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Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray." A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period. (less)
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
"weigh yourself daily and report a gain of 2lb (0.91 kg) in 1 day. " The nurse should instruct the client to weigh himself daily and report a gain of 2 lb (0.91 kg) in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all
The nurse is aware that the best position for a client with impaired gas exchange is what?
High Fowler's For a client with impaired gas exchange, high Fowler's position is the best position because it allows maximal chest expansion. If the client cannot tolerate high Fowler's position, semi-Fowler's is the next best choice, because it increases comfort and allows for chest expansion. The lateral decubitus and supine positions do not promote chest expansion. Sims position is recommended for perineal inspection. (less)
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2 (less)
A client is being prepared for a bronchoscopy. Which of the following preoperative activities would be appropriate for the nurse to delegate to the nursing assistant?
Placing the client on NPO status. It would be appropriate for the nurse to instruct the assistant to place the client on NPO status. It is the responsibility of the physician performing the procedure to obtain the client's informed consent and have the form signed. It is the responsibility of the registered nurse to teach clients and evaluate their health status. These responsibilities cannot be delegated to nursing assistants. (less)
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included?
Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. 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.
Which nursing action does not aid in meeting the goal of clear breath sounds?
The client should drink a minimum of 2,500 mL of fluid per day (not 1,000 mL) to keep secretions liquefied and easier to cough up and eliminate from the upper respiratory tract. The client should use pain medication before coughing. The client should use the incentive spirometer every 2 to 4 hours. The nurse should monitor the client's breath sounds and temperature to detect early signs of infection. The nurse should assist with early ambulation.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The rise in pH exists because the client's lungs:
are not able to blow off carbon dioxide. Correct Explanation: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, but the lungs' ability to remove carbon dioxide from the system is compromised. Although individuals with COPD frequently have a history of smoking, impaired ciliary function is not the cause of the acidosis
The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms? Select all that apply.
• Crackles or ronchi • Use of accessory muscles during respiration • Fever The client with pneumonia may have a fever, use accessory muscles for breathing, and exhibit crackles or rhonchi on auscultation. Other signs and symptoms of pneumonia include fever, malaise, pleuritic pain, pleural friction rub, dyspnea, tachypnea, tachycardia, and a cough that produces rusty green or bloody sputum (in pneumococcal pneumonia) or yellow-green sputum (in bronchopneumonia). A dry cough, bradycardia, and a pericardial friction rub are not manifestations of pneumonia. (less)