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen? 1. "I will take Singulair, a leukotriene modifier, every day to prevent allergic asthma attacks." 2. "I need to use my Intal, cromolyn, inhaler 15 minutes before I begin my exercise." 3. "I need to take oral glucocorticoids every day to prevent my asthma attacks." 4. "If I have an asthma attack, I need to use my Albuterol, a beta2 agonist, inhaler."

1. Leukotriene modifiers, such as Singulair, should be taken daily to prevent an asthma attack triggered by an allergen response. 2.Cromolyn inhalers, such as Intal, are used to prevent exercise-induced asthma attacks. 3.Glucocorticoids are administered orally or intravenously during acute exacerbations of asthma, not on a daily basis because of the long-term complications of steroid therapy. 4. Albuterol, a beta2 agonist, is used during attacks because of the fast action.

The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication? 1. Muscle weakness. 2. Purulent sputum. 3. Nuchal rigidity. 4. Intermittent loss of muscle control.

1. Muscle weakness is a sign/symptom of myalgia, but it is not a life-threatening complication of sinusitis. 2.Purulent sputum would be a sign/symptom of a lung infection, but it is not a life-threatening complication of sinusitis. 3.Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges. 4.Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis. TEST-TAKING HINT: A basic knowledge of anatomy and physiology would help to answer this question. The sinuses lie in the head and surround the orbital cavity. Options "1" and "4" refer to muscle problems, so both could be ruled out as wrong.

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

1. No fluctuation in the water-seal chamber four (4) hours post insertion indicates the tubing is blocked; the nurse can milk the chest tube, but it is not the first action. 2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle. 3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.

The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question? 1. Administer intravenous fluids of normal saline at 125 mL/hr. 2. Provide supplemental oxygen per nasal cannula at 2 L/min. 3. Continuous telemetry monitoring with strips every four (4) hours. 4. Administer a loop diuretic intravenously every six (6) hours.

1. Normal mean pulmonary artery pressure is about 15 mm Hg and an elevation indicates right ventricular heart failure or cor pulmonale, which is a comorbid condition of chronic obstructive pulmonary disease. The nurse should question this order because the rate is too high. 2. Supplemental oxygen should be administered at the lowest amount; therefore, this order should not be questioned. 3. Clients with hypoxia and cor pulmonale are at risk for dysrhythmias, so monitoring the ECG is an appropriate intervention. 4. Loop diuretics are administered to decrease the fluid and decrease the circulatory load on the right side of the heart; therefore, this order would not be questioned.

The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply. 1. Nursing. 2. Pharmacy. 3. Social work. 4. Occupational therapy. 5. Speech therapy.

1. Nursing is the one discipline remaining with the client around the clock. Therefore, nurses have knowledge of the client that other disciplines might not know. 2. The pharmacist will be able to discuss the medication regimen the client is receiving and make suggestions regarding other medications or medication interactions. 3. The social worker may be able to assist with financial information or home care arrangements. 4. Occupational therapists help clients with activities of daily living and modifications to home environments; nothing in the stem indicates a need for these services. 5. Speech therapists assist clients with speech and swallowing problems; nothing in the stem indicates a need for these services. TEST-TAKING HINT: Cost containment issues are always a concern the nurse must address. The use of limited resources (health-care personnel) should be on an as-needed basis only. Cost containment must be considered when using other disciplines or supplies.

Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy? 1. Alteration in comfort. 2. Altered level of conscious. 3. Alteration in elimination pattern. 4. Knowledge deficit.

1. Pain and discomfort are major problems for a client who had a thoracotomy because the chest wall has been opened and closed. 2. The client would be on a mechanical ventilator and have an adequate airway; therefore, altered consciousness would not be an appropriate client problem. 3. Altered elimination problem is not specific for the client with a thoracotomy. 4. A knowledge deficit problem is not an appropriate problem for the client who is one (1) day postoperative thoracotomy because the client is on a ventilator.

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

1. Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. 2. This would be an appropriate outcome for a knowledge-deficit problem. 3. This outcome does not ensure the client has an effective airway; increasing fluid does not ensure an effective airway. 4. This is not an appropriate outcome for any client problem because the client should be able to ambulate without dyspnea for 100 feet. TEST-TAKING HINT: The test taker needs to identify the outcome for the client problem cited—namely, "ineffective gas exchange." The only answer option addressing the airway is option "1," pursed-lip breathing.

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

1. The client should be in the high Fowler's position to facilitate lung expansion. 2. The system must be patent and intact to function properly. 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1," the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warm-up exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

1. Rescue inhalers are used to treat attacks, not prevent them, so this should not be administered prior to exercising. 2. Warm-up exercises decrease the risk of developing an asthma attack. 3.Using a bronchodilator immediately prior to exercising will help reduce bronchospasms. 4. Monosodium glutamate, a food preservative, has been shown to initiate asthma attacks. TEST-TAKING HINT: Option "1" has two words that are opposed "rescue" and "wait"—which might lead the test taker to eliminate this option. Remember basic concepts, which are contradicted in option "2." There are a few disease processes that encourage intake of sodium, but asthma is not one of them, which would cause option "4" to be eliminated.

The client diagnosed with pneumonia has arterial blood gases of pH 7.33, PaO2 94, PaCO2 47, HCO3 25. Which intervention should the nurse implement? 1. Administer sodium bicarbonate. 2. Administer oxygen via nasal cannula. 3. Have the client cough and deep breathe. 4. Instruct the client to breathe into a paper bag.

1. Sodium bicarbonate is administered for metabolic acidosis. 2. The arterial oxygen level is within normal limits (80 to 100); therefore, the client does not need oxygen. 3. The client is retaining CO2, which causes respiratory acidosis, and the nurse should help the client remove the CO2 by instructing the client to cough and deep breathe. 4. Breathing into a paper bag is not recommended for clients in respiratory acidosis.

The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.

1. Standard Precautions are used to prevent exposure to blood and body secretions on all clients. Tuberculosis is caused by airborne bacteria. 2. Contact Precautions are used for wounds. 3. Droplet Precautions are used for infections spread by sneezing or coughing but not transmitted over distances of more than three (3) to four (4) feet. 4. Tuberculosis bacteria are capable of disseminating over long distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross-contaminate the air in the hallway. TEST-TAKING HINT: Standard Precautions and Contact Precautions can be ruled out as the correct answer if the test taker is aware that Tb is usually a respiratory illness. This at least gives the reader a 1:2 chance of selecting the correct answer if the answer is not known.

The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Administer oxygen via a nasal cannula. 4. Notify the respiratory therapist STAT.

1. Taking the client's vital signs will not help the client's shortness of breath and difficulty in breathing. 2.Checking the pulse oximeter reading will not help the client's shortness of breath and difficulty breathing. [Do NOT assess in Distress; we already know the pt has difficulty in breathing, so we need to intervene to help the pt out} 3.After elevating the head of the bed, the nurse should administer oxygen to the client who is in respiratory difficulty. 4. Notifying the respiratory therapist will not help the client's shortness of breath and difficulty breathing.

Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

1. The Asthma Foundation of America is not appropriate for a client in this stage of COPD. 2. The American Cancer Society is helpful for a client with lung cancer but not for a client with COPD. 3.The American Lung Association has information helpful for a client with COPD. 4.Many clients with COPD end up with heart problems, but the American Heart Association does not have information for clients with COPD.

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? 1. The client's partial thromboplastin time (PTT) is 38. 2. The client's international normalized ratio (INR) is 5. 3. The client's prothrombin time (PT) is 22. 4. The client's erythrocyte sedimentation rate (ESR) is 10.

1. The PTT is not monitored to determine a serum therapeutic level for warfarin; normal is 30 to 45. 2. The INR therapeutic range is 2 to 3 for a client receiving warfarin. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this. {If INR is high, hold warfarin and prepare vitamin K} 3. The PT is monitored for oral anticoagulant therapy and should be 1.5 to 2 times the normal of 12; therefore, 22 is within therapeutic range and would not warrant the nurse questioning administering this medication. 4. The ESR is not monitored for oral anticoagulant therapy.

The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1. Assess respiratory rate and depth. 2. Provide for adequate rest period. 3. Administer oxygen as prescribed. 4. Teach slow abdominal breathing.

1. The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise. 2. Rest reduces metabolic demands, fatigue, and the work of breathing, which promotes a more effective breathing pattern, but it is not priority over assessment. 3. Oxygen therapy increases the alveolar oxygen concentration, reducing hypoxia and anxiety, but it is not priority over assessment. 4. This breathing pattern promotes lung expansion, but it is not priority over assessment.

20. The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in Trendelenburg position. 4. Notify the health-care provider.

1.The nares are the openings of the nostrils. Suctioning, if done, would be of the posterior pharynx. 2.Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. 3. Placing the client in the Trendelenburg position increases the risk of aspiration. 4. An immediate action is needed to protect the client. TEST-TAKING HINT: In a question requiring the test taker to determine the first action, all the answer options may be correct for the situation. The test taker must determine which has the greatest potential for improving the client's condition.

Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on arterial blood gases. 2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. 4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because of the effort expended to breathe.

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.

1. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. 2. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. 3. Clients are encouraged to drink at least 2,000 mL daily to thin secretions. 4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited {NOT DECREASED}. 5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. TEST-TAKING HINT: Maslow's hierarchy of needs lists oxygenation as the top priority. Therefore, the test taker should select interventions addressing oxygenation.

The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions? 1. "I will call 911 if my medications don't control an attack." 2. "I should wash my bedding in warm water." 3. "I can still eat at the Chinese restaurant when I want." 4. "If I get a headache, I should take a nonsteroidal anti-inflammatory drug."

1. The client must be able to recognize a life-threatening situation and initiate the correct procedure. 2. Bedding is washed in hot water to kill dust mites. 3. Many Chinese dishes are prepared with monosodium glutamate, an ingredient that can initiate an asthma attack. 4. Nonsteroidal anti-inflammatory medications, aspirin, and beta blockers have been known to initiate asthma attacks. TEST-TAKING HINT: Dietary questions or answer options should be analyzed for the content. The test taker should decide, "What about Chinese foods could be a problem for a client diagnosed with asthma?" or "What might be good for the client about this diet?"

Which intervention should the nurse implement for a male client who has had a left sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing. TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse? 1. The client refuses to perform shoulder exercises. 2. The client complains of a sore throat and is hoarse. 3. The client has crackles that clear with cough. 4. The client is coughing up pink frothy sputum

1. The client refusing to perform shoulder exercises is pertinent, but it does not require immediate intervention. 2. Sore throats and hoarseness are common postintubation and would not require immediate intervention. 3. Crackles that clear with coughing would not require immediate intervention. 4. Pink frothy sputum indicates pulmonary edema and would require immediate intervention.

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client's status.

1. The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. 2. Oxygen will be applied as soon as possible, but the least amount possible. If levels of oxygen are too high, the client may stop breathing. 3.Vital signs need to be monitored, but this is not the first priority. If the equipment is not in the room, another member of the health-care team should bring it to the nurse. The nurse should stay with the client. 4. The health-care provider needs to be notified, but the client must be treated first. The nurse should get assistance if possible so the nurse can treat this client quickly. TEST-TAKING HINT: When a question asks for the test taker to choose the intervention to implement first, the test taker should select an intervention directly caring for the client. Remember: in distress do not assess.

Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache.

1. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic- resistant bacteria. Sinus infections are difficult to treat and may become chronic, and will then require several weeks of therapy or possibly surgery to control. 2. If the sinuses are irrigated, it is done under anesthesia by a health-care provider. 3. Blowing the nose will increase pressure in the sinus cavities and will cause the client increased pain. 4. The nurse is not licensed to prescribe medications, so this is not in the nurse's scope of practice. Also, narcotic analgesic medications are controlled substances and require written documentation of being prescribed by the health-care provider; samples are not generally available. TEST-TAKING HINT: Note in this situation an "all" is in the correct answer. There are very few cases in which absolute adjectives will describe the correct answer. The test taker must be aware that general rules will not always apply.

Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy? 1. "I must avoid hair spray and powders." 2. "I should take a shower instead of a tub bath." 3. "I will need to cleanse around the stoma daily." 4. "I can use an electric larynx to speak."

1. The client should not let any spray or powder enter the stoma because it goes directly into the lung. 2.The client should not allow water to enter the stoma; therefore, the client should take a tub bath, not a shower. 3. The stoma site should be cleansed to help prevent infection. 4. The client's vocal cords were removed; therefore, the client must use an alternate form of communication.

The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored

1. The client with end-stage COPD has decreased peripheral oxygen levels; therefore, this would not warrant immediate intervention. 2. The client's ABGs would normally indicate a low oxygen level; therefore, this would not warrant immediate intervention. 3. The client who develops dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves. 4. Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. TEST-TAKING HINT: The test taker could rule out options "1" and "2" as correct answers because both describe the same data of decreased oxygen, which is characteristic of COPD.

The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

1. The client with pneumothorax has absent breath sounds and tachypnea. 2. Unequal lung expansion and dyspnea indicate a pneumothorax. 3. Consolidation occurs when there is no air moving through the alveoli, as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these terms should cause the test taker to select option "2" because unequal chest expansion would result from trauma.

Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection? 1. Monitor the client's current temperature. 2. Monitor the client's white blood cells. 3. Determine if a culture has been collected. 4. Determine the compatibility of fluids.

1. The client's current temperature would not affect the administration of the antibiotic. 2. The client's white blood cells may be elevated because of the infection, but this would not affect administering the medication. 3. A culture needs to be collected prior to the first dose of antibiotic, or the culture and sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified. 4. Compatibility of fluids should be assessed prior to administering each intravenous antibiotic, but when administering the first dose of an antibiotic, the nurse must check to make sure the sputum culture was obtained.

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching? 1. "If I lose weight I may not need treatment for sleep apnea." 2. "The CPAP machine holds my airway open with pressure." 3. "The CPAP will help me stay awake during the day while I am at work." 4. "It is all right to have a couple of beers because I have this CPAP machine."

1. The contributing factors to developing sleep apnea are obesity, smoking, drinking alcohol, and a short neck. In some situations, modifying lifestyle will improve sleep apnea. 2. Many clients need a continuous positive airway pressure (CPAP) machine, which continuously administers positive pressure to assist sleep during the night. 3. When clients have sleep apnea, the buildup of carbon dioxide causes the client to arouse constantly from sleep to breathe. This, in turn, causes the client to be sleepy during the day. 4. Drinking alcohol before sleep sedates the client, causing the muscles to relax, which, in turn, causes an obstruction of the client's airway. Drinking alcohol should be avoided even if the client uses a CPAP machine.

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients. 2. Child-care workers and children <four (4) years of age. 3. Hospital chaplains and health-care workers. 4. Schoolteachers and students living in a dormitory.

1. The elderly and chronically ill are at greatest risk for developing serious complications if they contract the influenza virus. 2.It is recommended people in contact with children receive the flu vaccine whenever possible, but these clients should be able to withstand a bout with the flu if their immune systems are functioning normally. 3.It is probable these clients will be exposed to the virus, but they are not as likely to develop severe complications with intact functioning immune systems. 4.During flu season, the more people the individual comes into contact with, the greater the risk the client will be exposed to the influenza virus, but this group of people would not receive the vaccine before the elderly and chronically ill. TEST-TAKING HINT: Sometimes the test taker may think the answer is too easy and obvious, but the test taker should not try to second-guess the question. Item writers are not trying to trick the test taker; they are trying to evaluate knowledge.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.

1. The elderly client diagnosed with pneumonia may present with {ATYPICAL SYMPTOMS such as} weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia. 2.Fever and chills are classic symptoms of pneumonia, but they are usually absent in the elderly client. 3.Frothy sputum and edema are signs and symptoms of heart failure, not pneumonia. 4.The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure. TEST-TAKING HINT: The question provides an age range—"elderly"—so age can be expected to affect the disease process—in this case, causing atypical symptoms. The prefix brady- means "slow" when attached to a word. Knowing the definition of medical prefixes can assist the test taker in determining the correct answer.

The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

1. The expected outcome showing no signs of respiratory distress indicates the plan of care is effective and should be continued. 2. An improved respiratory pattern indicates the plan should be continued. 3. The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision. 4.The client should participate in planning the course of care. The client is meeting the expected outcome. TEST-TAKING HINT: This question is an "except" question. Three of the options indicate desired outcomes and only one (1) option indicates the need for improvement.

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The words "implement first" in the stem of the question indicate to the test taker that possibly more than one (1) intervention could be warranted in the situation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2˚F and a dry cough. 3. There are one (1) to two (2) white blood cells in the urinalysis. 4. The client's current international normalized ratio (INR) is 1.0.

1. The hemoglobin and hematocrit given are within normal range. This would not warrant notifying the health-care provider. 2. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed. 3.One (1) to two (2) WBCs in a urinalysis is not uncommon because of the normal flora in the bladder. 4.The INR indicates that the client's bleeding time is within normal range. TEST-TAKING HINT: In this question, all the answer options contain normal data except for one. The nurse would not call the health-care provider to notify him or her of normal values.

The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

1. The number of years of smoking is information needed to treat the client but not the most important in health promotion. 2.The risk factors for complications are important in planning care. 3. Assessing the ability to deliver medications is an important consideration when teaching the client. 4.The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. TEST-TAKING HINT: The test taker should read the stem for words such as "health promotion." These words make all the other answer options incorrect because they do not promote health.

The client with a cold asks the nurse, "Is it all right to take Echinacea for my cold?" Which statement is the nurse's best response? 1. "You should discuss that with your health-care provider." 2. "No, you should not take any type of herbal medicine." 3. "Yes, but do not take it for more than 3 days." 4. "Echinacea may help with the symptoms of your cold."

1. The nurse can answer client's questions concerning herbal medication. Passing the buck should be eliminated as a possible correct answer. 2. The nurse should not be judgmental. If the client does not have comorbid conditions, is not taking other medications, or is not pregnant, herbal medications may be helpful in treating the common cold. 3. Echinacea should not be taken for more than two (2) weeks, not three (3) days. Nothing cures the common cold; the cold must run its course. 4. Echinacea is an herb that may reduce the duration and symptoms of the common cold, but nothing cures the common cold. If the client does not have comorbid conditions, is not taking other medications, and is not pregnant, herbal medications may be helpful in treating the common cold.

The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Check the ventilator to determine the cause. 3. Elevate the head of the client's bed. 4. Assess the client's oxygen saturation.

1. The nurse needs to notify the respiratory therapist to check the ventilator, but it is not the first intervention. 2. The nurse must determine what is causing the alarm; a high or low alarm will make a difference in the nurse's action. {Please note that in this case it is important to check the machine before the patient in order to know the cause of the problem as the intervention differs based on whether the high pressure alarm or low pressure alarm goes off} 3. Elevating the head of the bed will help lung expansion, but it is not the first intervention. 4. The ventilator alarm indicates something is wrong, and the nurse must first determine if the problem is with the ventilator or the client.

he alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. 2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. 3. This is a correct position to place the client in for a chest tube insertion, but it is not the first intervention. 4. The health care provider will discuss the procedure with the client, then informed consent must be obtained, and the nurse can do further teaching. TEST-TAKING HINT: The test taker must know invasive procedures require informed consent, and legally it must be obtained first before anyone can touch the client.

Which intervention should the nurse implement first when caring for a client with a respiratory disorder? 1. Administer a respiratory treatment. 2. Check the client's radial pulses daily. 3. Monitor the client's vital signs daily. 4. Assess the client's capillary refill time.

1. The nurse should gather data before implementing an intervention. 2. The radial pulse would indicate the cardiovascular status of the client, not the respiratory status, and the nurse should assess the apical pulse. 3. Daily vital signs would not indicate the respiratory status of the client. 4. Assessing the client's capillary refill time has the highest priority for the nurse because it indicates the oxygenation of the client.

The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

1. The nurse would not suspect a myocardial infarction for a client with a DVT who suddenly has chest pain. 2. These signs and symptoms should not make the nurse think the client has pneumonia. 3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary artery, and causes the chest pain; the client often feels as if he or she is going to die. 4. Chest pain is a sign of pneumothorax, but it is not a complication of deep vein thrombosis.

The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.

1. The specimen needs to be taken to the laboratory within a reasonable time frame, but a UAP can take specimens to the laboratory. 2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. 3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%. 4. Arterial oxygenation normal values are 80% to 100%. TEST-TAKING HINT: Be sure to read all the answer options. Pulse oximetry readings do not give the same information as arterial blood gas readings

The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL.Which intervention should the nurse implement? 1. Hang the next bag and continue the infusion. 2. Do not hang the next bag and decrease the rate. 3. Notify the health-care provider of the level. 4. Confirm the current serum theophylline level.

1. The therapeutic level is 10 to 20 mcg/mL; therefore, the nurse should hang the bag and continue the infusion to maintain the aminophylline level. 2. There is no reason not to hang the next bag of aminophylline. 3. There is no need to notify the health-care provider for a level of 18 mcg/mL. 4. There is no need for the nurse to confirm the laboratory results.

The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine? 1. The client diagnosed with congestive heart failure. 2. The client with a documented allergy to eggs. 3. The client who has had an anaphylactic reaction to penicillin. 4. The client who has an elevated blood pressure and pulse.

1. There would be no reason to question administering a vaccine to a client with heart failure. 2.In clients who are allergic to egg protein, a significant hypersensitivity response may occur when they are receiving the influenza vaccine. 3. There would be no reason to question administering a vaccine to a client who has had a reaction to penicillin. 4. There would be no reason to question administering a vaccine to a client who has elevated blood pressure and pulse.

Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM? 1. pH 7.38, PaO2 94, PaCO2 44, HCO3 24. 2. pH 7.46, PaO2 82, PaCO2 34, HCO3 22. 3. pH 7.48, PaO2 59, PaCO2 30, HCO3 26. 4. pH 7.33, PaO2 94, PaCO2 44, HCO3 20.

1. This ABG is within normal limits and would not be expected in a client with ARDS. 2. These ABG levels indicate respiratory alkalosis, but the oxygen level is within normal limits and would not be expected in a client with ARDS. 3. ABGs initially show hypoxemia with a PaO2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS. 4. This ABG is metabolic acidosis and would not be expected in a client with ARDS.

The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for 15 seconds before swallowing. 4. Take the medication immediately when an attack starts.

1. This applies to systemically administered steroids, not to inhaled steroids. 2.The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth (oral candidiasis). 3. Holding the medication in the mouth increases the risk of an oral yeast infection, and the medication is inhaled, not swallowed. 4. Inhaled steroids are not used first; the beta-adrenergic inhalers are used for acute attack. TEST-TAKING HINT: Option "3" suggests that an inhaled medication is swallowed; the two (2) terms do not match.

The client is admitted with a diagnosis of rule-out severe acute respiratory syndrome (SARS). Which information is most important for the nurse to ask related to this diagnosis? 1. Current prescription and over-the-counter medication use. 2. Dates of and any complications associated with recent immunizations. 3. Any problems with recent or past use of blood or blood products. 4. Recent travel to mainland China, Hong Kong, or Taiwan.

1. This information is important during an admission interview but is not specific to SARS. 2. The information would not be specific to the diagnosis of SARS. 3.This would be important to ask prior to the administration of any blood products, but it is not specific for SARS. 4.Recent travel to mainland China, Taiwan, and Hong Kong is a risk factor for contracting SARS. NOTE: SARS is Airborne Precautions, NOT droplet

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 2. At three (3) days post insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore, the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. 4. A client two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must understand that the LPN should be assigned the least critical client or the client who is stable and not exhibiting any complications secondary to the admitting disease or condition.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This statement describes a spontaneous pneumothorax. 2. This statement describes an open pneumothorax. 3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but the statement does not describe a tension pneumothorax. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between options "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids. 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. 3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis. 4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.

1. Tonsillectomies cause throat edema and difficulty swallowing; the nurse must observe the client's ability to swallow before this task can be delegated. 2. Clients with colds are encouraged to drink 2,000 mL of liquids a day. The UAP could do this. 3.Throat swabs for culture must be done correctly or false-negative results can occur. The nurse should obtain the swab. 4. Clients with laryngitis are instructed not to smoke. Smoking is discouraged in all health- care facilities. Sending nursing personnel outside encourages an unhealthy practice, which is not the best use of the personnel. TEST-TAKING HINT: Interventions requiring assessment, teaching, and evaluation can- not be delegated. Levels of activities being delegated should be appropriate for the level of training of the staff member carrying out the task. Tasks delegated must conform to safe health-care practice.

The health-care provider has ordered a continuous intravenous infusion of aminophylline. The client weighs 165 pounds. The infusion order is 0.3 mg/kg/hr. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump? ________

11 mL/hr. First, convert pounds to kilograms: 165 pounds ÷ 2.2 75 kg Then, determine how many milligrams of aminophylline per hour should be administered: 0.3 mg 75 kg 22.5 mg/hr Then, determine how much aminophylline is delivered per milliliter: 500 mg ÷ 250 mL 2 mg/1 mL If 2 mg/1 mL is delivered, then to deliver the prescribed 22.5 mg/hr, the rate must be set at: 22.5 ÷ 2 11.25 mL/hr Less than 0.5 should be rounded down, 0.5 and above is rounded up.

The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris prior to instilling formula. 2. Elevate the head of the bed after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.

1.A gastrostomy tube is placed directly into the stomach through the abdominal wall; the naris is the opening of the nostril. 2.Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. 3.The Sims position is the left lateral side-lying flat position. This position is used for administering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach. 4.Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily. TEST-TAKING HINT: The test taker should try to picture the positioning of the client to determine the correct answer. In option "4," the test taker should question if the time given, three (3) days, is the correct time interval for performing this intervention.

The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first? 1. Request STAT arterial blood gases. 2. Administer lidocaine intravenous push. 3. Assess for possible causes. 4. Request a STAT electrocardiogram.

1.ABGs may show hypoxia, which is a cause of PVCs, but it is not the first intervention the nurse should implement. 2.Lidocaine is the treatment of choice for PVCs, but it is not the first intervention. 3.The nurse should assess for possible causes of the PVCs; these causes may include hypoxia or hypokalemia. 4. An ECG further evaluates the heart function, but it is not the first intervention.

The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a Tb skin test every three (3) months to determine if I am well."

1.Clients diagnosed with Tb will need to take the medications for six (6) months to a year. 2.Compliance with treatment plans for Tb includes multidrug therapy for six (6) months to one (1) year for the client to be free of the Tb bacteria. 3.Clients are no longer contagious when three (3) morning sputum specimens are cultured negative, but this will not occur until after several weeks of therapy. 4.The Tb skin test only determines possible exposure to the bacteria, not active disease. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in option "1," months in option "2," or immediately in option "3" is the correct time interval.

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a "rescue inhaler." 3. Use of systemic steroids. 4. Leukotriene agonists.

1.Daily inhaled steroids are used for mild, moderate, or severe persistent asthma, not for intermittent asthma. 2.Clients with intermittent asthma will have exacerbations treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers. 3.Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma. 4. Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma. TEST-TAKING HINT: In the stem, there are two (2) words giving the test taker a clue about the correct answer. "Mild" and "intermittent" are words that indicate the client is not experiencing frequent or escalating symptoms. Steroid medications can have multiple side effects.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <three (3) seconds. 4. Substernal chest pain and diaphoresis.

1.Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. 2. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation. 3. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of <3 seconds is normal. 4. Substernal chest pain and diaphoresis are symptoms of myocardial infarction. TEST-TAKING HINT: Options "1" and "4" have chest pain as part of the answer. The adjectives describing the chest pain determine the correct answer.

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement? 1. Instruct the client to drink a mixture of brandy and honey several times a day. 2. Encourage the client to whisper instead of trying to speak at a normal level. 3. Provide the client with a blank notepad for writing any communication. 4. Explain that the client's aphonia may become a permanent condition.

1.The client with laryngitis is instructed to avoid all alcohol. Alcohol causes increased irritation of the throat. 2.Whispering places added strain on the larynx. 3.Voice rest is encouraged for the client experiencing laryngitis. 4.Aphonia, or inability to speak, is a temporary condition associated with laryngitis. TEST-TAKING HINT: Encouraging the use of alcohol, with the exception of a glass of red wine, is not accepted medical practice; therefore, option "1" could be eliminated. Option "4" has an absolute— "permanent"—in it and therefore could be eliminated from consideration.

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? 1. The client's arterial blood gases are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

1.The client would have low arterial oxygen when developing ARDS. 2.Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea. 3.As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and use of accessory muscles. 4. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

The nurse teaches pursed lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? A.Loosening secretions so that they may be coughed up more easily B.Promoting maximal inhalation for better oxygenation of the lungs C.Preventing bronchial collapse and air trapping in the lungs during exhalation D.Increasing the respiratory rate & giving the patient control of respiratory patterns

Answer C Rationale: Preventing bronchial collapse and air trapping in the lungs during exhalation The purpose of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A. This is a normal auscultatory finding. B. May indicate pneumothorax. C. May indicate pneumonia. D. May indicate severe emphysema.

Answer. C Rationale: This test (whispered pectoriloquy) demonstrates hyper resonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia) (C), and is not a normal finding (A). When lung tissue is filled with more air than normal, the voice sounds are absent or very diminished (e. g., pneumothorax, severe emphysema) (B and D).

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? A. Encourage increased intake of whole grains. B.Increase the patient's intake of fruits and fruit juices. C.Offer high-calorie snacks between meals and at bedtime. D.Assist the patient in choosing foods with high vegetable and mineral content.

Answer. C. Rationale: Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture like whole grains may take more energy to eat and get absorbed which lead to decreased intake. Although fruits, juices, and vegetables are not contraindicated, foods high in protein are a better choice.

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

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

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10."

Answer: 1. "It hurts more when I breathe in." Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1. A shunt unit exists. 2. Anatomical dead space is present. 3. Physiological dead space is present. 4. Ventilation-perfusion matching is occurring.

Answer: 1. A shunt unit exists. Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

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

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

The nurse in the post-anesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? 1. Frequent swallowing 2. Client complaints of discomfort 3. Ecchymosis around the client's eyes 4.Blood on the external nasal dressing

Answer: 1. Frequent swallowing Rationale: The client should be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? 1. It is painless and safe. 2. It causes only mild discomfort at the site. 3. It requires insertion of only a very small catheter. 4. It has an alarm to signal dangerous drops in oxygen saturation levels.

Answer: 1. It is painless and safe. Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

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

Answer: 1. Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle.{The apex of the lungs is on top and the bases are on the bottom, unlike the heart, in which the apex is on the bottom and the base is on top}.All of the other options are incorrect locations for assessing the left apex.

The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? 1. Lobes 2. Alveoli 3. Trachea 4. Main bronchi

Answer: 1. Lobes Rationale: Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1. Pleural pain and fever 2. Decreased respiratory rate 3. Diaphoresis during the day 4. Hyper-resonant breath sounds over the left thorax

Answer: 1. Pleural pain and fever Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

A client is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse should document this finding as which sound? Play Sound 1. Stridor 2. Crackles 3. Rhonchi 4. High-pitched wheezes

Answer: 1. Stridor Rationale: The sound that the nurse hears is stridor. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. The nurse immediately notifies the health care provider (HCP). The nurse also places the client in a high Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy. Rhonchi (low-pitched, coarse, loud, low snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. High-pitched wheezes are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? 1. Tidaling is present. 2. There is a leak in the system. 3. The client has residual pneumothorax. 4. Suction should be added to the system.

Answer: 1. Tidaling is present. Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. Options 2, 3, and 4 are inaccurate interpretations.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate? 1. "You lack the energy to cook wholesome meals." 2. "Blocked nasal passages impair the sense of smell." 3. "Loss of appetite is triggered by the infectious organism." 4. "Infection blocks sensation in the taste buds of the tongue."

Answer: 2. "Blocked nasal passages impair the sense of smell." Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider (HCP). 4. Change the chest tube drainage system.

Answer: 2. Document the findings. Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Therefore, it is unnecessary to call the HCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicates an air leak. If this occurs, it must be corrected.

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching? 1. "I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider."

Answer: 2. "I should remove the chest tube site dressing as soon as I get home." Rationale: When a chest tube is removed, an occlusive dressing, usually consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the health care provider says it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate? 1. "The numbness is normal and is likely to be permanent." 2. "In many cases the nose and upper lip are numb for up to 6 months." 3. "Numbness usually indicates nerve damage that occurred during the procedure." 4."You will need to see the health care provider because this may indicate a complication of the procedure."

Answer: 2. "In many cases the nose and upper lip are numb for up to 6 months." Rationale: The nurse should instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? 1. "It will open up the major airways." 2. "It will keep the small airways open." 3. "It will increase lubrication for the lungs." 4. "The lungs can better rid themselves of secretions."

Answer: 2. "It will keep the small airways open." Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not reasons for sustaining inflation.

The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? 1. 16% 2. 21% 3. 30% 4. 40%

Answer: 2. 21% Rationale: Room air contains 21% oxygen. It is not possible to give a client 16% oxygen because that is less than room air. Options 3 and 4 specify oxygen amounts that commonly are used to supplement clients who are experiencing respiratory difficulty.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

Answer: 2. Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe.

Answer: 2. Continue to monitor the client. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded. Because this finding is expected, it is not necessary to notify the HCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.

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

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

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

Answer: 2. Document the findings. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? 1. Do not exceed 1 L/min. 2. Do not exceed 2 L/min. 3. Adjust the oxygen depending on SpO2. 4. Adjust the oxygen depending on respiratory rate.

Answer: 3. Adjust the oxygen depending on SpO2. Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. All other options are incorrect.

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system? 1. Empty the drainage collection chamber every shift. 2. Ensure the water level in the water seal chamber is at the 2-cm level. 3. Maintain the drainage collection device at the level of the client's chest. 4. Clamp the chest tube before moving the client from the bed to the chair.

Answer: 2. Ensure the water level in the water seal chamber is at the 2-cm level. Rationale: The water seal chamber acts as a 1-way valve. It allows air and fluid to leave the pleural space but prevents reentry of atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. A chest tube should not be clamped unless specifically prescribed.

The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse should document this finding as which sound? Play Sound 1. Crackles 2. High-pitched wheezes 3. Bronchial breath sounds 4. Bronchovesicular breath sounds

Answer: 2. High-pitched wheezes Rationale: The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

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

Answer: 2. Increase to 3 L/min and titrate until the SpO2 is 88%. Rationale: Oxygen is used cautiously and should be titrated to the lowest amount needed; however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and the current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%.An SpO2 of 95% is the recommended level for a healthy individual{with no COPD};therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect.

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1. Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal, expected finding.

Answer: 2. Notify the health care provider (HCP). Rationale: Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. {Other options that if present will be correct include: A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty & subcutaneous emphysema. The nurse should check for an air leak. First, check to see if someone has increased the suction rate; if it is not on high, then check to see if the problem is with the pt or the system (leak)}. The remaining options are incorrect.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape

Answer: 2. Petrolatum gauze and sterile 4 × 4 gauze Rationale: On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the HCP as the tape of choice to make the dressing occlusive

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4.The occlusive dressing at the insertion site needs reinforcement.

Answer: 2. The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water seal chamber.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.

Answer: 2. The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1. The drainage is serous. 2. The drainage is bloody. 3. The drainage is serosanguineous. 4. The drainage is bloody, with frequent small clots.

Answer: 2. The drainage is bloody. Rationale: In the first few hours after surgery the drainage from the chest tube is bloody. After several hours it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1. Air flows by gravity. 2. The respiratory muscles relax. 3. The respiratory muscles contract. 4. Air is flowing against a pressure gradient.

Answer: 2. The respiratory muscles relax. Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.

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

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

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

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

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

Answer: 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L Rationale: A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction? 1. "I should sleep on 2 pillows to elevate my head." 2. "I should avoid any activities such as bending over." 3. "I should be sure to run a dehumidifier in my home." 4."I need to sneeze through the mouth and not blow through the nose."

Answer: 3. "I should be sure to run a dehumidifier in my home." Rationale: After rhinoplasty, the client is taught to sleep on at least 2 pillows; this elevates the head and reduces edema. The client also is told to avoid any activities, such as bending over, that would increase intracranial pressure and cause nasal bleeding. A humidifier (not a dehumidifier) decreases the dry throat associated with mouth breathing. The client should be instructed to sneeze through the mouth and not blow through the nose.

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

Answer: 3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." Rationale: Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? 1. Instruct the client to limit fluid intake. 2. Place the client in low Fowler's position. 3. Administer the prescribed bronchodilator. 4. Place a continuous pulse oximeter on the client.

Answer: 3. Administer the prescribed bronchodilator. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing. {In distress, don't assess, option 4 is assessment. We know the pt has SOB and decreased breath sounds, so, we need intervention rather than assessment}.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? 1. Place the client in supine position. 2. Apply an ice collar around the client's neck. 3. Assist the client to a sitting position with the head tilted forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled.

Answer: 3. Assist the client to a sitting position with the head tilted forward. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1. Dry cough 2. Hematuria 3. Bronchospasm 4.Blood-streaked sputum

Answer: 3. Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? 1. Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

Answer: 3. Document the findings. Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction? 1. Drink water while chewing the gum. 2. Only chew the gum for a maximum of 10 minutes. 3. Hold the gum between the cheek and teeth periodically. 4. Eat a light snack immediately before chewing the gum.

Answer: 3. Hold the gum between the cheek and teeth periodically. Rationale: Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink should be avoided 15 minutes before or during use.

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? 1. Prevents the client from getting a nosebleed 2. Gives the client added fluid via the respiratory tree 3. Humidifies the oxygen that is bypassing the client's nose 4. Prevents fluid loss from the lungs during mouth breathing

Answer: 3. Humidifies the oxygen that is bypassing the client's nose Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. A client who is breathing through the mouth is not at risk for nosebleeds. The humidified oxygen may help keep mucous membranes moist, but it will not substantially alter fluid balance (options 2 and 4).

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

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

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1. Position the client in semi Fowler's position. 2. Add water to the suction chamber as it evaporates. 3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system.

Answer: 3. Instruct the client to avoid coughing and deep breathing. Rationale: It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

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

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

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1. Dilate the major bronchi. 2. Increase surfactant production. 3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree.

Answer: 3. Maintain inflation of the alveoli. Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1. Aids in exhalation 2. Moves up and inward 3. Moves downward and out 4. Makes the thoracic cage smaller

Answer: 3. Moves downward and out Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? 1. Aids in exhalation as it contracts 2. Moves up and inward as it contracts 3. Moves downward and out as it contracts 4. Makes the thoracic cage smaller as it contracts

Answer: 3. Moves downward and out as it contracts Rationale: As the diaphragm contracts it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, the remaining options are incorrect.

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

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

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? 1. Alveoli 2. Trachea 3. Pleural space 4. Main bronchi

Answer: 3. Pleural space Rationale: Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1. Initiate and maintain supplemental oxygen as prescribed. 2. Plan activities with rest periods to conserve oxygen needs. 3. Provide nasotracheal suctioning as needed to remove secretions. 4. Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

Answer: 3. Provide nasotracheal suctioning as needed to remove secretions. Rationale: Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is in the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance.

The nurse is caring for a client who has just returned from the post-anesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period? 1. Serous 2. Grossly bloody 3. Serosanguineous 4. Serous with sputum

Answer: 3. Serosanguineous Rationale: Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The remaining options are not expected findings.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tube may be obstructed.

Answer: 4. The chest tube may be obstructed. Rationale: Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.

While assisting a client to a sitting position, a chest tube becomes dislodged from the chest wall. Which of the following should the nurse do? A.Immediately apply a sterile dressing over the site B.Reinsert the chest tube C. Pace the water seal collection chamber on the floor. D.Assess vital signs

Answer: A Rationale: When a chest tube becomes dislodged, the nurse should immediately apply a sterile dressing over the site and tape 3 sides to create a one-way valve. Choice B is incorrect because the nurse is not permitted to reinsert a chest tube. Choice C is incorrect because the collection chamber can be placed anywhere. Choice D would be done after the dressing is applied.

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

Answer: 4. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." Rationale: Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? 1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

Answer: 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Rationale: Clients should be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.

The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1. Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal chamber during inspiration and expiration.

Answer: 4. Continuous bubbling is observed in the water seal chamber during inspiration and expiration. Rationale: Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of reexpansion of the lung or obstruction or kinking of the chest tube.

The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action? 1. Ensure that suction is turned on. 2. Reinforce the occlusive dressing. 3. Encourage the client to breathe deeply. 4. Document the accurate functioning of the tube.

Answer: 4. Document the accurate functioning of the tube. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. There is no need to ask the client to breathe deeply or reinforce the dressing. The suction should be turned on if prescribed, but there are no data in the question to indicate this HCP prescription.

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

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

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? 1. The client will lose consciousness. 2. The client's sodium and chloride levels will rise. 3. The client will complain of facial numbness and tingling. 4. The client's arterial blood gas results will reflect acidosis.

Answer: 4. The client's arterial blood gas results will reflect acidosis. Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding. SATA A. Peripheral edema B. Elevated temperature C. Clubbing of the fingers D.Complaints of chest pain E. Ascites

Answer: A,E

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

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

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

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

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? 1. Continue to monitor. 2. Document the findings. 3. Change the chest tube drainage system. 4. Perform a focused respiratory assessment.

Answer: 4. Perform a focused respiratory assessment. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system are not indicated at this time. Continuing to monitor delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1. Focus only on the physical examination. 2. Obtain all information from family members. 3. Use the health care provider's medical history. 4. Plan short sessions with the client to obtain data.

Answer: 4. Plan short sessions with the client to obtain data. Rationale: The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information.Option 3 is incorrect because the health care provider's medical history provides data that are different from the nurse's assessment. All efforts should be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

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

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

A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min 4. Respiratory rate of 22 breaths/min

Answer: 4. Respiratory rate of 22 breaths/min Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

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

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

A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? 1. Take a deep breath. 2. Exhale immediately. 3. Breathe in and out quickly. 4. Take a deep breath and hold it.

Answer: 4. Take a deep breath and hold it. Rationale: When the chest tube is removed, the client is asked to take a deep breath and hold it. The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seal themselves off, and the wound heals in less than 1 week.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

Answer: 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.

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

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

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

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

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

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

A client has the following arterial blood gases: pH 7.42; PaCO2 30 mm Hg; HCO3 19 mEg/L; Pa02 82; BE -3 . What is the acid base interpretation for this client? A. Respiratory alkalosis with full metabolic acidosis compensation B. Respiratory acidosis with partial metabolic alkalosis compensation. C. Metabolic alkalosis with full respiratory acidosis compensation. D.Metabolic acidosis with full compensation of respiratory alkalosis

Answer: A

The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? A. Frequent swallowing B. Client complaints of discomfort C. Ecchymosis around the client's eyes D. Blood on the external nasal dressing

Answer: A

A client with gastroenteritis has been vomiting for several days and feels weak and exhausted. Which arterial blood gas results should the nurse be expecting for this client? A. pH 7.5 CO2 35 mmHg HCO3- 30 mmHg B.pH 7.2 CO2 37 mmHg HCO3- 17 mmHg C. pH 7.5 CO2 28 mmHg HCO3- 24 mmHg D.pH 7.2 CO2 50 mmHg HCO3- 22 mmHg

Answer: A Rationale: A client with gastroenteritis and vomiting would have metabolic alkalosis due to the loss of chloride in the form of hydrochloric acid from the stomach. Choice B is incorrect because these results indicate metabolic acidosis which is seen with diarrhea due to loss of bicarbonate. Choice C is incorrect because these results indicate respiratory alkalosis which is seen with hyperventilation. Choice D is incorrect because these results indicate respiratory acidosis which is seen in COPD or respiratory depression.

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? A.22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg B.34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C.45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg D. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

Answer: A Rationale: The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible but do not require interventions as quickly as the 22-year-old.

A client is diagnosed with a spontaneous right-sided pneumothorax. What should the nurse expect to assess in this client? A.Hyperresonance on the right side B.Rales on the right side C. Tracheal displacement to the left side D. Hematemesis

Answer: A. Rationale: Hyperresonance over the affected side is an expected assessment finding. Choice B is incorrect because diminished breath sounds and not rales are characteristic of pneumothorax. Choice C is incorrect because in spontaneous pneumothorax tracheal deviation would be towards the affected side. Deviation towards the unaffected side occurs in clients with a tension pneumothorax. Choice D is incorrect because hematemesis is not an expected assessment finding with a pneumothorax.

The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? A. The patient inhales slowly through the nose. B. The patient puffs up the cheeks while exhaling. C. The patient practices by blowing through a straw. D. The patient's ratio of inhalation to exhalation is 1:3

Answer: B

A pt is suspected to have SARS. Which teaching is the most important to prevent transmission of the virus? A.Discard all tissues B.Wear N95 respirator C.Cover mouth and turn head when coughing D.Use meticulous handwashing technique

Answer: B Rationale: SARS is highly contagious

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? A. Call the physician and request a prescription for food and water. B. Provide the client with ice chips instead of a drink of water. C. Assess the client's gag reflex before giving any food or water. D. Let the client have a small sip to see whether he or she can swallow.

Answer: C

An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a constant cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A.Apply a high flow venturi mask B.Encourage the client to drink water C.Assist her to an upright position D.Administer a prescribed sedative

Answer: C

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation of the nurse hears the spoken words "99" very clearly through the stethoscope? A. This is a normal auscultatory finding. B. May indicate pneumothorax. C. May indicate pneumonia. D. May indicate severe emphysema.

Answer: C

A client recovering from surgery who is using a PCA pump with morphine for pain control has a respiratory rate of 7. Arterial blood gas results are pH 7.18, PaCO2 65, and HCO3- 22. What acid-base imbalance is this client demonstrating? A.Metabolic acidosis, uncompensated B.Metabolic acidosis, compensated C.Respiratory acidosis, uncompensated D.Respiratory acidosis, compensated

Answer: C Rationale: A pH of 7.18 indicates acidosis. Normal PaCO2 values range between 34-45 mmHg. A value>45 in combination with an acidic pH indicates respiratory acidosis. Normal HCO3- values range between 26-22 mmHg. An HCO3- of 22 indicates respiratory acidosis that is not compensated. The other choices indicate the interpretation of the client's arterial blood gas values.

A client tells the nurse that he will not accept the annual flu inoculation since every year he develops the flu. Which of the following should the nurse respond to this client? A."Are you sure that you are receiving the right flu vaccination?" B."Everyone reacts to the flu differently. Are you sure you had the flu?" C."It can take up to two weeks after receiving the vaccination for your body to develop antibodies to the illness." D."I would have to agree with you."

Answer: C Rationale: It can take up to two weeks after a vaccination for the body to develop sufficient antibodies. This is what the nurse should respond to and explain to the client. Choice A is incorrect since it does not address why the client does not want to accept future flu vaccinations. Choice B is also incorrect since it questions the clients statement about developing the flu. Choice D is incorrect and an inappropriate statement for the nurse to make to the client.

A client is admitted with multiple injuries sustained from a motor vehicle accident. Which of the following injuries would be the highest priority for the nurse to address? A. Bleeding from a lacerated femoral artery and BP 90/60 mm Hg. B. Scalp lacerations and Glasgow Coma Scale of 10. C. Absent breath sounds over the left lung, distended neck veins, RR 27/min, and pulse 120 bpm. D. Fractured humerus with lack of sensation in the lower arm and hand.

Answer: C. Rationale: Absent breath sounds, distended neck veins, a respiratory rate of 27 and tachycardia are all symptoms of tension pneumothorax. Following A-B-C rules, this injury would be the highest priority for the nurse to address. After stabilizing the client by insertion of a chest tube, the next injury of priority would be Choice A, bleeding from a lacerated femoral artery. Choices B and D can be addressed last. Note: the new C-A-B guidelines (chest compression, airway, breathing) apply ONLY in the event of cardiac arrest when CPR is needed. In all other situations (including trauma), you'll need to follow the ABC guidelines.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? A. The client rates pain as a 5/10 at the site of the procedure. B. A small amount of drainage from the site is noted. C. Pulse oximetry is 93% on 2 liters of oxygen. D. The trachea is deviated toward the opposite side of the neck.

Answer: D

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing patterns related to anxiety. Which nursing action is most appropriate to include in the plan of care? A. Titrate oxygen to keep saturation at least 90% B. Discuss a high-protein, a high-calorie diet with the patient C. Suggest the use of over-the-counter sedative medications. D. Teach the patient how to effectively use pursed lip breathing.

Answer: D

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? A. Schedule the procedure 1 hour after the patient eats. B. Maintain the patient in the lateral position for 20 minutes. C. Perform percussion before assisting the patient to the drainage position. D. Give the ordered albuterol (Proventil) before the patient receives the therapy.

Answer: D

The nurse is assisting the healthcare provider with the removal of a chest tube. The nurse should instruct the patient to do which action? A. Stay still B. Exhale very quickly C. Inhale and exhale very quickly D. Perform the Valsalva removal

Answer: D

A client with a previous diagnosis of chronic obstructive pulmonary disease is recovering from general surgery. Currently, the client is receiving oxygen 4 liters via face mask, has a respiratory rate of 8 per minute, a PaO2 of 96%, and PaCO2 of 30 mm Hg. Which of the following would be indicated for this client? A.Increase the flow of oxygen B. Encourage the use of an incentive spirometer C.Coach to cough and deep breaths D. Reduce the flow of oxygen

Answer: D Rationale: The client has been diagnosed with chronic obstructive pulmonary disease. For COPD patients low O2 levels are the main stimulus to breathe (and not high CO2 levels- as seen in regular patients. We call this hypoxic drive. It can be explained by the fact that the body is adapted to the chronically increased CO2 levels- that are the result of the COPD- Therefore, high CO2 no longer causes "stress.") By administering 4L of oxygen, the patient's oxygen levels will spike. A high O2 level means no breath stimulus (remember: breathing is only stimulated by LOW O2)- therefore, the patient's respiratory rate will drop. In order to improve the client's respiratory rate, oxygen administration should be reduced. Choice A would further reduce the client's respiratory rate.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply. 1. Anosmia 2. Chronic cough 3. Purulent nasal discharge 4. Intolerance to hot weather 5. Intolerance to strong aromas

Answers: 1. Anosmia 2. Chronic cough 3. Purulent nasal discharge Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and strong aromas are not characteristics.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. 1. Dry air 2. Clean air 3. Exercise 4. Rest and sleep 5. An upper respiratory infection (URI) 6. Nonsteroidal antiinflammatory drugs (NSAIDs)

Answers: 1. Dry air 3. Exercise 5. An upper respiratory infection (URI) 6. Nonsteroidal antiinflammatory drugs (NSAIDs) Rationale: Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

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

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

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. 1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 4. Get a flu shot immediately. 5. Eat fruits and vegetables high in vitamin C.

Answers: 1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 5. Eat fruits and vegetables high in vitamin C. Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. 1. Sit upright in the bed or in a chair. 2. Inhale as deeply and quickly as possible. 3. Hold the device in a downward position. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

Answers: 1. Sit upright in the bed or in a chair. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Rationale: For optimal lung expansion with an incentive spirometer, the client should assume a semi Fowler's or high Fowler's position while holding the incentive spirometer in an upright position. The mouthpiece should be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly.

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

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

The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply. 1. The dry suction control regulation set to the prescribed amount 2. The water filled suction control chamber filled to the prescribed amount 3. Increased intermittent bubbling in the water seal chamber when the system is to gravity 4. Continuous bubbling in the water seal chamber when the system is connected to suction 5. The drainage in the collection chamber marked each shift to monitor the amount of drainage

Answers: 1. The dry suction control regulation set to the prescribed amount 5. The drainage in the collection chamber marked each shift to monitor the amount of drainage Rationale: There are 2 types of chest drainage systems: the wet drainage system and the dry drainage system. On routine assessment of the system, the nurse should look at the different chambers. For a dry drainage system, the nurse should check the dry suction control regulation and make sure it is set to the prescribed amount. The nurse should also look for the orange floater ball to appear in the window; this indicates that the suction is being applied correctly. Tidaling should be noted in the water seal chamber. The nurse should also check the water seal chamber; if the system is connected to suction (as opposed to gravity), tidaling may not be seen and the suction should be turned off to check for tidaling. If continuous bubbling is noted or the bubbling increases, an air leak may be present and the connections should be checked. In a dry drainage system, water is not added to the suction control chamber; this is done with a wet drainage system. The drainage collection chamber should be monitored and marked each shift to monitor the amount of drainage, if any.

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

Answers: 2. Cigarette smoking 3. Genetic risk factor 4. Environmental factors 6. Alpha-1 antitrypsin (AAT) deficiency Rationale: Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

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

Answers: 2. Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

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

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

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

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

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

Answers: 3,4,5,6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

Answers: 4 Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside.

Correct Answer: 1, 4, 3, 2, 5 1. The nurse should begin the care by assessing the client. Remember the nursing process. 4. The nurse should have the client's chest and dressing exposed and should check to make sure the chest tube is securely taped at this time. 3. The nurse then follows the chest tube to the drainage system and assesses the system. 2. The last part of the chest tube drainage system to assess is the suction system. 5. The nurse should make sure that emergency supplies are at the bedside last.

The husband of a client diagnosed with a terminal lung cancer asks the nurse, "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate? 1. Notify the social worker about the husband's concerns. 2. Contact the hospital chaplain to talk to the husband. 3. Leave a note on the chart for the HCP to talk to the husband. 4. Reassure the husband that everything will be all right.

Correct answer: 1 1. A social worker is qualified to assist the client with referrals to any agency or personnel that may be needed after the client is discharged home. 2. The chaplain should be contacted if spiritual guidance is required, but the stem did not specify this need. 3. The HCP can talk to the husband but will not be able to address his concerns of taking care of his wife when she is discharged home. 4. This is false reassurance and does not address the husband's concern after his wife is discharged home. The nurse does not know whether everything is going to be all right.

The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of an effective group process? 1. The nurse involves all committee members in the discussion. 2. The nurse makes sure all members of the group agree with the decisions. 3. The nurse asks two of the committee members to do the work. 4. The nurse does not allow deviation from the agenda to occur.

Correct answer: 1 1. Effective group process involves all members of the group. 2. Unanimous decisions may indicate group- think, which can be a problem in a group process. 3. Effective group process involves all members of the group, not just two. 4. Not allowing deviation from the agenda is an autocratic style and limits the creativity and involvement of the group.

Which client should the medical unit nurse assess first after receiving the shift report? 1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. 2. The 25-year-old client diagnosed with influenza who is febrile and has a headache. 3. The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. 4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose.

Correct answer: 1 1. Elderly clients diagnosed with pneumonia may not present with the "normal" symptoms, such as fever. The client's increased restlessness may indicate a decrease in oxygen to the brain. This client should be seen first. 2. The client with influenza would be expected to have an elevated temperature and a headache; therefore, this client would not need to be assessed first. 3. Tidaling in the water-seal compartment is expected; therefore, the nurse would not need to assess this client first. 4. Sinus drainage is to be expected in a client diagnosed with a sinus infection.

The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization? 1. The Commission reviews facilities for compliance with standards of care. 2. Accreditation by the Commission guarantees the facility will be reimbursed for care provided. 3. Accreditation by the Commission reduces liability in a legal action against the facility. 4. The Commission eliminates the need for Medicare to survey a hospital.

Correct answer: 1 1. The Joint Commission is an organization that monitors healthcare facilities for compliance with standards of care. Accreditation is voluntary, but most third-party payers will not reimburse a facility that is not accredited by some outside organization. 2. Accreditation does not guarantee reimbursement, although most third-party payers require some accreditation by an outside organization. 3. Accreditation does not reduce the hospital's liability. 4. Medicare/Medicaid will not review a facility routinely if the Joint Commission has accredited the facility, but a representative will review the facility in cases of reported problems.

The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client's oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner.

Correct answer: 1 1. The client with end-stage COPD usually prefers a cool climate, with fans to help ease breathing. A warm area would increase the effort the client would require to breathe. This action would warrant intervention by the nurse. 2. The client with end-stage COPD should be maintained on a low oxygen rate, such as 2 L/min to prevent depression of the hypoxic drive. High levels of oxygen will depress the client's ability to breathe. This action would not warrant intervention by the nurse. 3. The client will usually sit in the orthopneic position, usually slumped over a bedside table, to help ease breathing. This is called the three-point stance. This action would not warrant intervention by the nurse. 4. The client in end-stage COPD has great difficulty breathing; therefore, sleeping in a recliner is sometimes the only way the client can sleep. This action would not warrant intervention by the nurse.

The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement? 1. Administer oxygen 2 L/min via nasal cannula. 2. Encourage the client to take deep breaths. 3. Administer intravenous sodium bicarbonate. 4. Assess the client's respiratory status.

Correct answer: 1 1. The client's PaO2 is below the normal level of 80-100; therefore, the nurse should administer oxygen. {If all the ABGs values are within normal limits (WNL) except the PaO2 is low, then the pt will be given oxygen}. 2. The client should take deep breaths if the client's PaCO2 is greater than 45 {Respiratory Acidosis}. 3. The nurse should administer sodium bicarbonate if the client's HCO3 is less than 22 {Metabolic Alkalosis}. 4. The client needs oxygen due to the low arterial oxygen level; the client does not need a respiratory assessment.

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.

Correct answer: 2 1. After 3 days, the nurse should suspect that the lung has re-expanded. The nurse should not expect dependent loops to have caused this situation. 2. After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse's first intervention. 3. This will be done if it is determined the lungs have re-expanded, but it is not the first intervention. 4. The nurse should notify the HCP if it is determined the lungs have re-expanded; a chest x-ray can be taken prior to removing the chest tubes.

The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first? 1. The elderly client with pneumonia who reports being dizzy when getting up. 2. The client with cystic fibrosis who needs a prescription for pancreatic enzymes. 3. The client with lung cancer on chemotherapy who reports nausea. 4. The client with pertussis who reports coughing spells so severe that they cause vomiting.

Correct answer: 1 1. The elderly client should be called first so that the nurse can determine whether the dizziness when getting up is the result of medication or some other reason. Orthostatic hypotension can be life threatening; therefore, this client may need to be assessed immediately. 2. Ordering a prescription is not priority over a client with a physiological problem. 3. Nausea is often expected with chemotherapy; therefore, this client's phone call would not be returned prior to calling a client with a potentially life-threatening problem. 4. Pertussis—known as whooping cough—is a serious, very contagious disease that causes severe, uncontrollable coughing fits. The coughing makes it difficult to breathe and often ends with a "whoop" noise. Because coughing spells are expected, the nurse would not call this client first

The clinic nurse is reviewing laboratory results for clients seen in the clinic. Which client requires additional assessment by the nurse? 1. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%. 2. The client who has a WBC count of 9.0 mm3. 3. The client who has a serum potassium level of 4.8 mEq/L. 4. The client who has a serum sodium level of 137 mEq/L.

Correct answer: 1 1. The normal hemoglobin level is 12 to 15 g/dL, and normal hematocrit is 39% to 45%. This client's H&H is low. The nurse should contact the client and make an immediate appointment. 2. The normal WBC count is 4.0 to 10.0 mm3. This client's WBC count is within normal range and does not warrant intervention from the clinic nurse. 3. The normal serum potassium level is 3.5 to 5.5 mEq/L. This client's level is within normal range and does not warrant intervention from the clinic nurse. 4. The normal serum sodium level is 135 to 145 mEq/L. This client's level is within the normal range, and the client does not warrant intervention from the clinic nurse.

At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client's chart. Which is the most appropriate response by the charge nurse? 1. Call the lab and have the lab supervisor talk with the HCP. 2. Discuss the HCP's complaints with the nursing supervisor. 3. Form a committee of lab and nursing personnel to fix the problem. 4. Tell the HCP to stop yelling and calm down.

Correct answer: 1 1. The problem is not a nursing problem. The HCP should be discussing the problem with an individual from the department that "owns" the problem. 2. This is not a nursing problem. 3. This is not a nursing problem. 4. This will only make the HCP angrier. The HCP should be directed to discuss the problem with the department that can "fix" the problem.

The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.

Correct answer: 1 1. These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. 2. The PaO2 level is within normal limits, 80 to 100. Administering oxygen is not the first intervention. 3. The nurse knows the arterial blood gas oxygen level, which is an accurate test. The pulse oximeter only provides an approximate level. 4. This is not the first intervention. The nurse can intervene to treat the client before notifying the HCP.

The emergency department nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure? 1. Have the client sit upright and bend over the over bed table. 2. Place the client in the left lateral recumbent position. 3. Have the client sit on the side of the bed with the back arched like a Halloween cat. 4. Place the client lying on the back with the head of the bed up 45 degrees.

Correct answer: 1 1. This position allows for access to the client's back area. The chest tube for a hemothorax is positioned low and posterior to allow for gravity to assist in the removal of fluid from the thoracic area. 2. This is the position for giving an enema. 3. This is the position used to assist with a lumbar puncture. 4. This is a resting position; it is not preparing for a chest tube placement.

The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse? 1. "I do not give her a lot of fluids so she won't wet the bed." 2. "I perform passive range-of-motion exercises every morning." 3. "I put her on her side so that there will be no pressure on her butt." 4. "I do not pull her across the sheets when I am moving her in bed."

Correct answer: 1 1. This statement warrants intervention because fluids will help prevent dehydration and renal calculi. The nurse should explain the client needs to increase fluids. 2. ROM exercises help prevent deep vein thrombosis (DVT). This statement does not require intervention by the nurse. The UAP can perform skills if taught and performance is evaluated by the nurse. 3. Keeping the client off the buttocks is an appropriate intervention for a client on strict bed rest. This comment does not require intervention by the nurse. 4. Pulling the client across the sheets will cause skin breakdown. Because the UAP is not doing this, no intervention by the nurse is needed.

Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Perform mouth care on the client with pneumonia. 2. Apply oxygen via nasal cannula to the client. 3. Empty the trashcans in the clients' rooms. 4. Take the empty blood bag back to the laboratory. 5. Show the client how to ambulate on the walker.

Correct answer: 1 and 4 1. The UAP can perform mouth care on a client who is stable.2. Oxygen is a medication and the nurse cannot delegate medication administration to the UAP.3. The housekeeping staff empty trashcans, not the UAP. Remember not to assign tasks that should be done by another hospital department.4. The UAP can take the empty blood bag to the laboratory.5. The nurse cannot delegate teaching to the UAP.

The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form? 1. The 16-year-old married client who is diagnosed with an ectopic pregnancy. 2. The 39-year-old client diagnosed with paranoid schizophrenia. 3. The 50-year-old client who admits to being a recovering alcoholic. 4. The 84-year-old client diagnosed with chronic obstructive pulmonary disease (COPD).

Correct answer: 2 1. An emancipated minor under the age of 18 but married or independently earning his or her own living would not warrant the nurse's questioning whether she should sign the permit. "Married" indicates an independently functioning individual. 2. An incompetent client cannot sign the consent form. An incompetent client is an individual who is not autonomous and cannot give or withhold consent, for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. The client may be able to sign the permit, but the nurse should question the client's ability to sign the permit because paranoid schizophrenia is a mental illness. 3. A recovering alcoholic is not considered incapacitated. If the client is currently under the influence of alcohol, then the permit could not legally be signed by the client. 4. The elderly client is considered competent until deemed incompetent in a court of law or meets the criteria to be considered incompetent.

he nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site.

Correct answer: 2 1. Consolidation indicates fluid or exudates in the lung—pneumonia. This would not indicate the client is improving. 2. Bilateral breath sounds indicate the left lung has re-expanded and the treatment is effective. 3. Vigorous bubbling in the suction chamber indicates that there is a leak in the system, but this does not indicate the treatment is effective. 4. Crepitus (subcutaneous emphysema) indicates that oxygen is escaping into the subcutaneous layer of the skin, but this does not indicate the lung has re-expanded, which is the goal of the treatment.

The nurse caring for client BC is preparing to administer medications. Based on the laboratory data given in this table, which intervention should the nurse implement? 1. Administer warfarin (Coumadin) IVP. 2. Continue the heparin drip. 3. Hold the next dose of warfarin. 4. Administer the daily aspirin.

Correct answer: 2 1. Coumadin is an oral, not intravenous, medication. 2. The therapeutic PTT results should be 1.5 to 2 times the control, or 51 to 68 seconds. The client's value of 53 is within the therapeutic range. The nurse should continue the heparin drip as is. 3. The INR is 1.7, not up to therapeutic range yet, so warfarin (Coumadin) should be administered. 4. These lab values do not provide any information about aspirin administration, but the nurse should ask the HCP whether aspirin (an antiplatelet) should be discontinued because the client is receiving two anticoagulants—heparin and warfarin.

The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first? 1. The patient diagnosed with end-stage COPD complaining of shortness of breath after ambulating to the bathroom. 2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication. 3. The patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the laboratory. 4. The patient diagnosed with an empyema who has a temperature of 100.8°F, pulse of 118, respiration rate of 26, and BP of 148/64.

Correct answer: 2 1. Shortness of breath after ambulating is expected for a patient diagnosed with COPD. 2. Patients diagnosed with deep vein thrombosis are at risk for pulmonary embolism (PE). Anxiety is a symptom of PE. The nurse must determine if interventions are needed for PE, a life-threatening emergency. 3. Anyone can take a specimen to the laboratory. 4. An empyema is an abscess in the thoracic cavity. These vital signs would be expected for this patient.

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider's order should be implemented first? 1. 1,000 mL normal saline at 125 mL/hour. 2. Obtain sputum for Gram stain and culture. 3. Ceftriaxone (Rocephin) 1,000 mg IVPB every 12 hours. 4. Ultrasonic nebulization treatment every 6 hours.

Correct answer: 2 1. Starting an intravenous line must be done prior to being able to initiate a piggyback medication. 2. In order to treat the client with the most effective medication and not skew the results of a sputum culture, the specimen must be obtained prior to initiating antibiotics. 3. New orders for intravenous antibiotics must be considered a priority to prevent the client from going into gram-negative sepsis, a potentially lethal situation. However, in order to initiate the antibiotic the nurse must make sure a correct diagnosis is able to be made. 4. Respiratory treatments are important, but not before starting the antibiotics.

The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client's surgical dressing.

Correct answer: 2 1. The client is in distress; therefore, the nurse should do something to help the client. {In distress Do NOT Assess} 2. The Rapid Response Team was mandated by The Joint Commission. It is a team of healthcare professionals who respond to clients who are breathing but who the nurse thinks are in an emergency situation. A code is called if the client is not breathing. 3. The Trendelenburg position is used for a client who is in hypovolemic shock, so this would not be appropriate for a client in respiratory distress. 4. The stem of the question provides enough information to indicate the client is in distress, and assessing the surgical dressing will not help the client. {In distress Do NOT Assess}

The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client's oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths.

Correct answer: 2 1. The client's oxygen should always be placed correctly but it is not the priority intervention for difficulty breathing. 2. Because the client has difficulty breathing while lying in bed, allowing the client to sit in a recliner will help the client; therefore, this is the priority intervention. 3. Often clients report a fan blowing on the face helps with difficulty breathing but this is not a priority intervention. 4. Slow, deep breaths will not help the client with difficulty breathing as much as will sitting in a recliner.

The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first? 1. Complete the accident/occurrence report. 2. Immediately wash the area with soap and water. 3. Ask the client whether he or she has AIDS or hepatitis. 4. Place an antibiotic ointment and bandage on the site.

Correct answer: 2 1. The documentation of the accident must be completed but it is not priority over caring for the wound first. 2. The nurse should wash the area with soap and water and attempt to squeeze the area to make it bleed. 3. The nurse should not ask this question directly to the client. The nurse could ask whether the client would agree to have blood drawn for testing, but not directly ask whether the client has AIDS or hepatitis. 4. The puncture site would not require antibiotic ointment unless it is infected, which it wouldn't be immediately after the incident.

The female charge nurse on the respiratory unit tells the male nurse, "You are really cute and have a great body. Do you work out?" Which action should be taken by the male nurse if he thinks he is being sexually harassed? 1. Document the comment in writing and tell another staff nurse. 2. Ask the charge nurse to stop making comments like this. 3. Notify the clinical manager of the sexual harassment. 4. Report this to the corporate headquarters office.

Correct answer: 2 1. The male nurse should document the comment and tell other people, such as family, friends, and staff, but this is not the nurse's first intervention. 2. The first action is to ask the person directly to stop. The harasser needs to be told in clear terms that the behavior makes the nurse uncomfortable and that he wants it to stop immediately. 3. The male nurse could take this action, but it is not the first action. 4. This male nurse could take this action, but only if direct contact and the chain of command at the hospital do not stop the charge nurse's behavior.

The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the client's lung sounds. 2. Check for any kinks in the tubing. 3. Ask the client to take deep breaths. 4. Turn the client from side to side.

Correct answer: 2 1. The nurse should assess the client's breath sounds but not prior to determining why there is no tidaling in the water-seal chamber. 2. The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted, it is probably a kink or a dependent loop, or the client is lying on the tubing. The nurse should first check for this prior to taking any other action. {However, if there's no fluctuation in the water-seal chamber of the Pleurovac a couple of days after the insertion of the chest tube, then most likely the lungs have expanded and the pt does not need the chest tube anymore; so first the nurse will auscultate the lung sounds and if clear, a CXR will be done to confirm no more hemo/pneumothorax after which the chest tube will be removed BY THE PROVIDER, NOT the nurse} 3. The nurse should encourage the client to take deep breaths and cough, which may push a clot through the tubing, but should not do so before checking for a kink. 4. Turning the client side to side will not help determine why there is no tidaling in the water-seal compartment of the Pleurovac.

The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first? 1. Type and crossmatch the client for PRBCs. 2. Start two IVs with large-bore catheters. 3. Obtain the client's history and physical. 4. Check the client's allergies to medications.

Correct answer: 2 1. The nurse should first prevent circulatory collapse by starting two IVs and initiating normal saline or Ringer's lactate. The cross- match may be needed if the shock condition is caused by hemorrhage. 2. The client is exhibiting symptoms of shock. The nurse should start IV lines to prevent the client from progressing to circulatory collapse. 3. All clients have a history taken and physical examination performed as part of the admission process to the emergency department, but this is not the first intervention. 4. Checking the client's allergies to medications is important, but it is not the first intervention in a client exhibiting signs of shock.

In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse? 1. Do not approach the staff member in the restaurant. 2. Ask the staff member not to discuss anything about the client. 3. Contact the staff member's clinical manager and report the behavior. 4. Tell the client that the staff member was discussing confidential information.

Correct answer: 2 1. The staff member is violating HIPAA, and the nurse should take action immediately. 2. The nurse should first ask the staff member not to discuss the client with a friend. Discussing any information about a client is a violation of HIPAA. 3. The nurse should address the staff member in the restaurant. The nurse could tell the clinical manager, but the nurse must stop the conversation in the restaurant immediately. 4. The nurse should not tell the client about the breach of confidentiality.

The respiratory unit nurse is calculating the shift intake and output for a client diagnosed with right-sided chest tube. The client has received 1,500 mL of D5W, IVPB of 100 mL of 0.9% NS, 12 ounces of water, 6 ounces of milk, and 4 ounces of chicken broth. The client has had a urinary output of 800 mL and chest drainage of 125 mL. What is the total intake and output for this client? _______ mL intake; _______ mL output

Correct answer: 2160 mL intake and 925 mL output The urinary output is not used in this calculation. The nurse must add up both intravenous fluids and oral fluids to obtain the total intake for this client; 1500 + 100 = 1500 IV fluids; (1 ounce = 30 mL) 12 ounces ? 30 mL = 360 mL, 6 ounces ? 30 mL = 180 mL, 4 ounces ? 30 mL = 120 mL; 360 + 180 + 120 = 660 oral fluids. Total intake is 1,500 + 660 = 2,160. The urinary output 800 mL plus chest drainage 125 mL equals 925 mLs for shift output.

The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client's priority nursing diagnosis? 1. Activity intolerance. 2. Altered coping. 3. Impaired gas exchange. 4. Self-care deficit.

Correct answer: 3 1. Activity intolerance is not priority over gas exchange. If gas exchange does not occur, the client will die. 2. Coping is a psychosocial problem, and physiological problems are priority. 3. Impaired gas exchange is the priority problem for this client. If the client does not have adequate gas exchange, the client will die. Remember Maslow's Hierarchy of Needs. 4. Self-care deficit is not priority over gas exchange.

The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.

Correct answer: 3 1. Although these are abnormal ABG values, respiratory acidosis, they are expected in a client with COPD; therefore, the nurse would not need to see this client first. 2. The client with ARDS would be expected to have a low arterial oxygen level; therefore, the nurse would not assess this client first. 3. The ABG shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature. 4. These are normal ABGs; therefore, the nurse would not need to assess this client first.

The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN? 1. The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. 2. The client diagnosed with pneumonia whose pulse oximeter reading is 90%. 3. The client with acute bronchitis who has a chronic clear mucous cough and low fever. 4. The client with reactive airway disease who has bilateral wheezing.

Correct answer: 3 1. An induration greater than 10 mm is positive for tuberculosis. This client needs to be assessed and followed up to rule out tuberculosis. This client should not be assigned to an LPN. 2. A pulse oximeter reading less than 93% is life threatening; therefore, this client should not be assigned to an LPN. 3. Acute bronchitis is an inflammation of the bronchial tubes, the major airways into the lungs. The client is exhibiting expected signs/symptoms; therefore, the LPN could care for this client. 4. The client is exhibiting wheezing, an acute exacerbation of reactive airway disease. This client should be assigned to a nurse.

The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take? 1. Ask the husband to allow his wife to answer the questions. 2. Request the husband to leave the examination room. 3. Continue to allow the husband to answer the wife's questions. 4. Do not ask any further questions until the client starts answering.

Correct answer: 3 1. In the Hispanic culture, the husband often speaks for the wife and family, and requesting the husband not to speak may be insulting. This action may cause the wife to leave as well. 2. In the Hispanic culture, the husband often is the spokesperson and makes decisions for the wife and family. Asking the husband to leave the room may cause the client to leave as well. 3. This behavior may be cultural, and the nurse should continue to allow the husband to answer the questions, while the nurse looks at the client. The nurse must be respectful of the client's culture. The nurse can, however, ask whether the client agrees with the husband's answers. 4. This is disrespectful to the client's culture. Many times the nurse must honor the client's culture while caring for the client.

The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?" Which statement is the nurse's best response? 1. "Take prophylactic antibiotics for 10 days after being exposed to influenza." 2. "Stay away for large crowds and wear a scarf over your mouth during cold weather." 3. "The best way to prevent getting influenza is to get a yearly flu vaccine." 4. "You must eat three well-balanced meals a day and exercise daily to prevent influenza."

Correct answer: 3 1. Influenza, or the flu, is a serious respiratory illness caused by a virus. Antibiotics are not prescribed to treat influenza. 2. Staying away from large crowds and a scarf over the mouth is not the best way to prevent getting influenza. 3. Influenza, or flu, is a serious respiratory illness. It is easily spread from person to person and can lead to severe complications, even death. The best way to prevent the influenza is to get a flu vaccine every year. The influenza virus is constantly changing. Each year, scientists work together to identify the virus strains that they believe will cause the most illness, and a new vaccine is made based on their recommendations. 4. Three meals a day and daily exercise will help the client stay healthy in general but it is not the best way to prevent getting influenza.

The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client's output is greater than the intake.

Correct answer: 3 1. Jugular vein distention would indicate the client has CHF. This is not a complication of a loop diuretic. 2. Rales and rhonchi are symptoms of pulmonary edema, not a complication of a loop diuretic. 3. Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic. {You MUST know the meds, Bumetanide is a loop diuretic, similar to Furosemide, NEED TO KNOW hypokalemia is a serious side effect of both} 4. This would indicate the medication is effective and is not a complication of the medication.

The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients. 2. The bed baths and oral care. 3. Evaluating the client's progress. 4. Transporting a client to dialysis.

Correct answer: 3 1. The LPN may be assigned to administer the routine oral medications to the clients. 2. Bed baths and oral care can be performed by the UAP. 3. The nurse cannot delegate or assign tasks that require nursing judgment, such as evaluating a client's progress. 4. The UAP can transport a client to dialysis

The UAP enters the elderly female client's room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP? 1. Tell the UAP to complete the bath at this time. 2. Have the UAP skip the client's bath for the day. 3. Instruct the UAP to give the bath after the program. 4. Document the attempt to give the bath as refused.

Correct answer: 3 1. The UAP should be sensitive to the client's preferences and not insist that the client miss the program. 2. The UAP should arrange an acceptable time for the client, and the UAP can return to complete the task at the agreed-on time. 3. This is the best instruction for the nurse to give to the UAP. 4. The bath has not been refused. The client does not want the program interrupted.

The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs? 1. Assess the client to rule out any complications secondary to the client's pain. 2. Determine the last time the client was medicated for abdominal pain. 3. Check the amount of suction on the client's nasogastric tube. 4. Administer intravenous sodium bicarbonate to the client.

Correct answer: 3 1. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 2. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 3. The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the N/G tube. Therefore, the nurse should check the N/G wall suction. 4. Sodium bicarbonate is administered for metabolic acidosis not metabolic alkalosis.

The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first? 1. The healthcare provider. 2. The unit manager. 3. The respiratory therapist. 4. The case manager.

Correct answer: 3 1. The client's HCP should be consulted if the nurse determines a need, but at this time, the nurse should discuss the client with the respiratory therapist. 2. The unit manager may or may not be capable of helping the nurse assess a client with adventitious breath sounds; therefore, this is not the first person the nurse should consult. 3. Respiratory therapists assess and treat clients with lung problems multiple times every day. Therefore, this is the best person to consult when the nurse needs help identifying a respiratory problem. 4. The case manager is usually capable of maneuvering through the maze of healthcare referrals, but is not necessarily an expert in lung sounds.

The charge nurse in the intensive care unit asks a nurse to float from the medical/ surgical unit to the ICU. Which client should the charge nurse assign to the float nurse? 1. The client who is 3 hours postoperative lung transplant. 2. The client who has a central venous pressure of 13 cm H2O. 3. The client who is diagnosed with bacterial pneumonia. 4. The client who is diagnosed with Hantavirus pulmonary syndrome.

Correct answer: 3 1. This client is critical and there is a possibility of organ rejection; therefore, this client should not be assigned to a float nurse. 2. The normal CVP is 4-10 cm H2O and an elevated CVP indicates right ventricular failure or volume overload; therefore, this client should not be assigned to a float nurse. 3. The float nurse from the medical unit is able to administer antibiotic therapy and complete respiratory assessments; therefore, this client would be the most appropriate client to assign to the float nurse. 4. Hantavirus pulmonary syndrome is a disease that results from contact with infected rodents or their urine, droppings, or saliva. HPS is potentially deadly. There is no specific treatment for HPS, and there is no cure. This client should be assigned to a more experienced nurse.

The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select the patient/patients that apply. 1. The client who had four coronary artery bypass grafts 3 days ago. 2. The client who has anterior and posterior chest tubes after a motor vehicle accident. 3. The client who will be moved to the intensive care unit when a bed is available. 4. The client who has a do not resuscitate order and is requesting to see a chaplain. 5. The client who is on multiple intravenous drip medications needed to be titrated.

Correct answer: 3 and 5 1. This client is nearing discharge status. Postoperative clients are progressed rapidly. A medical-surgical nurse could take care of this client. 2. Chest tubes are frequently cared for on a medical-surgical unit, the medical-surgical nurse can care for this client. 3. This client's status is uncertain. The ICU nurse would be an appropriate assignment for this client since the patient will be moved to ICU soon. 4. A medical-surgical nurse can care for this client. 5. The intensive care nurse should care for this client requiring titration of multiple medications simultaneously.

Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? 1. Changing the client's subclavian dressing. 2. Reinserting the client's Foley catheter. 3. Demonstrating ambulation with a walker. 4. Getting the client up in a chair three times a day.

Correct answer: 4 1. The UAP cannot perform sterile dressing changes. 2. The UAP cannot perform sterile procedures. 3. The UAP cannot teach the client. 4. The UAP can transfer the client from the bed to the chair three times a day.

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is most important for the nurse to ask the client? 1. "Have you ever had a chest x-ray before?" 2. "Can you hold your breath for a minute?" 3. "Do you smoke or have you ever smoked cigarettes?" 4. "Is there any chance you may be pregnant?"

Correct answer: 4 1. The nurse could ask this question because the radiologist may need to compare the previous chest x-ray with the current one, but this is not the most important question. 2. The client will have to hold her breath when the chest x-ray is taken, but this is not the most important question. 3. Smoking or a history of smoking is pertinent to the diagnosis of pneumonia, but it is not the most important question. 4. This is the most important question because if the client is pregnant, the x-rays can harm the fetus.

The clinic nurse is scheduling a 14-year-old client for a tonsillectomy. Which intervention should the clinic nurse implement? 1. Obtain informed consent from the client. 2. Send a throat culture to the laboratory. 3. Discuss the need to cough and deep breathe. 4. Request the laboratory to draw a PT and a PTT.

Correct answer: 4 1. The parent/guardian must sign the consent for surgery because the client is under the age of 18. 2. The client has already been diagnosed with tonsillitis; therefore, a throat culture is not needed prior to surgery. 3. The client should not cough after this surgery because it could cause bleeding from the incision site. 4. A PT/PTT will assess the client for any bleeding tendencies. This is priority before this surgery because bleeding is a life-threatening complication.

he nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP since this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

The client diagnosed with COPD needs oxygen at all times, especially when exerting energy such as ambulating to the bathroom. 2. The client needs the oxygen, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. 3. The nurse should not verbally correct a UAP in front of the client; the nurse should correct the behavior and then talk to the UAP in private. 4. The primary nurse should confront the UAP and take care of the situation. Continued unsafe client care would warrant notifying the charge nurse. TEST-TAKING HINT: The test taker must know management concepts, and the nurse should first address the behavior with the person directly, then follow the chain of command.