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"124.A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1.An obstruction is present in the chest tube. 2.The client is developing subcutaneous emphysema. 3.The chest tube system is functioning properly. 4.There is a leak in the chest tube system.

"145.Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? 1.Tracheostomy. 2.Use of a nasal cannula. 3.Mechanical ventilation. 4.Insertion of a chest tube.

"150.A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? 1.Initiate gastric lavage. 2.Maintain body temperature. 3.Administer 100% oxygen by mask. 4.Obtain a psychiatric referral.

3 "Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature; thus, steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate."

"42.A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: 1.A mild but constant aching in the chest. 2.Severe midsternal pain. 3.Moderate pain that worsens on inspiration. 4.Muscle spasm pain that accompanies coughing.

3 "Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.

"156.Which of the following individuals has the highest priority for receiving seasonal influenza vaccination? 1.A 60-year-old man with a hiatal hernia. 2.A 36-year-old woman with three children. 3.A 50-year-old woman caring for a spouse with cancer. 4.A 60-year-old woman with osteoarthritis.

3 "Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described because her husband is likely to be immunocompromised and particularly susceptible to the flu. A healthy 60-year-old man or a healthy 36-year-old woman is not in a high-priority category for influenza vaccination. A 60-year-old woman with osteoarthritis does not have a higher priority for influenza vaccination than a home care provider."

82.The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan? 1.Clubbing of nail beds. 2.Hypertension. 3.Peripheral edema. 4.Increased appetite.

3 "Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites."

160.While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first action should be to: 1.Push the "code blue" (emergency response) button. 2.Call the rapid response team. 3.Open the client's airway. 4.Call for a defibrillator.

3 "The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be necessary nor the appropriate action once the client's airway has been opened."

"135.The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1.The family is coming in to visit. 2.The client has increased secretions requiring frequent suctioning. 3.The SpO2 and PO2 have decreased. 4.The client is tachycardic with drop in blood pressure. 5.The face has increased skin breakdown and edema.

3 4 5 "The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern."

"153.The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation? 1.Standard precautions. 2.Contact precautions. 3.Droplet precautions. 4.Airborne precautions.

151.A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: 1.Put all four side rails up on the bed. 2.Ask the unlicensed personnel to place restraints on the client's upper extremities. 3.Request that the client's roommate put the call light on when the client is attempting to get out of bed. 4.Check on the client at regular intervals to ascertain the need to use the bathroom.

38.Penicillin has been prescribed for a client admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the client: 1."Do you have a history of seizures?" 2."Do you have any cardiac history?" 3."Have you had any recent infections?" 4."Have you had a previous allergy to penicillin?

144.A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/L). The nurse determines that which of the following is a possible cause for these findings? 1.Chronic obstructive pulmonary disease (COPD). 2.Diabetic ketoacidosis with Kussmaul's respirations. 3.Myocardial infarction. 4.Pulmonary embolus

4 "A PaCO2 of 28 mm Hg (3.7 kPa) and PaO2 of 50 mm Hg (6.7 kPa) are both abnormal; the PaO2 of 50 mm Hg (6.7 kPa) signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin."

"147.Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1.Assessing the client's skin color. 2.Monitoring the respiratory rate. 3.Verifying the amount of cuff inflation. 4.Auscultating breath sounds bilaterally.

4 "Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the endotracheal tube."

138.Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1.Teaching cigarette smoking cessation. 2.Maintaining adequate serum potassium levels. 3.Monitoring clients for signs of hypercapnia. 4.Replacing fluids adequately during hypovolemic states.

4 "One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS."

136.The nurse has calculated a low PaO2/FIO2 (P/F) ratio less than 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? 1.Supine. 2.Semi-Fowler's. 3.Lateral side. 4.Prone.

4 "Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees."

148.Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1.Administering oxygen every 2 hours. 2.Turning the client every 4 hours. 3.Administering sedatives to promote rest. 4.Suctioning if cough is ineffective.

4 "The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress because sedatives can depress respirations.

146.Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? 1.Septic shock. 2.Chronic obstructive pulmonary disease. 3.Asthma. 4.Heart failure

90. A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 (6.4 kPa); Po2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which of the following prescriptions should the nurse perform first? 1.Albuterol nebulizer. 2.Chest x-ray. 3.Ipratropium inhaler. 4.Sputum culture.

152.Which of the following is an expected outcome for a client with carbon dioxide poisoning? 1.A relatively matched ventilation-to-perfusion ratio. 2.A low ventilation-to-perfusion ratio. 3.A high ventilation-to-perfusion ratio. 4.An equal PaO2 and PaCO2 ratio.

1 "In the normal lung, the volume of blood perfusing the lungs each minute is approximately equal to the amount of fresh gas that reaches the alveoli each minute. Blood gas analysis evaluates respiratory function; the level of dissolved oxygen (PaO2) should be greater than the level of dissolved carbon dioxide (PaCO2)."

"142.A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. The nurse should report which of the following to the health care provider? 1.Arterial oxygen level of 46 mm Hg. 2.Respirations of 12. 3.Lack of adventitious lung sounds. 4.Oxygen saturation of 96% on room air.

1 "Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg to the health care provider. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation."

143.A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which of the following conclusions would be accurate? 1.The client is severely hypoxic. 2.The oxygen level is low but poses no risk for the client. 3.The client's PaO2 level is within normal range. 4.The client requires oxygen therapy with very low oxygen concentrations.

1 "Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When PaO2 falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg (7.3 to 8 kPa) or more."

141.A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for: 1.Initiating IV sedation. 2.Starting a high-protein diet. 3.Providing pain medication. 4.Increasing the ventilator rate.

1 "The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate."

149.Which of the following complications is associated with mechanical ventilation? 1.Gastrointestinal hemorrhage. 2.Immunosuppression. 3.Increased cardiac output. 4.Pulmonary emboli.

1 149. 1. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis."

46.The client with pneumonia develops mild constipation, and the nurse administers docusate sodium (Colace) as prescribed. This drug works by: 1.Softening the stool. 2.Lubricating the stool. 3.Increasing stool bulk. 4.Stimulating peristalsis

1 Docusate sodium (Colace) is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis"

157.The nurse is a member of a team that is planning a client-centered approach to care of clients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply 1.The community. 2.Clinical information systems. 3.Delivery system design. 4.Administrative leadership. 5.Emphasis on the acute care setting.

1 2 3 "The process of changing a health care system from an acute care model to a CCM uses continuous quality improvement (CQI) methods. The goal of the CCM is to improve the health of chronically ill clients. The CCM identifies six basic areas upon which health care organizations need to focus to improve quality of care and delivery: health systems, delivery system design, decision support, clinical information systems, self-management support, and the community. This system requires health care services that are client-centered and coordinated among members of the health care staff and the client and the family. CCM does not focus on the administrative leadership or the care in the acute care setting alone."

"159.The nurse is caring for a client who has been placed on droplet precautions. Which of the following protective gear is required to take care of this client? Select all that apply. 1.Gloves. 2.Gown. 3.Surgical mask. 4.Glasses. 5.Respirator.

1 2 3 4

32.The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority in what order the nurse would assess these clients after receiving report. 1. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath. 2. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain. 3. A 35-year-old client with suspected tuberculosis who has a cough. 4. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.

1 2 4 3

"137.A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1.Monitor serum creatinine and blood urea nitrogen levels. 2.Administer a sedative. 3.Keep the head of the bed flat. 4.Administer humidified oxygen. 5.Auscultate the lungs.

1 4 5 "Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis."

Pseudoephedrine (Sudafed) has been prescribed as a nasal decongestant. Which of the following is a possible adverse effect of this drug? A. Constipation B. Bradycardia C. Diplopia D. Restlessness

D. Restlessness Rationale: -Adverse effects of pseudoephedrine (Sudafed) are experienced primarily in the cardiovascular system and through sympathetic effects on the CNS. The most common CNS adverse effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular adverse effects include tachycardia, hypertension, palpitations, and arrhythmias. -Constipation and diplopia are not adverse effects of Sedated. -Tachycardia, not bradycardia, is an adverse effect of Sudafed.

"33.An elderly client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. The nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? 1.Perform circulation checks to bilateral upper extremities each shift. 2.Attach the ties of the restraints to the bed frame. 3.Reevaluate the need for restraints and document weekly. 4.Ensure the restraint order has been signed by the physician within 72 hours.

"A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. pH 7.35 PaCo2 25 Hco3 22 Pao2 95 1. pH 2.PaCO2. 3.HCO3-. 4.PaO2.

139.The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? 1.Elevated carbon dioxide level. 2.Hypoxia not responsive to oxygen therapy. 3.Metabolic acidosis. 4.Severe, unexplained electrolyte imbalance

2 "A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

128.A client undergoes surgery to repair lung injuries. Postoperative prescriptions include the transfusion of one unit of packed red blood cells at a rate of 60 mL/h. How long will this transfusion take to infuse? 1.2 hours. 2.4 hours. 3.6 hours. 4.8 hours.

2 "One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia."

154.A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. 1.Administer the cefazolin. 2.Verify the medication prescription as written by the physician. 3.Contact the pharmacy and speak to a pharmacist. 4.Request that cephalexin be sent promptly. 5.Return the cefazolin to the pharmacy.

2 3 4 5

105.The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client? 1."It's okay to be scared. What is it about cancer that you're afraid of?" 2."It's normal to be scared. I would be, too. We'll help you through it." 3."Don't be so hard on yourself. You don't know if your smoking caused the cancer." 4."Do you feel guilty because you smoked?"

107.Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer? 1.The support available to assist the client at home." 2.The distance the client lives from the hospital. 3.The client's ability to do home blood pressure monitoring. 4.The client's knowledge of the causes of lung cancer.

40.Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's: 1.Decreased cellular demand for oxygen. 2.Reduced episodes of coughing. 3.Diminished pain when breathing deeply. 4.Ability to expectorate secretions more easily.

1 " Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body's need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths.

"102.The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should: 1.Assess breath sounds. 2.Remove the catheter. 3.Insert a peripheral IV. 4.Reposition the client.

1 " The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client. Repositioning may be considered after assessments are done."

73.When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to: 1.Develop respiratory infections easily. 2.Maintain current status. 3.Require less supplemental oxygen. 4.Show permanent improvement.

1 "A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely."

99.Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma? 1.Cough productive of yellow sputum. 2.Bilateral expiratory wheezing. 3.Chest tightness. 4.Respiratory rate of 30 breaths/min.

1 "A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present."

127.For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal? 1.Pain rating of 0 on a scale of 0 to 10 by the client. 2.Decreased client anxiety. 3.Respiratory rate of 26 breaths/min. 4.PaO2 of 70 mm Hg (9.31 kPa).

1 "If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/min is not within normal limits, nor is the PaO2 of 70 mm Hg (9.31 kPa), but these values are not measures of pain relief."

115.A client has a chest tube attached to a water-seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine that: 1.The lung has fully expanded. 2.The lung has collapsed. 3.The chest tube is in the pleural space. 4. The mediastinal space has decreased

1 "Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been re-established; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluctuation occurs because, during inspiration, intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space. CN: Physiological adaptation; CL: Analyze

134.When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should chart the breathing pattern as: 1.Cheyne-Stokes respiration. 2.Hyperventilation. 3.Obstructive sleep apnea. 4.Bior's respiration.

1 "Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is the increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Bior's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea"

29.A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care? 1.Maintain the head of the bed at 30 to 40 degrees. 2.Teach the client how to use esophageal speech. 3.Initiate small feedings of soft foods. 4.Irrigate drainage tubes as needed.

1 "Immediately after surgery, the client should be maintained in a position with the head of the bed elevated 30 to 40 degrees (semi-Fowler's position) to decrease tissue edema, facilitate breathing, and decrease pain related to edema formation. Immediately postoperatively, the client should be provided alternative means of communicating, such as a communication board. As healing progresses and edema subsides, a speech therapist should work with the client to explore various voice restoration options, such as the use of a voice prosthesis, electrolarynx, artificial larynx, or esophageal speech. Food is not initiated in the immediate postoperative phase; enteral feedings are usually used to meet nutritional needs until edema subsides. Irrigation of the drainage tubes is an inappropriate action."

117.A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should: 1.Check the tubing to ensure that the client is not lying on it or kinking it. 2.Increase the suction. 3.Lower the drainage bottles 2 to 3 feet (61 to 91.4 cm) below the level of the client's chest. 4.Ensure that the chest tube has two clamps on it to prevent air leaks.

1 "In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from re-expanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a physician's prescription. The normal position of the drainage bottles is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done. CN: Physiological adaptation; CL: Synthesize

93.A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? 1.Irregular heartbeat. 2.Constipation. 3.Pedal edema. 4.Decreased pulse rate.

1 "Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia."

"104.A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increases the client's risk of developing postoperative pulmonary complications? 1.Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). 2.The client tends to keep her real feelings to herself. 3.She ambulates and can climb one flight of stairs without dyspnea. 4.The client is 58 years of age.

1 "Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this client's height and weight. It is thought that emotional responses can affect overall health; however, not verbalizing one's feelings is not a contributing factor in postoperative pulmonary complications. The client's current activity level and age do not place her at increased risk for complications."

87.The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included? 1.Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. 2.Lie flat on the back, splint the thorax, take two deep breaths, and cough. 3.Take several rapid, shallow breaths and then cough forcefully. 4.Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

1 "The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing"

26.The nurse is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago. The nursing policy manual recommends use of the gauze pad. The nurse should: 1.Make sure the gauze pad is dry and the client is in a comfortable position. 2.Ask the nursing assistant to tie the tracheostomy tube ties in the back of the client's neck. 3.Reposition the gauze pad around the stoma with the open end downward. 4.Ask a registered nurse to change the ties and position another gauze pad around the stoma.

1 "The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad.

"The nurse is reviewing the history and physical and physician prescriptions on the chart of a newly admitted client. subjective: 19yrs reports a constant cough for the past "few weeks' with 'dark' sputum for the past few days. has night sweats, 10lb weight loss in past month, and always being tired, he took 1 tylenol about an hour before arrival BP 120/64 HR 84 RR 26 (slight sheezing) Spo2 92% temp 37.7 skin warm/slightly diaphoretic, possible resp infection order: chest x-ray, sputum specimen, O2 at 2L The nurse should first: 1.Initiate airborne precautions. 2.Apply oxygen at 2 L per nasal cannula. 3.Collect a sputum sample. 4.Reassess vital signs.

1 "There is a high risk and potential for tuberculosis, and airborne precautions should be implemented immediately to prevent the spread of infection. After initiating precautions the nurse can start the oxygen, check the vital signs, and collect the sputum specimen."

"81.When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: 1.While inhaling through an open mouth. 2.While exhaling through pursed lips. 3.After exhaling but before inhaling. 4.While taking a deep breath and holding it.

"130.A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1.Sudden, sharp chest pain. 2.Wheezing breath sounds over affected side. 3.Hemoptysis. 4.Cyanosis.

1 130. 1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax. CN: Physiological adaptation; CL: Analyze

23.The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client? 1.10 seconds. 2.15 seconds. 3.25 seconds. 4.30 seconds.

1 23. 1. A client should be suctioned for no longer than 10 seconds at a time. Suctioning for longer than 10 seconds may reduce the client's oxygen level so much that he becomes hypoxic.

97.Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? 1.Incorporate physical exercise as tolerated into the daily routine. 2.Monitor peak flow numbers after meals and at bedtime. 3.Eliminate stressors in the work and home environment. 4.Use sedatives to ensure uninterrupted sleep at night.

1 97. 1. Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.

79.Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1.Maintaining functional ability. 2.Minimizing chest pain. 3.Increasing carbon dioxide levels in the blood. 4.Treating infectious agents.

1 A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD

When suctioning a tracheostomy tube 3 days following insertion, the nurse should follow which of the following procedures? 1.Use a sterile catheter each time the client is suctioned. 2.Clean the catheter in sterile water after each use and reuse for no longer than 8 hours. 3.Protect the catheter in sterile packaging between suctioning episodes. 4.Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.

1 The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique.

34.A 79-year-old client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia? 1.Age. 2.Osteoarthritis. 3.Vegetarian diet. 4.Daily bathing.

1 pneumonia is more common in elderly or debilitated clients. smoking, upper resp tract infections, malnutrition, immunosuppression, the presence of a chronic illness

"112.When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following? 1.Contract the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale. 2.Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle. 3.Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds. 4.Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.

1 "The recommended procedure for teaching clients postoperatively to deep breathe includes contracting (pulling in) the abdominal muscles and taking a slow, deep breath through the nose. This breath is held 3 to 5 seconds, which facilitates alveolar ventilation by improving the inspiratory phase of ventilation. Exhaling slowly as if trying to blow out a candle is a technique used in pursed-lip breathing to facilitate exhalation in clients with chronic obstructive pulmonary disease. It is recommended that the abdominal muscles be contracted, not relaxed, to promote deep breathing. The client should breathe through the nose."

"133.A client is undergoing a thoracentesis. The nurse should monitor the client during and immediately after the procedure for which of the following? Select all that apply. 1.Pneumothorax. 2.Subcutaneous emphysema. 3.Tension pneumothorax. 4.Pulmonary edema. 5.Infection.

1 2 3 4 "Following a thoracentesis, the nurse should assess the client for possible complications of the procedure such as pneumothorax, tension pneumothorax, and subcutaneous emphysema, which can occur because of the needle entering the chest cavity. Pulmonary edema could occur if a large volume was aspirated causing a significant mediastinal shift. Although infection is a possible complication, signs of infection will not be evident immediately after the procedure."

74.The client with chronic obstructive pulmonary disease (COPD) is taking theophylline. The nurse should instruct the client to report which of the following signs of theophylline toxicity? Select all that apply. 1.Nausea. 2.Vomiting. 3.Seizures. 4.Insomnia. 5.Vision changes

1 2 3 4 "The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 μmol/L). At higher levels, the client will experience signs of toxicity such as nausea, vomiting, seizure, and insomnia. The nurse should instruct the client to report these signs and to keep appointments to have theophylline blood levels monitored. If the theophylline level is below the therapeutic range, the client may be at risk for more frequent exacerbations of the disease

88.A client uses a metered-dose inhaler (MDI) to aid in management of asthma. Which action indicates to the nurse that the client needs further instruction regarding its use? Select all that apply. 1.Activation of the MDI is not coordinated with inspiration. 2.The client inspires rapidly when using the MDI. 3.The client holds his breath for 3 seconds after inhaling with the MDI. 4.The client shakes the MDI after use. 5.The client performs puffs in rapid succession.

1 2 3 4 5 "Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a sufficient amount of time between puffs to provide an adequate amount of inhalation medication."

27.What areas of education should the nurse provide employees in a factory making products that cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply. 1.Stopping smoking. 2.Using a HEPA filter in the home. 3.Limiting alcohol intake. 4.Brushing teeth after every meal. 5. Avoiding raising the voice to be heard over the noise in the factory

1 3 27. 1, 3. The primary risk factors for laryngeal cancer are smoking and alcohol abuse. Smoking cessation is most successful with a support group or counseling. Heavy drinking should be avoided since the risk increases with amount of alcohol consumption. HEPA filters help trap small particles and allergens to reduce allergy symptoms and asthma. Poor oral hygiene is not a risk factor, nor is overusing the voice."

44.The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which of the following? Select all that apply. 1.Decreased pain when breathing. 2.Prolonged clotting time. 3.Decreased temperature. 4.Decreased respiratory rate. 5.Increased ability to expectorate secretions.

1 3 ASA is administered to clients with pneumonia cuz it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. "Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate and does not facilitate expectoration of secretions."

35.Which of the following are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1.Quality of breath sounds. 2.Presence of bowel sounds. 3.Occurrence of chest pain. 4. Amount of peripheral edema 5. Color of nail beds

1 3 5 "A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.

"92.The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following indicates that the client is using the MDI correctly? Select all that apply. 1.The inhaler is held upright. 2.The head is tilted down while inhaling the medicine. 3.The client waits 5 minutes between puffs. 4.The client rinses the mouth with water following administration. 5.The client lies supine for 15 minutes following administration.

1 4 "The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright."

76.Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? 1.Increased anteroposterior chest diameter. 2.Underdeveloped neck muscles. 3.Collapsed neck veins. 4.Increased chest excursions with respiration.

1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

"48.Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? 1.A respiratory rate of 25 to 30 breaths/min. 2.The ability to perform activities of daily living without dyspnea. 3.A maximum loss of 5 to 10 lb (2.27 to 4.53 kg) of body weight. 4.Chest pain that is minimized by splinting the rib cage.

108.Which of the following would be a significant intervention to help prevent lung cancer? 1.Encourage cigarette smokers to have yearly chest radiographs. 2.Instruct people about techniques for smoking cessation. 3.Recommend that people have their houses and apartments checked for asbestos leakage. 4.Encourage people to install central air filters in their homes.

125.A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1.Respiratory rate greater than 16 breaths/min. 2.Continuous bubbling in the water-seal chamber. 3.Fluid in the chest tube. 4.Fluctuation of fluid in the water-seal chamber.

"116.The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. The nurse should: 1.Continue monitoring as usual; this is expected. 2.Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. 3.Decrease the suction to −15 cm H2O and continue observing the system for changes in bubbling during the next several hours. 4.Drain half of the water from the water-seal chamber.

2 There should never be constant bubbling in the water-seal bottle; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction or draining part of the water in the water-seal chamber will not reduce the leak.

31.Which of the following home care instructions would be appropriate for a client with a laryngectomy? 1.Perform mouth care every morning and evening. 2.Provide adequate humidity in the home. 3.Maintain a soft, bland diet. 4.Limit physical activity to shoulder and neck exercises.

2 "Adequate humidity should be provided in the home to help keep secretions moist. A bedside humidifier is recommended. A high fluid intake is also important to liquefy secretions. Mouth care is important to prevent drying of mucous membranes and should be performed frequently throughout the day, especially before and after meals, to help stimulate appetite. The client may eat any food that can be chewed and swallowed comfortably. The client may resume physical activity as tolerated."

123.A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. Which is the primary client goal at this time? 1.Reduce the client's anxiety. 2.Maintain adequate oxygenation. 3.Decrease chest pain. 4.Maintain adequate circulating volume.

2 "Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation."

84.A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which of the following statements is true concerning oxygen administration to a client with COPD? 1.High oxygen concentrations will cause coughing and dyspnea. 2.High oxygen concentrations may inhibit the hypoxic stimulus to breathe. 3.Increased oxygen use will cause the client to become dependent on the oxygen. 4.Administration of oxygen is contraindicated in clients who are using bronchodilators

2 "Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators."

72.The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.35; PCO2 62 (8.25 kPa); PO2 70 (9.31 kPa) (34 mmol/L); HCO3 34. The nurse should first: 1.Apply a 100% nonrebreather mask. 2.Assess the vital signs. 3.Reposition the client. 4.Prepare for intubation.

2 "Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation

120.The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed? 1.Adhesive strip (Steri-strips). 2.Petroleum gauze. 3.4 × 4 gauze with antibiotic ointment. 4.No dressing is necessary.

2 "Gauze saturated with petroleum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dressings with antibiotic ointment or adhesives are not used."

"110.Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client? 1.Repositioning the client immediately after administering pain medication. 2.Reassessing the client 30 minutes after administering pain medication. 3.Verbally reassuring the client after administering pain medication. 4.Readjusting the pain medication dosage as needed according to the client's condition.

2 "It is essential that the nurse evaluate the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of the pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client's pain, repositioning the client immediately after administering pain medication is not necessary."

80.A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3-, 36 mEq/L. The nurse should assess the client for: 1.Cyanosis. 2.Flushed skin. 3.Irritability. 4.Anxiety.

2 "The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

"98.The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? 1.Occupational exposure to toxins. 2.Viral respiratory infections. 3.Exposure to cigarette smoke. 4.Exercising in cold temperatures.

2 "The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

129.The primary reason for infusing blood at a rate of 60 mL/h is to help prevent which of the following complications? 1.Emboli formation. 2.Fluid volume overload. 3.Red blood cell hemolysis. 4.Allergic reaction.

2 "Too-rapid infusion of blood, or any intravenous fluid, can cause fluid volume overload and related problems such as pulmonary edema. Emboli formation, red blood cell hemolysis, and allergic reaction are not related to rapid infusion. CN: Pharmacological and parenteral therapies; CL: Apply

"36.A client with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? 1.Urinalysis. 2.Sputum culture. 3.Chest radiograph. 4.Red blood cell count.

2 36. 2. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Urinalysis, a chest radiograph, and a red blood cell count do not need to be obtained before initiation of antibiotic therapy for pneumonia."

89.A client with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply. 1.Treatment of recurrent malignant effusion. 2.Diagnosis of underlying disease. 3.Palliation of symptoms. 4.Relief of acute respiratory distress. 5.Removal of the cancer cells.

2 3 4 "Thoracentesis is usually successful for diagnosis of underlying disease, palliation of symptoms, and treating the acute respiratory distress; alleviation of the symptoms and distress is usually short term. The thoracentesis is not used as a treatment for recurrent pleural effusion because the fluid accumulates rapidly. Thoracentesis does not remove cancer cells"

"The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should do which of the following? Select all that apply. 8am: Temp 38.3 HR 90 RR 16 BP 112/74 Spo2 93% 10am HR 104 RR 18 BP 110/68 Spo2 92% 12pm Temp 38.8 HR 118 RR 24 BP 116/78 Spo2 92% 1.Assure the client is maintaining complete bed rest. 2.Check the urine output. 3.Ask the client to drink more fluids. 4.Notify the physician. 5.Administer acetaminophen (Tylenol) as prescribed."

2 3 5 A client with pneumonia experiencing diaphoresis is at risk for dehydration and increased temperature and heart rate. The fluid status, intake, and urine output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume deficit may also increase the heart rate. The underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and increased intake of fluids. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety. It is not necessary to notify the physician

"113.Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis? 1.Turn from side to side. 2.Raise and lower the head. 3.Raise the arm on the affected side over the head. 4.Flex and extend the elbow on the affected side.

30.Which of the following is an expected outcome for a client recovering from a total laryngectomy? The client will: 1.Regain the ability to taste and smell food. 2.Demonstrate appropriate care of the gastrostomy tube. 3.Communicate feelings about body image changes. 4.Demonstrate sterile suctioning technique for stoma care."

94.A client who has been taking flunisolide nasal spray, two inhalations a day, for treatment of asthma has painful, white patches in the mouth. Which response by the nurse would be most appropriate? 1."This is an anticipated adverse effect of your medication. It should go away in a couple of weeks." 2."You are using your inhaler too much and it has irritated your mouth." 3."You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent." 4."Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem."

45.Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? 1.Coma. 2.Apathy. 3.Irritability. 4.Depression.

3 "Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.

"119.Which of the following should be readily available at the bedside of a client with a chest tube in place? 1.A tracheostomy tray. 2.Another sterile chest tube. 3.A bottle of sterile water. 4.A spirometer.

3 "A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use."

"86.An adult has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to: 1.Lie still to prevent a pneumothorax. 2.Sit upright with arms on an overhead table to promote lung expansion. 3.Change position frequently to distribute the agent. 4.Lie on the side where the thoracentesis was done to hold pressure on the chest tube site."

3 "Changing positions frequently aids in distributing the agent to the pleura for sealing. The majority of the pleural fluid is drained, and the lung should already be re-expanded before instillation of the sclerosing agent. A pressure dressing is applied to the chest tube exit site, and it is not necessary to lie on that side to hold pressure on the area."

91.A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? 1.Promote bronchodilation. 2.Act as an expectorant. 3.Have an anti-inflammatory effect. 4.Prevent development of respiratory infections.

3 "Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections."

"39.A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? 1.Position changes every 4 hours. 2.Nasotracheal suctioning to clear secretions. 3.Frequent linen changes. 4.Frequent offering of a bedpan.

3 "Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario."

"28.A client has had hoarseness for more than 2 weeks. The nurse should: 1.Refer the client to a health care provider for a prescription for an antibiotic. 2.Instruct the client to gargle with salt water at home. 3.Assess the client for dysphagia. 4.Instruct the client to take a throat analgesic.

3 "Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat."

"121.A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1.Diminished bilateral breath sounds. 2.Muffled heart sounds. 3.Respiratory distress. 4.Tracheal deviation.

3 "Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade."

"101.The nurse is caring for a client who has asthma. The nurse should conduct a focused assessment to detect which of the following? 1.Increased forced expiratory volume. 2.Normal breath sounds. 3.Inspiratory and expiratory wheezing. 4.Morning headaches.

3 "The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [Forced Expiratory Flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found in more advanced cases of COPD signal nocturnal hypercapnia or hypoxemia"

86.The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for which of the following? 1.Suppression of the client's respiratory infection. 2.Decrease in bronchial secretions. 3.Less difficulty breathing. 4.Thinning of tenacious, purulent sputum.

3 "Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

111.While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action? 1.Lower the head of the bed and call the physician. 2.Prepare an aspiration tray. 3.Mark the area with a skin pencil at the outer periphery of the crackling. 4.Turn off the suction of the chest drainage system.

3 "This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual finding and is not dangerous if confined, and the nurse should mark the area to detect if the area is expanding. Progression can be serious, especially if the neck is involved; a tracheotomy may be needed at that point. If emphysema progresses noticeably in 1 hour, the physician should be notified. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and fluid; therefore, the system should not be turned off."

37.When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values? 1.Serum sodium. 2.Serum potassium. 3.Serum creatinine. 4.Serum calcium.

3 can cause acute tubular necrosis

56.What is the rationale that supports multidrug treatment for clients with tuberculosis? 1.Multiple drugs potentiate the drugs' actions. 2.Multiple drugs reduce undesirable drug adverse effects. 3.Multiple drugs allow reduced drug dosages to be given. 4.Multiple drugs reduce development of resistant strains of the bacteria.

"106.A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. The nurse should: 1.Let the client rest, so that the client is not stimulated to cough. 2.Encourage the client to take deep breaths to help control the pain. 3.Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve the pain. 4.Obtain a more detailed assessment of the client's pain using a pain scale.

"Postoperative nursing management of the client following a radical neck dissection for laryngeal cancer requires: 1.Complete bed rest minimizing head movement. 2.Vital signs once a shift. 3.Clear liquid diet started at 48 hours. 4.Frequent suctioning of the laryngectomy tube.

114.When caring for a client with a chest tube and water-seal drainage system, the nurse should: 1.Verify that the air vent on the water-seal drainage system is capped when the suction is off. 2.Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. 3.Ensure that the chest tube is clamped when moving the client out of the bed. 4.Make sure that the drainage apparatus is always below the client's chest level.

25.The client with a laryngectomy does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. The nurse should: 1.Initiate teaching about the care of a stoma. 2.Explain that the stoma will not always look as it does now. 3.Inform the client of the benefits of family support at this time. 4.Explore why the client believes the stoma is "disgusting."

"96.Which of the following is an expected outcome for an adult client with well-controlled asthma? 1.Chest x-ray demonstrates minimal hyperinflation. 2.Temperature remains lower than 100°F (37.8°C). 3.Arterial blood gas analysis demonstrates a decrease in PaO2. 4.Breath sounds are clear.

4 "Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest x-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal. CN: Physiological adaptation; CL: Evaluate

"126.Which of the following findings would suggest pneumothorax in a trauma victim? 1.Pronounced crackles. 2.Inspiratory wheezing. 3.Dullness on percussion. 4.Absent breath sounds.

4 "Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid."

77.When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? 1.Participate regularly in aerobic exercises. 2.Maintain a high-protein diet. 3.Avoid exposure to people with known respiratory infections. 4.Abstain from cigarette smoking."

4 "Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneficial, will not decrease the risk of COPD. Insufficient protein intake and exposure to people with respiratory infections do not increase the risk of COPD."

109.After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises? 1.Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange. 2.Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery. 3.Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated. 4.Deep breathing expands the alveoli and increases the lung surface available for ventilation.

4 "Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon."

83.The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? 1.Normal breath sounds. 2.Prolonged inspiration. 3.Normal chest movement. 4.Coarse crackles and rhonchi.

4 "Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended."

89.A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client? 1.Initiate oxygen therapy as prescribed and reassess the client in 10 minutes. 2.Draw blood for an arterial blood gas. 3.Encourage the client to relax and breathe slowly through the mouth. 4.Administer bronchodilators as prescribed.

4 "In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention."

"75.Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? 1.The client promises to do pursed-lip breathing at home. 2.The client states actions to reduce pain. 3.The client will use oxygen via a nasal cannula at 5 L/min. 4.The client agrees to call the physician if dyspnea on exertion increases.

4 "Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia. CN: Basic care and comfort; CL: Evaluate

22.A client who has had a total laryngectomy appears withdrawn and depressed. The client keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would most likely be therapeutic for the client? 1.Discussing the behavior with the spouse to determine the cause. 2.Exploring future plans. 3.Respecting the need for privacy. 4.Encouraging expression of feelings nonverbally and in writing.

4 "The client has undergone body changes and permanent loss of verbal communication. He may feel isolated and insecure. The nurse can encourage him to express his feelings and use this information to develop an appropriate plan of care. Discussing the client's behavior with his wife may not reveal his feelings. Exploring future plans is not appropriate at this time because more information about the client's behavior is needed before proceeding to this level. The nurse can respect the client's need for privacy while also encouraging him to express his feelings.

"85.Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? 1.Low-fat, low-cholesterol diet. 2.Bland, soft diet. 3.Low-sodium diet. 4.High-calorie, high-protein diet.

4 "The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.

"118.The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, which should the nurse do? 1.Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. 2.Notify the physician of the amount of chest tube drainage. 3.Add water to maintain the water seal. 4.Lower the drainage system to maintain gravity flow.

4 118. 4. To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.

131.The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1.For administration of oxygen. 2.To promote formation of lung scar tissue. 3.To insert antibiotics into the pleural space. 4.To remove air and fluid.

4 131. 4. A chest tube is inserted to re-expand the lung and remove air and fluid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax. CN: Basic care and comfort; CL: Evaluate

41.The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? 1.Decreased cardiac output. 2.Pleural effusion. 3.Inadequate peripheral circulation. 4.Decreased oxygenation of the blood

4 A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia"

"78.Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? 1.To promote oxygen intake. 2.To strengthen the diaphragm. 3.To strengthen the intercostal muscles. 4.To promote carbon dioxide elimination.

4 Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

43.Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? 1.Encourage the client to breathe shallowly. 2.Have the client practice abdominal breathing. 3.Offer the client incentive spirometry. 4.Teach the client to splint the rib cage when coughing.

4 The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain."

88. "A client has malignant pleural effusions. The nurse should conduct a focused assessment to determine if the client has which of the following? Select all that apply. 1.Hiccups. 2.Weight gain. 3.Peripheral edema. 4.Chest pain. 5.Dyspnea. 6.Cough.

4 5 "A malignant pleural effusion is an accumulation of excessive fluid within the pleural space that occurs when cancer cells irritate the pleural membrane. Dyspnea can result from the increased pressure that may contribute to increased anxiety and fear of suffocation. Pain is a consequence of the pleural irritation. Cough is related to the atelectasis of the bronchi and inability to clear the airways. Hiccups are usually associated with pericardial effusions. Weight gain and peripheral edema may occur with peritoneal effusion."

Guaifenesin (Robitussin) 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5 ml. How many milliliters should the nurse administer each dose?

7.5 ml 300 mg/ X = 200 mg/5 ml X= 7.5 ml

A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply. A. Operating machinery and driving may be dangerous while taking antihistamines. B. Continue taking antihistamines even if nasal infection develops. C. The effect of antihistamines is not felt until a day later. D. Do not use alcohol with antihistamines. E. Increase fluid intake to 2,000 mL/day.

A, D, E Rationale: Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least eight glasses per day due to the drying effect of the drug. Antihistamines have no antibacterial action. The effect of antihistamines is prompt, not delayed.

A nurse is completing the health history for a client who has been taking echinacea for a head cold. The client asks, "Why isn't this helping me feel better?" Which of the following responses by the nurse would be the *most accurate? A. "There is limited information as to the effectiveness of herbal products." B. "Antibiotics are the agents needed to treat a head cold." C. "The head cold should be gone within the month." D. "Combining herbal products with prescription antiviral medications is sure to help you."

A. "There is limited information as to the effectiveness of herbal products." Rationale: -At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. -Antibiotics are effective against bacteria; the head cold may have a viral cause. -An uncomplicated upper respiratory tract infection subsides within 2-3 weeks. -There may be a drug-drug interaction with herbal products and prescriptions.

The nurse teaches the client how to instill nose drops. Which of the following techniques is correct? A. The client uses sterile technique when handling the dropper. B. The client blows the nose gently before instilling drops. C. The client uses a new dropper for each instillation. D. The client sits in a semi-Fowler's position with the head tilted forward after administration of the drops.

B. The client blows the nose gently before instilling drops. Rationale: -The client should blow the nose before instilling nose drops. -Instilling nose drops is a clean technique. -The dropper should be cleaned after each administration, but it does not need to be changed. -The client should assume a position that will allow the medication to reach the desired area; this is usually a supine position.

A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which of the following statements would demonstrate to the nurse that the client understands the instructions? A. "I should limit the use of the inhaler to early morning and bedtime use." B. "It is important to not shake the canister because that can damage the spray device." C. "I should hold one nostril closed while I insert the spray into the other nostril." D. "The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall."

C. "I should hold one nostril closed while I insert the spray into the other nostril." Rationale: -When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the other nostril to ensure the best inhalation of the spray. -Use of the inhaler is not limited to mornings and bedtime. --The canister should be shaken immediately before use. -The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation of the medication.

The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis? A. Avoid the use of caffeinated beverages. B. Perform postural drainage every day. C. Take hot showers twice daily. D. Report a temperature of 102 degrees F or higher.

C. Take hot showers twice daily. Rationale: -The client with chronic sinusitis should be instructed to take hot showers in the morning and evening to promote drainage of secretions. -There is no need to limit caffeine intake. -Performing postural drainage will inhibit removal of secretions, not promote it. Client should elevate the head of the bed to promote drainage. -Clients should report all temperatures higher than 100.4 degrees F, because a temperature that high can indicate infection.

A client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea. Which of the following instructions would be appropriate for the nurse to give the client? A. "Use your nasal decongestant spray regularly to help clear your nasal passages." B. "Ask the doctor for antibiotics. Antibiotics will help decrease the secretion." C. "It is important to increase your activity. A daily brisk walk will help promote drainage." D. "Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks."

D. "Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks." Rationale: -It is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify those triggers. -Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. -Antibiotics are not appropriate for allergic rhinitis because an infection is not present. -Increasing activity will not control the client's symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen.

Which of the following would be an expected outcome for a client recovering from on upper respiratory tract infection? The client will: A. Maintain a fluid intake of 800 ml every 24 hours. B. Experience chills only once a day. C. Cough productively without chest discomfort. D. Experience less nasal obstruction and discharge.

D. Experience less nasal obstruction and discharge. Rationale: -A client recovering from an upper respiratory tract infection should report decreasing or no nasal discharge and obstruction. -Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. -The temperature should be below 100 degrees F with no chills or diaphoresis. -A productive cough with chest pain indicates a pulmonary infection, not an upper respiratory tract infection.

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