Respiratory NCLEX review Saunders

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? 1. Pain with deep breathing 2. Increased chest tube drainage 3. Lung crackles in the remaining lung 4. Respiratory rate of 20 breaths/minute

3. Lung crackles in the remaining lung Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? 1."I need to protect the stoma from water." 2."Soaps should be avoided near the stoma." 3."I should use diluted alcohol on the stoma to clean it." 4."I should apply a non-oil-based ointment to the skin surrounding the stoma."

3."I should use diluted alcohol on the stoma to clean it." Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. I need to continue medication therapy for 1 month." 2."I can't shop at the mall for the next 6 months." 3."I can return to work if a sputum culture comes back negative." 4."I should not be contagious after 2 to 3 weeks of medication therapy."

"I should not be contagious after 2 to 3 weeks of medication therapy." The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1.A 25-year-old woman with diabetic ketoacidosis 2.A 65-year-old man out of bed 1 day after prostate resection 3.A 73-year-old woman who has just had pinning of a hip fracture 4.A 38-year-old man with pulmonary contusion sustained in an automobile crash

3.A 73-year-old woman who has just had pinning of a hip fracture Rationale:Clients frequently at risk for pulmonary embolism include those who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age

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

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

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. 1. Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

1. Dyspnea 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2.Gown 3.Gloves 4.Eye protection

1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing

1. Positive Rationale:The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

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

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

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

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

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

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

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? 1. This is expected and will last for at least 1 year. 2. This is expected, and the client should gradually increase activity as tolerated. 3. This is an unexpected finding with TB, but it should resolve within 1 month or so. 4. This is a short-lived problem that should be gone within 1 week after beginning medication therapy.

2. This is expected, and the client should gradually increase activity as tolerated. Rationale:The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 3, and 4 are incorrect information.

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

2."Blocked nasal passages impair the sense of smell. Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because 1 of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom

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

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

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

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

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

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

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken

3.Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? 1. Document the finding in the client's record. 2. Call the employee health service department. 3. Contact the primary health care provider (PHCP). 4. Call the radiology department for a chest radiographic study to be done.

3. Contact the primary health care provider (PHCP). Rationale:The nurse who obtains a positive test reading should call the PHCP immediately. The PHCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1.Cyanosis 2.Hyperinflated chest 3.Rapid, shallow respirations 4.Coarse crackles auscultated bilaterally

3.Rapid, shallow respirations Rationale:An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client? 1. Drink hot tea throughout the day. 2. Drink hot cocoa instead of coffee. 3. Restrict fluid intake to 1000 mL daily. 4. Eat foods that are highly seasoned in moderation

4. Eat foods that are highly seasoned in moderation Rationale: Foods that are highly seasoned are irritating to the throat and should be completely avoided. The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated

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

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

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate

4. Increased respiratory rate The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

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

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

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? 1.6 to 12 hours 2.12 to 24 hours .24 to 28 hours 4.48 to 72 hour

4.48 to 72 hour Rationale:The tuberculin skin test is an accurate and reliable test that will provide information to the primary health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result should be done 48 to 72 hours after the injection.

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds? 1.Effectiveness of medication therapy 2.The deep breaths that the client is taking 3.Decreased inflammatory reaction at the site 4.Accumulation of pleural fluid in the inflamed area

4.Accumulation of pleural fluid in the inflamed area Rationale:Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. The remaining options are incorrect interpretations.

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

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

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position? 1.Sims' 2.Supine .Side-lying 4.Semi-Fowler's

4.Semi-Fowler's Rationale:After any procedure involving lung surgery, the nurse should position the client in semi-Fowler's position. This position allows for maximal lung expansion and promotes drainage through the chest tube that may be placed during surgery. The positions identified in the remaining options will limit lung expansion

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? 1. Fever 2.Fatigue 3.Weight loss 4.Shortness of breath

4.Shortness of breath Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

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

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

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

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

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? 1. "My nails may become clubbed." 2. "My nails may have multiple small pits." 3. "I may develop flattening of the nail plate." 4. "I may develop horizontal depressions on my nails."

1. "My nails may become clubbed." A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1. Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary, because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary, because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary, because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2.Headache 3.Weight gain 4.Hypothermia

1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? 1."I will discard used tissues in a plastic bag." 2."I need to wash my hands at least 4 times a day." 3."I will brush my teeth and rinse my mouth once a day." 4."I will turn my head to the side if I need to cough or sneeze.

1."I will discard used tissues in a plastic bag." Rationale: Used tissues are discarded in a plastic bag. The client with TB should wash the hands carefully after each contact with respiratory secretions. Oral care should be done more frequently than once a day. The client should not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

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

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

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

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

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

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

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1.Activities should be resumed gradually. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. Rationale:The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

1.Cough 2.Dyspnea 5.Chills and night sweats Rationale:The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? 1.Dyspnea 2.Headache 3.Weight gain 4.Hypothermia

1.Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply. 1.Fatigue 2.Malaise 3.Anorexia 4.Weight gain 5.Dyspnea at rest

1.Fatigue 2.Malaise 3.Anorexia Rationale:Silicosis is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli leading to fibrosis. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.

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

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

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

1.Just under the left clavicle Rationale:The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

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

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

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

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

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1.Suctioning the client as needed 2.Encouraging coughing every 2 hours 3.Placing the bed in low-Fowler's position 4.Supporting the neck incision when the client coughs 5.Monitoring the respiratory status frequently as prescribed

1.Suctioning the client as needed 2.Encouraging coughing every 2 hours 4.Supporting the neck incision when the client coughs 5.Monitoring the respiratory status frequently as prescribed Rationale: The client's respiratory status is promoted by the use of high-Fowler's position after this surgery. Low-Fowler's position is avoided because it could result in increased venous pressure on the surgical site and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when coughing, to suction periodically as needed, and to monitor the respiratory status frequently as prescribed

The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures? 1."I should restrict my fluid intake for 2 weeks." 2."I should perform arm exercises 2 or 3 times a day." 3."If I experience any soreness in my chest or shoulder, I should notify the primary health care provider." 4."If I experience any numbness or altered sensation around the incision, I should contact the primary health care provider."

2."I should perform arm exercises 2 or 3 times a day." Rationale:The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the primary health care provider if these symptoms occur

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1.Edema 2.Dyspnea 3.Frothy sputum 4.Diminished breath sounds

2.Dyspnea Rationale:In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2.Flushing 3.Dizziness 4.Tachycardia

2.Flushing Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside? 1.Code cart 2.Intubation tray 3.Thoracentesis tray 4.Chest tube and drainage system

2.Intubation tray Rationale:The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

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

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

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? 1.Pallor 2.Low arterial PaO2 3.Elevated arterial PaO2 4.Decreased respiratory rate

2.Low arterial PaO2 Rationale:The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? 1. Systemic tuberculosis 2. Pulmonary tuberculosis 3. Exposure to tuberculosis 4. No evidence of tuberculosis

3. Exposure to tuberculosis Rationale:A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Options 1, 2, and 4 are incorrect interpretations of the data presented in the question.

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

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

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

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

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

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

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

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

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

3. Encouraging active range-of-motion exercises Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a primary health care provider's prescription.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? 1."I should avoid all contact with my family." 2."I should avoid large crowds for at least 3 weeks." 3."I cannot give Legionnaires' disease to other people." 4."I will have to take antibiotics until my symptoms disappear."

3."I cannot give Legionnaires' disease to other people." Rationale:Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription; therefore, the remaining options are incorrect.

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

3.Administer the prescribed bronchodilator. Rationale:Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high-Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1.Administration of plasma expanders, low-flow oxygen, and suctioning 2.Administration of bronchodilators, intubation, and mechanical ventilation 3.Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4.Administration of anti-hypertensives, high-flow oxygen, and continuous positive airway pressure mask

3.Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure Rationale: Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. The remaining options are incorrect

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

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

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? 1.Atelectasis and viral infection 2.Bronchoconstriction and stridor 3.Collapse of alveoli and decreased compliance 4.Decreased ciliary action and retained secretions

3.Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease? 1.It is caused by a tick bite. 2.It is caused by contamination from cat feces. 3.It can be caused by the inhalation of spores from bird droppings. 4.It can be contagious by respiratory contact with an infected person.

3.It can be caused by the inhalation of spores from bird droppings. Rationale: Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. This disease cannot be transmitted from 1 person to another. Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.

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

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

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

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

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

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

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder? 1. The stretch receptors in the lungs are irritated. 2. The diaphragm is weak and is difficult to move. 3. This condition causes nerve endings to be especially sensitive. 4. The inflamed pleurae cannot glide against each other as they normally do.

4. The inflamed pleurae cannot glide against each other as they normally do. Rationale: Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. The remaining options are incorrect

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

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

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

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

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? 1.Allow the client to deal with the disease in an individual fashion. 2.Ask family members whether they wish a psychiatric consultation. 3.Encourage the client to visit with the pastoral care department's chaplain. 4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale: A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Encourage the client to sleep until arterial blood gas results improve. 3.Ask the primary health care provider for a prescription for succinylcholine. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed

4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed Rationale:Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? 1.1 or 2 days 2.1 to 2 weeks 3.Almost 1 week 4.Several weeks to months

4.Several weeks to months Rationale:The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? 1.The client has no risk of acquiring TB and needs no further workup. 2.The client is at increased risk for acquiring TB and needs immediate medication therapy. 3.The client's test result will be negative, and a sputum culture will be required for diagnosis. 4.The client's test result will be positive, and a chest x-ray study will be required for evaluation.

4.The client's test result will be positive, and a chest x-ray study will be required for evaluation. Rationale: The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Need for repeat testing

Rationale: The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.