Respiratory Disorders
Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination? 30-year-old pregnant woman 75-year-old woman with diabetes 50-year-old man with angina 40-year-old man with benign prostatic hypertrophy
75-year-old woman with diabetes
The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube? preventing clots removing air removing fluid facilitating "milking" of the tubes
removing fluid
The nurse is caring for a client who states an increase in dyspnea. Which intervention would the nurse perform first? vitals oxygen nebulizer call hcp
vitals
An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom? abdominal distension pleural friction rub dyspnea peripheral edema
dyspnea
The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? promote bronchodilation act as an expectorant have an anti-inflammatory effect prevent the development of respiratory infections
have an anti-inflammatory effect
The nurse is assessing the lungs of a client who had abdominal surgery 2 days ago and hears rhonchi. Currently, the client reports mild abdominal pain 2 hours after receiving an oral narcotic pain medication. What should the nurse do next? Assist the client to use the incentive spirometer and cough up secretions. Ensure the client has a fluid intake to 1000 mL per shift. Contact the surgeon to request additional pain medication. Assess the client's breath sounds again in 10 minutes.
Assist the client to use the incentive spirometer and cough up secretions.
A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare a chest tube insertion tray. Prepare to start an I.V. line.
Apply a dressing over the wound and tape it on three sides.
Which registered nurse should be assigned to the client who had a chest tube inserted yesterday? a charge nurse pulled from the psychiatric unit a licensed practical nurse with 10 years of experience a registered nurse who use to work on the cardiovascular unit a registered nurse who worked as a head nurse on the orthopedic unit
a registered nurse who use to work on the cardiovascular unit
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "Breathe in and out quickly." "You need to start using the incentive spirometer 2 days after surgery." "Before you do the exercise, I'll give you pain medication if you need it." "Don't use the incentive spirometer more than 5 times every hour."
"Before you do the exercise, I'll give you pain medication if you need it."
For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs? "Take the medications 1 hour apart, two times a day." "Take the albuterol first and follow with beclomethasone two times a day." "Take the albuterol on awakening and alternate the medications every 4 hours." "Take the beclomethasone inhaler first and follow with albuterol."
"Take the albuterol first and follow with beclomethasone two times a day."
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? 5-mm induration reddened area 15-mm induration a blister
15-mm induration
The nurse is teaching a client with asthma to administer Zyflo CR 1200 mg orally twice a day. The drug is available in 600-mg tablets. How many tablets will the nurse teach the client to take at each dose?
2 tablets/per
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 3 to 5 days 1 to 3 weeks 2 to 4 months 6 to 12 months
6 to 12 months
A client 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. What should the nurse do first? Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes. Draw blood for an arterial blood gas test. Encourage the client to relax and breathe slowly through the mouth. Administer bronchodilators as prescribed.
Administer bronchodilators as prescribed.
An adult with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the client has a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used. Start an IV access site. Call the health care provider (HCP). Open the airway. Explain the situation to the family.
Open the airway. Start an IV access site. Call the health care provider (HCP). Explain the situation to the family.
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern? Cheyne-Stokes respiration hyperventilation obstructive sleep apnea Biot respiration
Cheyne-Stokes respiration
A client with chronic obstructive pulmonary disease who is having trouble raising respiratory secretions. Which action should the nurse take to reduce the tenacity of secretions? Take a diet history to determine if the client's diet is low in salt. Ensure that the client's oxygen therapy is continuous. Help the client maintain an adequate fluid intake. Keep the client in a semi-sitting position as much as possible.
Help the client maintain an adequate fluid intake.
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, what should the nurse do? Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. Notify the health care provider (HCP) of the amount of chest tube drainage. Add water to maintain the water seal. Lower the drainage system to maintain gravity flow.
Lower the drainage system to maintain gravity flow.
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel, a compound fracture of the right tibia and fibula, and multiple lacerations and contusions. What is the priority nursing goal for this client? Reduce the client's anxiety. Maintain adequate oxygenation. Decrease chest pain. Maintain adequate circulating volume.
Maintain adequate oxygenation.
A client has a tracheostomy. Which nursing action would prevent complications of suctioning? Suction for at least 15 seconds. Keep a replacement cuff at the bedside. Maintain sterility of the suction catheter. Record time, amount, character of secretions.
Maintain sterility of the suction catheter.
The nurse is teaching a client who had a lobectomy for lung cancer and the client's partner how to promote comfort and optimal respiratory expansion during sexual intimacy. What can the nurse suggest the couple do? Use a nasal decongestant inhaler. Raise the affected partner's head and upper torso on pillows. Have the affected partner assume a dependent position. Limit the duration of the sexual activity.
Raise the affected partner's head and upper torso on pillows.
The nurse is giving rescue breaths to a client who just had a cardiac arrest while a team member performs chest compressions. The chest wall fails to rise after the team has been performing cardiopulmonary resuscitation for 30 seconds. What should the nurse do next? Try using a bag-mask device. Decrease the rate of compressions. Intubate the client. Reposition the airway.
Reposition the airway.
The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which action will be most helpful to promote effective airway clearance? Administer oxygen every 2 hours. Turn the client every 4 hours. Administer sedatives to promote rest. Suction if cough is ineffective.
Suction if cough is ineffective.
A client has the following arterial blood gas values: pH 7.52 partial pressure of arterial oxygen (PaO2) 50 mm Hg (6.7 kPa) partial pressure of carbon dioxide (PaCO2) 28 mm Hg (3.72 kPa) HCO3− 24 mEq/L (24 mmol/L) Based upon the client's PaO2, which nursing clinical judgment should the nurse make? The client is severely hypoxic. The oxygen level is low but poses no risk for the client. The client's PaO2 level is within normal range. The client requires oxygen therapy with very low oxygen concentrations.
The client is severely hypoxic.
The nurse is suctioning a tracheostomy for a client who had the tracheostomy tube placed 3 days ago. Which is the correct procedure for suctioning at this time? Use a sterile catheter each time the client is suctioned. Clean the catheter in sterile water after each use, and reuse for no longer than 8 hours. Protect the catheter in sterile packaging between suctioning episodes. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.
Use a sterile catheter each time the client is suctioned.
An older adult 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 client information would most likely be a predisposing factor for the diagnosis of pneumonia? age osteoarthritis vegetarian diet daily bathing
age
An epidemic of severe acute respiratory syndrome (SARS) is occurring in a community of 10,000 people. Three people are being admitted to the emergency department. Two people are vomiting. Which type of precautions should the nurse institute? enteric precautions hand-washing precautions reverse isolation precautions airborne precautions
airborne precautions
A 6-year-old child is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report? anti-inflammatory analgesic antibiotic antipyretic
antibiotic
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? posting a "no smoking" sign over the client's bed measuring the client for the appropriate sized mask assessing the client's respiratory status, orientation, and skin color collaborating with respiratory therapy to determine the flow rate
assessing the client's respiratory status, orientation, and skin color
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should assist the client to a sitting position on the edge of the bed, leaning over the bedside table. raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position.
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should: collaborate with the social worker to investigate possible availability of funds. contact the community's free clinic for medications. call the public health nurse to research free medications. coordinate with the pharmaceutical company for free samples.
collaborate with the social worker to investigate possible availability of funds.
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the health care provider when the client has which symptom? loud wheezing tenacious, thick sputum decreased breath sounds persistent cough
decreased breath sounds
A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? impaired color discrimination increased urinary frequency decreased hearing acuity increased appetite
decreased hearing acuity
The nurse is conducting a focused assessment of a client at risk for acute respiratory distress syndrome (ARDS). Which finding indicates the client is becoming hypoxemic? elevated carbon dioxide level hypoxia not responsive to oxygen therapy metabolic acidosis severe, unexplained electrolyte imbalance
hypoxia not responsive to oxygen therapy
When assessing a client with advanced chronic obstructive pulmonary disease (COPD), the nurse would expect which findings? increased anteroposterior chest diameter underdeveloped neck muscles collapsed neck veins increased chest excursions with respiration
increased anteroposterior chest diameter
A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse should instruct the client to report which adverse effect? irregular heartbeat constipation pedal edema decreased pulse rate
irregular heartbeat
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately? leukocytosis anemia low hemoglobin level normal erythrocyte sedimentation rate
leukocytosis
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? tracheostomy cleaning kit water-seal chest drainage set-up manual resuscitation bag oxygen analyzer
manual resuscitation bag
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? mumps impetigo measles cholera
measles
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis
metabolic acidosis
A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause nasal congestion. nervousness. lethargy. hyperkalemia.
nervousnes.
The client is taking a corticosteroid inhalant to treat bronchial asthma. The nurse should assess the client for which side effect of this drug? oral candidiasis hyperglycemia gastric ulcer fluid retention
oral candidiasis
A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg
The nurse has received lab reports for several clients undergoing care. Which set of arterial blood gas (ABG) results will the nurse investigate first? pH 7.34, partial pressure of arterial carbon dioxide (PaCO2) 36 mmHg, partial pressure of arterial oxygen (PaO2) 95 mmHg, bicarbonate (HCO3-) 20 mEq/L pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L pH 7.47, PaCO2 43 mmHg, PaO2 99 mmHg, and HCO3- 29 mEq/L pH 7.35, PaCO2 48 mmHg, PaO2 91 mmHg, and HCO3- 28 mEq/L
pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L
A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? septicemia pneumonia meningitis pulmonary edema
pneumonia
A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which complication should the nurse be prepared to treat? bronchopneumonia pneumothorax sepsis clotted catheter
pneumothorax
A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance? respiratory alkalosis respiratory acidosis metabolic acidosis metabolic alkalosis
respiratory acidosis
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? respiratory acidosis metabolic alkalosis respiratory alkalosis metabolic acidosis
respiratory acidosis
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: metabolic acidosis. respiratory alkalosis. increased PaCO2. acute CNS disturbances.
respiratory alkalosis.
The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia? somnolence restlessness chills urgency
restlessness
A client has had a central venous pressure line inserted. The nurse should immediately report which sign to the health care provider? sharp pain on the affected side urinary output of 50 mL per hour heart rate of 88 bpm discomfort at the insertion site
sharp pain on the affected side
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? offering the client emotional support teaching the client about the disease and its treatment coordinating various agency services assessing the client's environment for sanitation
teaching the client about the disease and its treatment
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign? foot drop knee swelling and pain tingling in the arm absence of the Achilles reflex
tingling in the arm
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? blood pressure 140/80 mm Hg PaO2 80 mm Hg crackles auscultated halfway up lungs, previously in bases trace peripheral edema, previously +2
trace peripheral edema, previously +2
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client: asks for an additional pillow. has a pulse oximetry reading of 91%. uses the sternocleidomastoid muscles. wants the head of the bed raised to a 90-degree level.
uses the sternocleidomastoid muscles.
The nurse is caring for a client with cystic fibrosis (CF) who has increased dyspnea. Which intervention should the nurse include in the plan of care? Schedule a sweat chloride test. Perform chest physiotherapy. Place the client on a fluid restriction. Suction the client's upper airway.
Perform chest physiotherapy.
A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? "I should take my bronchodilator at bedtime to prevent insomnia." "I should do my most difficult activities when I first get up in the morning." "I should try to eat several small meals during the day." "I should plan to do most of my exercises after I eat."
"I should try to eat several small meals during the day."
The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse-manager would take which step to meet the needs of the staff? Contact the institutional ethics committee for strategies. Arrange a meeting with the client's family and nursing staff. Assign only nurses who agree with the client's plan of care. Encourage the staff to talk to the client about their concerns.
Contact the institutional ethics committee for strategies.
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? Position in orthopneic position and encourage the client to calm down. Position in Fowler's position and administer oxygen. Position in a semi-prone position and encourage deep breathing. Position in high Fowler's position and administer an albuterol sulfate inhaler.
Position in high Fowler's position and administer an albuterol sulfate inhaler.
For a client with an endotracheal (ET) tube, which nursing action is the most important? auscultating the lungs for bilateral breath sounds turning the client from side to side every 2 hours monitoring serial blood gas values every 4 hours providing frequent oral hygiene
auscultating the lungs for bilateral breath sounds
A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction? The client has: active tuberculosis. been exposed to Mycobacterium tuberculosis. developed resistance to tubercle bacilli. developed passive immunity to tuberculosis.
been exposed to Mycobacterium tuberculosis.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis
respiratory acidosis
As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance? respiratory alkalosis metabolic alkalosis respiratory acidosis metabolic acidosis
respiratory acidosis
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? respiratory acidosis respiratory alkalosis metabolic alkalosis metabolic acidosis
respiratory acidosis
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative after 1 month of medication." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test."
"I'll stop being contagious when I have a negative acid-fast bacilli test."
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
A client 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. What should the nurse do first? Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes. Draw blood for an arterial blood gas test. Encourage the client to relax and breathe slowly through the mouth. Administer bronchodilators as prescribed.
Administer bronchodilators as prescribed.
A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs? Administer the triamcinolone and then administer the salmeterol. Administer the salmeterol and then administer the triamcinolone. Allow the client to choose the order in which the drugs are administered. Monitor the client's theophylline level before administering the medications.
Administer the salmeterol and then administer the triamcinolone.
An elected official has asked the nurse for information on anthrax and the risk it could pose to residents of the community. What information would the provide? All community members should receive the anthrax vaccine. The primary mode of transmission is contact with the blood or body secretions of infected individuals. Helath care providers use isoniazid (INH), rifampin, and pyrazinamide to treat anthrax. Anthrax can infect the integumentary, GI, and respiratory systems.
Anthrax can infect the integumentary, GI, and respiratory systems.
A nurse is caring for a client diagnosed with a deep vein thrombosis (DVT). The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 beats per minute, blood pressure of 100/60 mm Hg, and respirations of 40 breaths per minute. What is the nurse's priority action? Assess the client's oxygen saturation (SaO2) level. Order a 12-lead electrocardiogram. Complete a neurological evaluation. Document the findings and continue to monitor.
Assess the client's oxygen saturation (SaO2) level.
A client has had a bronchoscopy under local anesthesia. Which action should the nurse take as the client recovers from the anesthesia? Irrigate the nasogastric (NG) tube with 30 mL of normal saline every 2 hours. Offer 200 mL of oral fluids every hour to liquefy lung secretions. Observe the abdomen for signs of distention and boardlike rigidity. Restrict oral intake until the gag reflex returns.
Restrict oral intake until the gag reflex returns.
On the second day after surgery for an abdominal hysterectomy, the nurse is assessing the client's breath sounds to determine the effectiveness of the client's use of an incentive spirometer. The nurse auscultates the client's lungs and hears normal bronchial sounds. What action should the nurse take next? Tell the client to increase the use of the spirometer from every 2 hours to every hour. Tell the client that the lungs are clear and to continue to use the spirometer as they have been. Notify the health care provider to request a prescription for a bronchodilator. Place the client on fluid restrictions.
Tell the client that the lungs are clear and to continue to use the spirometer as they have been.
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? An obstruction is present in the chest tube. The client is developing subcutaneous emphysema. The chest tube system is functioning properly. There is a leak in the chest tube system.
The chest tube system is functioning properly.
A client experiencing a severe asthma attack has the following arterial blood gas results: -pH 7.33 -partial pressure of arterial carbon dioxide (PaCO2) 48 mm Hg (6.4 kPa) -partial pressure of arterial oxygen (PaO2) 58 mm Hg (7.7 kPa) -bicarbonate (HCO3−) 26 mEq/L (26 mmol/L) Which prescription should the nurse implement first? albuterol nebulizer chest X-ray ipratropium inhaler sputum culture
albuterol nebulizer
The nurse has suctioned a client's tracheostomy tube. Which finding indicates the suctioning has been effective? respirations unlabored hollow sound on chest percussion decreased mucus production breath sounds clear on auscultation
breath sounds clear on auscultation
What is the best way for the nurse to position a chest tube for a client to prevent dislocation? coiled flat on the bed and positioned loosely coiled flat on the bed and secured without putting tension on the tube coiled flat and secured to the bedrail coiled flat and secured in dependent loops along the side of the bed
coiled flat on the bed and secured without putting tension on the tube
A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important? monitoring intake and output obtaining daily weights monitoring the client for indications of constipation obtaining stool samples to test for occult blood
monitoring intake and output
In preparation for discharge, the nurse teaches the parent of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the parent indicates successful teaching? "I need to be sure to take my child's temperature every day." "I hope I do not get a cold from my child." "Next time my child gets a cold I need to listen to the chest." "I need to wash my hands more often."
"I need to wash my hands more often."
The nurse is reconciling the prescriptions for a client diagnosed recently with pulmonary tuberculosis who is being admitted to the hospital for a total hip replacement (see medication prescription sheet). The client asks if it is necessary to take all of these medications while in the hospital. What should the nurse tell the client? "I'll ask your health care provider (HCP) to review the prescriptions for a duplication between isoniazid and ethambutol." "I can't discontinue any of these drugs until you can eat solid foods." "I'll ask the pharmacist to check for drug interactions between the rifampin and isoniazid." "It's important to continue to take the medications because the combination of drugs prevents bacterial resistance."
"It's important to continue to take the medications because the combination of drugs prevents bacterial resistance."
A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? Perform circulation checks to bilateral upper extremities during each shift. Attach the ties of the restraints to the bed frame. Reevaluate the need for restraints and document weekly. Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours.
Attach the ties of the restraints to the bed frame.
A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse? Place in supine position, initiate oxygen, and administer bronchodilators as ordered. Position in high Fowler's position and administer bronchodilators as ordered. Position in high Fowler's position, initiate oxygen, and administer bronchodilators as ordered. Encourage ambulation and administer bronchodilators and steroids as ordered.
Position in high Fowler's position, initiate oxygen, and administer bronchodilators as ordered.
A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH? increased respiratory rate increased urine output decreased blood pressure increased body temperature
increased respiratory rate
A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene? A surgical face mask is applied before entering the client's room. Hand washing is performed before entering the client's room. A box of tissues is brought to the client from the supply room. A sputum culture is collected, labeled, and taken to lab as ordered.
A surgical face mask is applied before entering the client's room.
The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client? "After surgery, nasal packing will be in place for 7 to 10 days." "Normal saline nose drops will need to be administered preoperatively." "The results of the surgery will be immediately obvious postoperatively." "Do not take aspirin-containing medications for 2 weeks before surgery."
"Do not take aspirin-containing medications for 2 weeks before surgery."
The nurse is caring for an older adult client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Obtain vital signs. Initiate oxygen therapy as needed. Apply antiembolic stockings. Assess the client's breath sounds. Keep the client oriented.
Obtain vital signs. Apply antiembolic stockings. Keep the client oriented.
A client with pneumonia has pleuritic chest pain. Which action should the nurse take to help the client manage the pain? Encourage the client to breathe shallowly. Have the client practice abdominal breathing. Offer the client incentive spirometry. Teach the client to splint the rib cage when coughing.
Teach the client to splint the rib cage when coughing.
The nurse teaches the client how to instill nose drops. Which technique is correct? The client uses sterile technique when handling the dropper. The client blows the nose gently before instilling drops. The client uses a new dropper for each instillation. The client sits in a semi-Fowler position for 2 minutes.
The client blows the nose gently before instilling drops.
A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. Keep the client flat for at least 2 hours. Provide sips of water to moisten the client's mouth. Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Alert the client to resume food and fluids when the client's voice returns. Monitor the client's vital signs.
Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the provider orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. The nurse should be aware that acetylcysteine must be used cautiously in a client with asthma because it can have which effect? be a respiratory depressant act as a respiratory stimulant induce bronchospasm inhibit the cough reflex
induce bronchospasm
A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values (see report of laboratory results). Which finding is concerning? pH --> 7.35 partial pressure of carbon dioxide (PaCO2) --> 25 mmHg bicarbonate (HCO3-) --> 22mEq/L partial pressure of arterial oxygen (PaO2) --> 95 mmHg
partial pressure of carbon dioxide (PaCO2) --> 25 mmHg
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing. Use chest breathing.
Use diaphragmatic breathing.
A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? Impaired gas exchange Impaired skin integrity Activity intolerance Imbalanced nutrition: Less than body requirements
Impaired gas exchange
After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? Take analgesics every 4 hours around the clock. Use corticosteroid nasal spray as needed to control symptoms. Use a bedside humidifier while sleeping. Apply cold compresses to the area.
Apply cold compresses to the area.
