Respiratory Quest #2 (Iggy)

*ANS: A, D* Varenicline (Chantix) has a black box warning stating that the drug can cause manicbehavior and hallucinations. The nurse should assess for changes in behavior and thoughtprocesses, including impaired judgment and visual hallucinations. Tachycardia andincreased thirst are not adverse effects of this medication. Decreased cravings is atherapeutic response to this medication. DIF: Understanding/Comprehension REF: 496 KEY: Medication| smoking cessation MSC: Integrated Process: Nursing Process: Analysis

*1. A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)* a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

*ANS: C, E* Suprasternal retraction caused by inhalation usually indicates that the client is usingaccessory muscles and is having difficulty moving air into the respiratory passages becauseof airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygensaturation also supports this finding. The asthma is not responding to the medication, andintervention is needed. Administration of a rescue inhaler is indicated, probably along withadministration of oxygen. The nurse would not do a peak flow reading at this time, norwould a code be called. Midline trachea is a normal and expected finding. DIF: Applying/Application REF: 575 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*1. A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)* a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

"*ANS: C* Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and othercontrolled substances. Because the client may have guilt or denial about this habit, assume anonjudgmental attitude during the interview. This will encourage the client to be honestabout the exposure. Ask the client whether any of these substances are used now or wereused in the past. Assess whether the client has passive exposure to smoke in the home orworkplace. If the client smokes, ask for how long, how many packs per day, and whether heor she has quit smoking (and how long ago). Document the smoking history in pack-years(number of packs smoked daily multiplied by the number of years the client has smoked).Quitting smoking may not stop further cancer development. This statement would be givingthe client false hope, which should be avoided, but is not as important as maintaining anonjudgmental attitude. DIF: Applying/Application REF: 494 KEY: Patient-centered care| smoking cessation MSC: Integrated Process: Communication and Documentation

*1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?* a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

*ANS: B* The client joining a book club that meets outside the home and requires him or her to go outin public is the best sign that goals for Impaired Self-Esteem are being met. The otherfindings are all positive signs but do not relate to this nursing diagnosis. DIF: Evaluating/Synthesis REF: 528 KEY: Tracheostomy| nursing evaluation| psychosocial response MSC: Integrated Process: Nursing Process: Evaluation

*10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?* a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

*ANS: C* The topical anesthetic used during the procedure will have affected the client's gag reflex.Before allowing the client anything to eat or drink, the nurse must check for the return ofthis reflex. DIF: Applying/Application REF: 511 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment

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

*ANS: C* The client will not be able to speak after surgery. The nurse should assist the client tochoose a communication method that he or she would like to use after surgery. Assessingthe client's airway and administering IV pain medication are done after the procedure.Although ambulation promotes health and decreases the complications of any surgery, thisclient's gait should not be impacted by a total laryngectomy and therefore is not a priority. DIF: Applying/Application REF: 540 KEY: Surgical care MSC: Integrated Process: Caring

*10. A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?* a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

*ANS: B* Immediately covering the insertion site helps prevent air from entering the pleural space andcausing a pneumothorax. The area will not reseal quickly enough to prevent air fromentering the chest. The nurse should not leave the client to obtain a suture kit. An occlusivedressing may cause a tension pneumothorax. The site should only be assessed after theinsertion site is covered. The provider should be called to reinsert the chest tube or prescribeother treatment options. DIF: Applying/Application REF: 578 KEY: Drains| surgical care MSC: Integrated Process: Nursing Process: Implementation

*10. While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?* a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

"*ANS: A* Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips andnares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning theclient is not related to comfort measures for oxygen. DIF: Applying/Application REF: 515 KEY: Oxygen| comfort measures| oral care| skin care| delegation MSC: Integrated Process: Communication and Documentation

*11. A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?* a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the client's nose. d. Turn the client every 2 hours or as needed.

*ANS: A* The drug reduces local immunity and increases the risk for local infection, especiallyCandida albicans. Rinsing the mouth after using the inhaler will decrease the risk fordeveloping this infection. Use of mouthwash and broad-spectrum antibiotics is notwarranted in this situation. The nurse should document the finding, but the best action totake is to have the client start rinsing his or her mouth after using fluticasone. An oralspecimen for culture and sensitivity will not provide information necessary to care for thisclient. DIF: Applying/Application REF: 554 KEY: Medication| fungal infection MSC: Integrated Process: Nursing Process: Implementation

*11. A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?* a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

*ANS: A* A client with dyspnea and difficulty completing activities such as climbing a flight of stairshas class III dyspnea. The nurse should provide assistance with activities of daily living.These clients should be encouraged to participate in activities as tolerated. They should notbe on complete bedrest, may not be able to tolerate daily physical therapy, and only needoxygen if hypoxia is present. DIF: Applying/Application REF: 503 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*11. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care?* a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

*ANS: A* Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is thehighest priority. Clients who experience stridor and hypoxia, manifested by anxiety andrestlessness, should be immediately intubated to ensure airway patency. Albuterol decreasesbronchi and bronchiole inflammation, not facial and neck edema. Although putting theclient in high-Fowler's position and asking the client to perform breathing exercises maytemporarily improve the client's comfort, these actions will not decrease the underlyingproblem or improve airway patency. DIF: Applying/Application REF: 534 KEY: Trauma MSC: Integrated Process: Nursing Process: Implementation

*11. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?* a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler's position. d. Ask the client to perform deep-breathing exercises.

*ANS: B* Oxygen is a drug that needs to be delivered constantly. The nurse should determine if theprovider has approved switching to a nasal cannula during meals. If not, the nurse shouldconsult with the provider about this issue. The oxygen should not be turned off. Lifting themask to eat will alter the FiO 2 delivered. DIF: Applying/Application REF: 517 KEY: Oxygen therapy| oxygen MSC: Integrated Process: Nursing Process: Implementation

*12. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?* a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

*ANS: C* Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) relatedto sleep apnea. This medication promotes daytime wakefulness. DIF: Remembering/Knowledge REF: 535 KEY: Medication MSC: Integrated Process: Teaching/Learning

*12. A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "How will this medication help me?" How should the nurse respond?* a. "This medication will treat your sleep apnea." b. "This sedative will help you to sleep at night." c. "This medication will promote daytime wakefulness." d. "This analgesic will increase comfort while you sleep."

*ANS: C* Clients who smoke while using drugs for nicotine replacement therapy increase the risk ofstroke and heart attack. Nurses should teach clients not to smoke while taking this drug. Theother responses are inappropriate. DIF: Applying/Application REF: 495 KEY: Smoking cessation| medication MSC: Integrated Process: Teaching/Learning

*12. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?* a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."

*ANS: D* Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tubebecomes disconnected from the drainage system, air can be sucked into the pleural spaceand cause a pneumothorax. A red, warm, and painful insertion site does not increase theclient's risk for a pneumothorax. Tube drainage should decrease and become serous as theclient heals. Sanguineous drainage is a sign of bleeding but does not increase the client'srisk for a pneumothorax. DIF: Applying/Application REF: 578 KEY: Drain| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*14. A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?* a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

*ANS: B* Priority teaching related to the use of a room humidifier focuses on infection control. Clientsshould be taught to meticulously clean the humidifier to prevent the spread of mold or othersources of infection. Peppermint oil should not be added to a humidifier. The humidifiershould be refilled with water as needed and should be used while awake and asleep. DIF: Understanding/Comprehension REF: 544 KEY: Surgical care MSC: Integrated Process: Teaching/Learning

*14. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?* a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."

*ANS: A* Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heartfailure. Increased pressures in the lungs make it more difficult for blood to flow through thelungs. Blood backs up into the right side of the heart and then into the peripheral venoussystem, creating distended neck veins and dependent edema. Inflammation in bronchi andbronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in thelungs has no impact on distended neck veins and edema. Left ventricular hypertrophy isassociated with left heart failure and is not caused by a 40-year smoking history. DIF: Remembering/Knowledge REF: 58 KEY: Heart failure| cor pulmonale MSC: Integrated Process: Nursing Process: Implementation

*15. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations?* a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

*ANS: C* Clients with severe COPD may not be able to perform daily activities, including bathing andeating, because of excessive shortness of breath. The nurse should ask the client if shortnessof breath is interfering with basic activities. Although the nurse should know about theclient's support systems, current knowledge, and medications, these questions do notaddress the client's appearance. DIF: Applying/Application REF: 561 KEY: Functional ability MSC: Integrated Process: Nursing Process: Assessment

*16. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?* a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

*ANS: D* Long-acting beta 2 agonists should be used every day to prevent asthma attacks. Thismedication should not be taken when an attack starts. Asthma medications can beexpensive. Telling the client that he or she is using the inhaler incorrectly does not addressthe client's financial situation, which is the main issue here. Clients with limited incomesshould be provided with community resources. Asking the client about fears related tobreathlessness does not address the client's immediate concerns. DIF: Applying/Application REF: 554 KEY: Case management| medication MSC: Integrated Process: Communication and Documentation

*17. The nurse is caring for a client who is prescribed a long-acting beta 2 agonist. The client states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How should the nurse respond?* a. "You are using the inhaler incorrectly. This medication should be taken daily." b. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." c. "Tell me more about your fears related to feelings of breathlessness." d. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."

"*ANS: B* The client who is in a tripod position and using accessory muscles is working to breathe.This client must be assessed first to establish how well the client is breathing and provideinterventions to minimize respiratory failure. The other clients are not in acute distress. DIF: Applying/Application REF: 559 KEY: Health screening MSC: Integrated Process: Nursing Process: Assessment

*18. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?* a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

*ANS: C* Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygenorders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearingoxygen while grilling and smoking increases the risk for fire. DIF: Applying/Application REF: 563 KEY: Safety| patient education| oxygen therapy MSC: Integrated Process: Nursing Process: Assessment

*19. The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?* a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

*ANS: B* Since this is an operative procedure, the client must sign an informed consent, which mustbe on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also berequired but do not take priority. DIF: Applying/Application REF: 522 KEY: Informed consent| autonomy MSC: Integrated Process: Communication and Documentation

*2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?* a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

*ANS: C* A potentially serious complication after biopsy is pneumothorax, which is indicated bydecreased or absent breath sounds. The physician needs to be notified immediately.Dizziness after the procedure is not an expected finding. If the client's heart rate is 55beats/min, no reason is known to withhold pain medication. A respiratory rate of 18breaths/min is a normal finding and would not warrant changing the oxygen flow rate. DIF: Applying/Application REF: 512 KEY: Assessment/diagnostic examination| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?* a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication. c. Client has reduced breath sounds. - Nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.

*ANS: A* The client with nasal drainage after facial trauma could have a skull fracture that hasresulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regulardrainage by the fact that it forms a halo when dripped on filter paper. The other actionswould be appropriate but are not as high a priority as assessing for CSF. A CSF leak wouldincrease the client's risk for infection. DIF: Applying/Application REF: 532 KEY: Trauma| medical emergencies MSC: Integrated Process: Nursing Process: Implementation

*2. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?* a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

*ANS: B, C, D* Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blooddyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, andintranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels donot cause epistaxis. DIF: Understanding/Comprehension REF: 532 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*2. A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.)* a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

*ANS: B* Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma insome people. This results from increased production of leukotriene when aspirin or NSAIDssuppress other inflammatory pathways and is a high priority given the client's history.Reviewing pulmonary function test results will not address the immediate problem offrequent asthma attacks. This is a good intervention for reviewing response tobronchodilators. Questioning the client about the use of bronchodilators will addressinterventions for the attacks but not their cause. Reviewing arterial blood gas results wouldnot be of use in a client between attacks because many clients are asymptomatic when nothaving attacks. DIF: Applying/Application REF: 553 KEY: Respiratory distress/failure| medication MSC: Integrated Process: Nursing Process: Assessment

*2. A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?* a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

*ANS: C* Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must bemutated for the disorder to be expressed. The nurse should encourage both the client andpartner to be tested for the abnormal gene. The other statements are not true. DIF: Applying/Application REF: 567 KEY: Gene| allele| health screening MSC: Integrated Process: Teaching/Learning

*22. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should the nurse respond?* a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."

*ANS: B* Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympatheticnervous system. This allows the sympathetic nervous system to dominate and releasenorepinephrine that actives beta 2 receptors. Bronchodilators relax bronchiolar smoothmuscles by binding to and activating pulmonary beta 2 receptors. Corticosteroids disrupt theproduction of pathways of inflammatory mediators. Cromones stabilize the membranes ofmast cells and prevent the release of inflammatory mediators. DIF: Remembering/Knowledge REF: 554 KEY: Medications MSC: Integrated Process: Nursing Process: Analysis

*23. A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication?* a. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta 2 receptors d. Cromone - Disrupts the production of pathways of inflammatory mediators

*ANS: A* Stridor is the sound heard, and it indicates severe airway constriction. The nurse mustadminister a bronchodilator to get air into the lungs. Administering oxygen, assessing vitalsigns, and elevating the client's head will not help until the client's airways are open. DIF: Applying/Application REF: 575 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Implementation

*25. A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.)* a. Assess for airway obstruction. b. Initiate oxygen therapy. c. Assess vital signs. d. Elevate the client's head.

*ANS: A* The proper order for obtaining a peak expiratory flow rate is as follows. Make sure thedevice reads zero or is at base level. The client should stand up (unless he or she has aphysical disability). The client should take as deep a breath as possible, place the meter inthe mouth, and close the lips around the mouthpiece. The client should blow out as hard andas fast as possible for 1 to 2 seconds. The value obtained should be written down. Theprocess should be repeated two more times, and the highest of the three numbers should berecorded in the client's chart. DIF: Applying/Application REF: 552 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment

*26. The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart."* a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4

*ANS: C* The proper order for correctly using an inhaler with a spacer is as follows. Insert themouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unitvigorously three or four times. Place the mouthpiece into the mouth, over the tongue, andseal the lips tightly around it. Press down firmly on the canister of the inhaler to release onedose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiecefrom the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Thenbreathe out slowly. Wait at least 1 minute between puffs. DIF: Applying/Application REF: 555 KEY: Medication safety MSC: Integrated Process: Teaching/Learning

*27. The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds."* a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

*ANS: A* This client may have subcutaneous emphysema, which is air that leaks into the tissuessurrounding the tracheostomy. The nurse should first assess the client's oxygen saturationand other indicators of oxygenation. If the client is stable, the nurse can palpate the skin ofthe upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid ResponseTeam. Using a bag-valve-mask device may or may not be appropriate for the unstable client. DIF: Applying/Application REF: 523 KEY: Oxygenation| tracheostomy| nursing assessment MSC: Integrated Process: Nursing Process: Assessment

*3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority?* a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

*ANS: A, D, E* The client with a tracheostomy may be shy and hesitant to go out in public. The clientshould have a sound communication method to ease frustration. The nurse can also suggestways of enhancing appearance so the client is willing to leave the house. These can includewearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound isnot good advice. DIF: Understanding/Comprehension REF: 528 KEY: Tracheostomy| psychosocial response| patient education MSC: Integrated Process: Caring

*3. A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)* a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

*ANS: A, D* Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, orbruising, behind the ear is called "battle sign" and indicates basilar skull fracture.Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirationsor neurologic function, and therefore are not priorities for immediate intervention. DIF: Applying/Application REF: 534 KEY: Trauma| medical emergencies MSC: Integrated Process: Nursing Process: Assessment

*3. A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)* a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

*ANS: D* Clients are usually unaware that they have sleep apnea, but it should be suspected in peoplewho have persistent daytime sleepiness and report waking up tired. Causes of the problemshould be assessed before the client is offered suggestions for treatment. DIF: Applying/Application REF: 535 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*3. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?* a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

*ANS: D* Many respiratory problems occur as a result of chronic exposure to inhalation irritants usedin a client's occupation and hobbies. Although it will be important for the nurse to assess theclient's fluid intake, height, and weight, these will not be as important as determining hisoccupation and hobbies. Determining the client's neck circumference will not be animportant part of a respiratory assessment. DIF: Applying/Application REF: 496 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment

*3. A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?* a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

*ANS: A, B, C* Fluids can make a client feel bloated and should be avoided with meals. Resting before themeal will help a client with dyspnea. Six small meals a day also will help to decreasebloating. Fibrous foods can produce gas, which can cause abdominal bloating and canincrease shortness of breath. The client should increase calorie and protein intake to preventmalnourishment. The client should not increase carbohydrate intake as this will increasecarbon dioxide production and increase the client's risk of for acidosis. DIF: Applying/Application REF: 565 KEY: Nutrition| patient education MSC: Integrated Process: Teaching/Learning

*3. A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.)* a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

*ANS: B* Any client on antibiotics must be instructed to complete the entire course of antibiotics. Notcompleting them can lead to complications or drug-resistant strains of bacteria. The otherinstructions are appropriate, just not the most important. DIF: Understanding/Comprehension REF: 585 KEY: Antibiotics| infectious respiratory problems| patient education MSC: Integrated Process: Teaching/Learning

*3. Which teaching point is most important for the client with bacterial pharyngitis?* a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

*ANS: A, D, E* Nurses should assess clients who have allergies for the specific cause, treatment, andresponse to treatment. The nurse should also document the allergies in a prominent place inthe client's medical record. The nurse should collaborate with food services to ensure noavocados are placed on the client's meal trays. Asking about the last time the client ateavocados does not provide any pertinent information for the client's plan of care. DIF: Applying/Application REF: 502 KEY: Allergies/allergic response MSC: Integrated Process: Communication and Documentation

*3. While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.)* a. "What response do you have when you eat avocados?" b. "I will remove any avocados that are on your lunch tray." c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?"

*ANS: B* Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading todilation of the tracheal passage. This can be manifested by food particles seen in secretionsor by noting that larger and larger amounts of pressure are needed to keep the tracheostomycuff inflated. The nurse should measure the pressures and compare them to previous ones todetect a trend. Elevating the head of the bed, placing the client on NPO status, andrequesting a swallow study will not correct this situation. DIF: Analyzing/Analysis REF: 523 KEY: Tracheostomy| patient safety| nursing assessment MSC: Integrated Process: Nursing Process: Assessment

*4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?* a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

*ANS: D* Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratoryinfections. The client does have manifestations of the flu (influenza), but it is too late to startantiviral medications; to be effective, they must be started within 24 to 48 hours of symptomonset. The client does not need hospital admission. The client should be instructed to have aflu vaccination, but now that he or she has the flu, vaccination will have to wait until nextyear. DIF: Applying/Application REF: 587 KEY: Influenza| antiviral| medications| patient education| infection control MSC: Integrated Process: Teaching/Learning

*4. A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?* a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

*ANS: B, C, E* Difficulty sleeping could indicate worsening breathlessness, as could taking longer toperform activities of daily living. Weight loss could mean increased dyspnea as the clientbecomes too fatigued to eat. The color of the client's sputum would not assist in determiningactivity tolerance. Asking whether the client walks upstairs every day is not as pertinent asdetermining if the client becomes short of breath on walking upstairs, or if the client goesupstairs less often than previously. DIF: Applying/Application REF: 559 KEY: Functional ability MSC: Integrated Process: Nursing Process: Assessment

*4. A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.)* a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

*ANS: B* Assessing the client's level of consciousness will be most important because it will showhow the client is responding to the presence of the infection. Although it will be importantfor the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise thehead of the bed; increase oral fluid intake; and humidify the oxygen administered, none ofthese actions will be as important as assessing the level of consciousness. Also, the clientwho has a pulmonary infection may not be able to cough effectively if an area of abscess ispresent. DIF: Applying/Application REF: 501 KEY: Older adult| pulmonary infection MSC: Integrated Process: Nursing Process: Assessment

*4. A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?* a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

*ANS: A, B, D, E* The older adult is at risk for having impairments in cognition, dexterity, range of motion,and vision that could limit the ability to perform tracheostomy care and should be assessed.Hydration is not directly related to the ability to perform self-care. DIF: Understanding/Comprehension REF: 529 KEY: Older adult| tracheostomy| patient education MSC: Integrated Process: Nursing Process: Assessment

*4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)* a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

*ANS: B* The client with open vocal cord paralysis may aspirate. The nurse should teach the client totuck in his or her chin during swallowing to prevent aspiration. Tilting the head back wouldincrease the chance of aspiration. Breathing slowly would not decrease the risk ofaspiration, but holding the breath would. Keeping the head still and straight would notdecrease the risk for aspiration. DIF: Applying/Application REF: 535 KEY: Aspiration precaution MSC: Integrated Process: Teaching/Learning

*4. A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?* a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

*ANS: B, E* The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days agoand the client who is awaiting gastric tube placement are stable. The client who is 6 hourspost-surgery is not yet stable. The RN is the only one who can perform discharge andpreoperative teaching; teaching cannot be delegated. DIF: Applying/Application REF: 540 KEY: Interdisciplinary team| delegation MSC: Integrated Process: Teaching/Learning

*4. A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)* a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

"*ANS: B, C* Tracheal deviation and sudden onset of shortness of breath are manifestations of a tensionpneumothorax. The nurse must intervene immediately for this emergency situation. Pinksputum is associated with pulmonary edema and is not a complication of a chest tube. Painat the insertion site and drainage of 75 mL/hr are normal findings with a chest tube. DIF: Applying/Application REF: 579 KEY: Drain| respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*5. A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)* a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

*ANS: C* The client at highest risk would be the one who is extremely overweight. None of the otherclients have risk factors for sleep apnea. DIF: Applying/Application REF: 535 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?* a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

*ANS: C* Side effects of radiation therapy may include inflammation of the esophagus. Clients shouldbe taught that bland, soft, high-calorie foods are best, along with liquid nutritionalsupplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilledcheese sandwich is too difficult to swallow with this condition, and orange juice and otherfoods with citric acid are too caustic. DIF: Applying/Application REF: 576 KEY: Cancer| nutrition MSC: Integrated Process: Nursing Process: Assessment

*5. A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?* a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

*ANS: C* Wheezes are indicative of narrowed airways, and bronchodilators help to open the airpassages. Hollow sounds are typically heard over the trachea, and no intervention isnecessary. If crackles are heard, the client may need a diuretic. Crackles represent a deepinterstitial process, and coughing forcefully will not help the client expectorate secretions.Vesicular sounds heard in the periphery are normal and require no intervention. DIF: Applying/Application REF: 506 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis

*5. A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?* a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply.

*ANS: A, B, C, E* Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucousmembranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication. DIF: Understanding/Comprehension REF: 515 KEY: Respiratory system| oxygen therapy| home safety| patient education MSC: Integrated Process: Teaching/Learning

*5. A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)* a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

*ANS: A, B, C, D* The client needs to know how to cut the wires in case of emergency. If the client vomits, heor she may aspirate. The client should also be taught to eat soft or liquid meals multipletimes a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in asemi-Fowler's position to assist in avoiding aspiration. Mouthwash with Benadryl is usedfor clients who have mouth pain after radiation treatment; it is not used to treat pain in aclient with a mandibular fracture. DIF: Applying/Application REF: 534 KEY: Surgical care| aspiration precautions MSC: Integrated Process: Teaching/Learning

*5. A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this client's teaching? (Select all that apply.)* a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Irrigate your mouth every 2 hours to prevent infection." d. "Sleep in a semi-Fowler's position after the surgery." e. "Gargle with mouthwash that contains Benadryl once a day."

*ANS: A, D, E* The nurse should teach a client who is interested in smoking cessation to find an activitythat keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8glasses of water each day, and to make a list of reasons for quitting smoking. The nurseshould also encourage the client not to be upset if he or she backslides and has a cigarette. DIF: Applying/Application REF: 496 KEY: Smoking cessation| patient-centered care MSC: Integrated Process: Teaching/Learning

*5. A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.)* a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a punishment for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking."

*ANS: A* The priority is to check the client's oxygenation because he or she may have aspirated. Oncethe client has been assessed, the nurse can consult with the registered dietitian aboutappropriately thickened liquids. The UAP should have reported the incident immediately,but addressing that issue is not the immediate priority. DIF: Applying/Application REF: 524 KEY: Delegation| aspiration| tracheostomy| nursing assessment| unlicensed assistive personnel (UAP) MSC: Integrated Process: Nursing Process: Assessment

*5. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?* a. Assess the client's lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

*ANS: B* Preventing the spread of pandemic flu is equally important as caring for the clients whohave it. Clients can be cohorted together in the same set of rooms on one part of the unit touse distancing to help prevent the spread of the disease. The other actions are notappropriate. DIF: Applying/Application REF: 588 KEY: Infection control| Transmission-Based Precautions| emergency and disaster preparedness/management plans MSC: Integrated Process: Nursing Process: Implementation

*5. The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best?* a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

*ANS: A, C, D, E* Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused bypoor oral hygiene. Clients at risk include those with altered mental status and level ofconsciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic)and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). Theclient with a fractured femur is at risk for a pulmonary embolism. DIF: Applying/Application REF: 536 KEY: Medical emergencies MSC: Integrated Process: Nursing Process: Assessment

*6. A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)* a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

*ANS: B* The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first. DIF: Applying/Application REF: 503 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment

*6. A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?* a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

*ANS: A, B, D* Interventions to decrease thick tenacious secretions include maintaining adequate hydrationand providing humidified oxygen. These actions will help to thin secretions, making themeasier to remove by coughing. The use of a vibrating positive expiratory pressure device canalso help clients remove thick secretions. Although suctioning may assist with the removalof secretions, frequent suctioning can cause airway trauma and does not support the client'sability to successfully remove secretions through normal coughing. Diaphragmatic breathingis not used to improve the removal of thick secretions. DIF: Applying/Application REF: 564 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*6. A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)* a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

*ANS: C* To prevent pressure ulcers and for client safety, when ties are used that must be knotted, theknot should be placed at the side of the client's neck, not in back. The other actions areappropriate. DIF: Applying/Application REF: 527 KEY: Tracheostomy| tracheostomy care| patient safety| supervision MSC: Integrated Process: Communication and Documentation

*6. A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?* a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

*ANS: B* Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. Theclient has to be educated not to even whisper when resting the voice. It is also appropriatefor the client to stay out of rooms where people are smoking, to stay hydrated, and to usestool softeners. DIF: Applying/Application REF: 536 KEY: Cancer| patient education MSC: Integrated Process: Teaching/Learning

*6. After teaching a client who is prescribed "voice rest" therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching?* a. "I will stay away from smokers to minimize inhalation of secondhand smoke." b. "When I speak, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least three quarts of water each day to stay hydrated."

*ANS: C* Clients should be encouraged to take their pain medications; addiction usually is not anissue with a client in pain. The nurse would not request that the pain medication be changedunless it was not effective. Other methods to decrease pain can be used, in addition to painmedication. DIF: Applying/Application REF: 576 KEY: Cancer| pain| pharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation

*6. The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond?* a. "I will ask the provider to change your medication to a drug that is less potent." b. "Would you like me to use music therapy to distract you from your pain?" c. "It is unlikely you will become addicted when taking medicine for pain." d. "Would you like me to give you acetaminophen (Tylenol) instead?"

*ANS: A* The nurse should implement Standard Precautions and don gloves prior to completing theother actions. DIF: Applying/Application REF: 532 KEY: Trauma MSC: Integrated Process: Nursing Process: Implementation

*7. A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?* a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

*ANS: A, C, E* Intravenous prostacyclin agents should be administered in a central venous catheter with adedicated intravenous line for this medication. Death has been reported when the drugdelivery system is interrupted; therefore, a backup drug cassette should also be available.The nurse should use strict aseptic technique when using the drug delivery system. Thenurse should teach the client that this medication decreases pulmonary pressures andincreases lung blood flow. DIF: Understanding/Comprehension REF: 571 KEY: Medication administration| safety MSC: Integrated Process: Nursing Process: Implementation

*7. A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication? (Select all that apply.)* a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

*ANS: B* Absent breath sounds may indicate that the client has a pneumothorax, a seriouscomplication after a needle biopsy or open lung biopsy. The other manifestations are not lifethreatening. DIF: Applying/Application REF: 512 KEY: Assessment/diagnostic examination| respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?* a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

*ANS: B* It is essential to obtain an early chest x-ray in older adults suspected of having pneumoniabecause symptoms are often vague. Waiting until definitive manifestations are present toobtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are alwaysordered does not give the family definitive information. The x-ray can be done whilelaboratory values are still pending, but this also does not provide specific information aboutthe importance of a chest x-ray in this client. The client has manifestations of pneumonia, sothe staff is not testing for any possible source of infection but rather is testing for asuspected disorder. DIF: Understanding/Comprehension REF: 592 KEY: Older adult| pneumonia| infection| communication MSC: Integrated Process: Communication and Documentation

*7. An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?* a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

*ANS: C* Many clients with moderate to severe COPD become socially isolated because they areembarrassed by frequent coughing and mucus production. They also can experience fatigue,which limits their activities. The nurse needs to encourage the client to verbalize thoughtsand feelings so that appropriate interventions can be selected. Joining a support group wouldnot decrease feelings of social isolation if the client does not verbalize feelings. Antianxietyagents will not help the client with social isolation. Encouraging a client to participate inactivities without verbalizing concerns also would not be an effective strategy for decreasingsocial isolation. DIF: Applying/Application REF: 561 KEY: Coping| support MSC: Integrated Process: Caring

*8. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?* a. "There are a variety of support groups for people who have COPD." b. "I will ask your provider to prescribe you with an antianxiety agent." c. "Share any thoughts and feelings that cause you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

*ANS: B* Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosisof Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for thisdiagnosis are being met. Nutrition and weight are not related to using oxygen.Understanding the need for oxygen is important but would not take priority over a physicalproblem. DIF: Evaluating/Synthesis REF: 515 KEY: Oxygen| skin integrity| nursing diagnosis| oxygen therapy MSC: Integrated Process: Nursing Process: Evaluation

*8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?* a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

*ANS: D* A thoracentesis is an invasive procedure with many potentially serious complications.Verifying that the client understands complications and explaining the procedure to beperformed will be done by the physician or nurse practitioner, not the nurse. Measurementof oxygen saturation before and after a 12-minute walk is not a procedure unique to athoracentesis. DIF: Applying/Application REF: 511 KEY: Assessment/diagnostic examination MSC: Integrated Process: Communication and Documentation

*8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?* a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

**ANS: A, B, C, E* Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegatecomfort measures, give simple explanations the client will understand, and stay with theclient. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medicationsare not used routinely because they can contribute to hypoxia. If the client's anxiety isinterfering with diagnostic testing or treatment, they can be used, but there is no evidencethat this is the case. DIF: Applying/Application REF: 609 KEY: Pulmonary embolism| thromboembolic events| psychosocial response| anxiety| support MSC: Integrated Process: Nursing Process: Implementation* d. The trachea is deviated toward the opposite side of the neck. ANS: D A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. DIF: Applying/Application REF: 511 KEY: Assessment/diagnostic examination| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?* a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted.

*ANS: D* This client may have a trachea-innominate artery fistula, which can be a life-threateningemergency if the artery is breached and the client begins to hemorrhage. Since no bleedingis yet present, the nurse stays with the client and asks someone else to notify the provider. Ifthe client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure atthe bleeding site. The client will need to be prepared for surgery. DIF: Applying/Application REF: 523 KEY: Tracheostomy| medical emergencies| communication MSC: Integrated Process: Nursing Process: Implementation

*9. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?* a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

*ANS: C* Clients with CF often are malnourished due to vitamin deficiency and pancreaticmalfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are notessential actions. Genetic screening would not help the client manage CF better. DIF: Applying/Application REF: 567 KEY: Nutrition| patient education MSC: Integrated Process: Teaching/Learning

*9. A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching?* a. "Take an antibiotic each day." b. "Contact your provider to obtain genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."

*ANS: A, B, C* Oxygen is an accelerant, which means it enhances combustion, so precautions are neededwhenever using it. The nurse should assess if the client allows smoking near the oxygen,whether electrical cords are in good shape or are frayed, and if flammable liquids are stored(and used) in the garage away from the oxygen. Light bulbs and pets are not related tooxygen safety. DIF: Understanding/Comprehension REF: 515 KEY: Patient safety| fire| oxygen| home safety| nursing assessment MSC: Integrated Process: Nursing Process: Assessment

*Control 1. A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)* a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

*ANS: A, B, C, D* The nurse should observe for clear drainage because of the risk for cerebrospinal fluidleakage. The nurse should assess for signs of bleeding by asking the client to open his or hermouth and observing the back of the throat for bleeding. The nurse should also note whetherthe client is swallowing frequently because this could indicate postnasal bleeding. A nasalsteroid would increase the risk for infection. It is too soon to change the packing, whichshould be changed by the surgeon the first time. DIF: Applying/Application REF: 531 KEY: Surgical care MSC: Integrated Process: Nursing Process: Implementation

*Control 1. A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)* a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

*ANS: D* A patent airway is the priority. The nurse first should make sure that the airway is patent andthen should determine whether the client is in pain and whether bone displacement or bloodloss has occurred. DIF: Applying/Application REF: 531 KEY: Trauma| medical emergencies MSC: Integrated Process: Nursing Process: Implementation

*Control 1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?* a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

*ANS: D* A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurseshould provide pain medication to minimize discomfort and encourage the client to takedeep breaths. The other responses do not address the client's discomfort and need to takedeep breaths to prevent complications. DIF: Applying/Application REF: 580 KEY: Pain| pharmacologic pain management| drain| surgical care MSC: Integrated Process: Nursing Process: Implementation

*Control 13. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?* a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client's anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

*ANS: A, D* The UAP can perform hygiene measures such as applying lip balm and reinforce teachingsuch as reminding the client to perform coughing and deep-breathing exercises. Oral carecan be accomplished with normal saline, not products that dry the mouth. Ensuring thehumidity is adequate and suctioning through the tracheostomy are nursing functions. DIF: Applying/Application REF: 515 KEY: Tracheostomy| oral care| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation

*Control 2. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)* a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

*ANS: D* Padded clamps should be kept at the bedside for use if the drainage system becomesdislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions shouldbe taped, not clamped. Wall suction should be set at the level indicated by the device'smanufacturer, not the provider. DIF: Remembering/Knowledge REF: 578 KEY: Drains| postsurgical care MSC: Integrated Process: Nursing Process: Implementation

*Control 20. A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?* a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

*ANS: C* The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT toprevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A clientwith two alleles is at high risk for COPD even if not exposed to smoke or other irritants. Theclient is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question. DIF: Applying/Application REF: 558 KEY: Gene| allele| health screening| a1AT (alpha1-antitrypsin) gene MSC: Integrated Process: Teaching/Learning

*Control 21. A nurse cares for a client who tests positive for alpha 1 -antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How should the nurse respond?* a. "Your children will be at high risk for the development of chronic obstructive pulmonary disease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and should have no impact on your health."

*ANS: A, D, E* To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators havebeen administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours priorto the test, and the client can follow basic commands, including different breathingmaneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is notused for this test. DIF: Applying/Application REF: 509 KEY: Assessment/diagnostic examination MSC: Integrated Process: Communication and Documentation

*Control 4. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)* a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

*ANS: A* Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss andcan lead to a degree of dehydration. The other options do not give the client usefulinformation. DIF: Applying/Application REF: 593 KEY: Pneumonia| fluid and electrolyte imbalances| patient education MSC: Integrated Process: Teaching/Learning

*Control 6. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best?* a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

*ANS: A* Suction should only be applied while withdrawing the catheter. The other actions areappropriate. DIF: Remembering/Knowledge REF: 525 KEY: Tracheostomy| tracheostomy care| suctioning| supervision MSC: Integrated Process: Nursing Process: Assessment

*Control 7. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?* a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

"*ANS: A* Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine ordiphenhydramine can provide relief from a sore throat after radiation therapy. Intravenouspain medications may be used if local anesthetics are unsuccessful. The nurse shouldexplain to the client that this is normal and assess the client's neck, but these options do notdecrease the client's discomfort. DIF: Remembering/Knowledge REF: 539 KEY: Cancer| pain| medication MSC: Integrated Process: Nursing Process: Implementation

*Control 8. A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?* a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the client's neck for redness and swelling.

*ANS: D* Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that isavailable. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation. DIF: Applying/Application REF: 552 KEY: Respiratory distress/failure| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment

*MULTIPLE CHOICE 1. A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?* a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

*ANS: B* Room air is 21% oxygen. DIF: Remembering/Knowledge REF: 514 KEY: Oxygen| physiology MSC: Integrated Process: Nursing Process: Assessment

*MULTIPLE CHOICE 1. A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?* a. 14% b. 21% c. 28% d. 31%

*ANS: C* First-generation antihistamines are not appropriate for use in the older population. Thesedrugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is asecond-generation antihistamine. DIF: Remembering/Knowledge REF: 584 KEY: Antihistamines| older adults| histamine blocker MSC: Integrated Process: Teaching/Learning

*Therapies 1. A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?* a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

*ANS: C* Burkholderia cepacia infection is spread through casual contact between cystic fibrosisclients, thus the need for these clients to be separated from one another. Strict isolationmeasures will not be necessary. Although the client should wash his or her hands frequently,the most important measure that can be implemented on the unit is isolation of the clientfrom other clients with cystic fibrosis. There is no need to implement Droplet Precautions ordon a surgical mask when caring for this client. Obtaining blood, sputum, and urine culturespecimens will not provide information necessary to care for a client with Burkholderiacepacia infection. DIF: Applying/Application REF: 568 KEY: Pulmonary infection| infection control MSC: Integrated Process: Nursing Process: Implementation

*Therapies 12. A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?* a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

*ANS: D* The string should be attached to the client's cheek to hold the packing in place. The nurseneeds to make sure that this does not move because it can occlude the client's airway. Theother options are good interventions, but ensuring that the airway is patent is the priorityobjective. DIF: Applying/Application REF: 533 KEY: Surgical care MSC: Integrated Process: Nursing Process: Implementation

*Therapies 13. A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?* a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek.

*ANS: B* Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, whichis an adverse effect of benzocaine spray. Death can occur if the level of methemoglobinrises and cyanosis occurs. The nurse should notify the Rapid Response Team to provideadvanced nursing care. An albuterol treatment would not address the client's oxygenationproblem. Assessment of pulses and cultures will not provide data necessary to treat thisclient. DIF: Applying/Application REF: 510 KEY: Assessment/diagnostic examination| medication MSC: Integrated Process: Nursing Process: Implementation

*Therapies 13. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?* a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

*ANS: C* For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly,usually between 4 and 10 L/min. The client's flow rate is too low and the nurse shouldincrease it. After increasing the flow rate, the nurse assesses the oxygen saturation anddocuments the findings. DIF: Analyzing/Analysis REF: 519 KEY: Oxygen| patient safety| oxygen therapy MSC: Integrated Process: Nursing Process: Implementation

*Therapies 13. The nurse assesses the client using the device pictured below to deliver 50% O 2 : The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?* a. Assess the client's oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.

*ANS: A* Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normalfinding over the trachea and larynx. The nurse should document this finding. There is noneed to implement oxygen therapy, administer albuterol, or change the client's positionbecause the finding is normal. DIF: Remembering/Knowledge REF: 506 KEY: Assessment/diagnostic examination MSC: Integrated Process: Communication and Documentation

*Therapies 14. A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?* a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler's position. d. Administer prescribed albuterol.

*ANS: B, D, E, F* Immediate intervention is warranted if the client has tracheal deviation because this couldindicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment ofthe tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr couldindicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion siteare not signs/symptoms that would require immediate intervention. DIF: Applying/Application REF: 579 KEY: Drain| respiratory distress/failure MSC: Integrated Process: Nursing Process: Assessment

*Therapies 2. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)* a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

*ANS: C* This client has rhinosinusitis. Comfort measures for this condition include breathing inwarm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increasedfluids, and avoiding cigarette smoke. The client does not need a CT scan. DIF: Understanding/Comprehension REF: 584 KEY: Infectious respiratory problems| nonpharmacologic comfort interventions| patient education MSC: Integrated Process: Teaching/Learning

*Therapies 2. A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?* a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

"*ANS: A, C, D* Regular pulmonary hygiene and activities to maintain health and fitness help to maximizefunctioning of the respiratory system and prevent infection. A client at high risk for apulmonary infection may need a specialty bed to help with postural drainage or percussion;this would not include an air mattress overlay, which is used to prevent pressure ulcers.Tylenol would not decrease the risk of a pulmonary infection. DIF: Applying/Application REF: 501 KEY: Respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*Therapies 2. A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)* a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

*ANS: A* A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lungwall. The other pathophysiologic processes would not cause a pleural friction rub.Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may beheard as stridor, and pulmonary vascular edema may be heard as crackles. DIF: Applying/Application REF: 575 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Implementation

*Therapies 24. A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.)* a. Inflammation of the pleura b. Constriction of the bronchioles c. Upper airway obstruction d. Pulmonary vascular edema

*ANS: D* Oxygen should be administered to a client who is hypoxic even if the client has COPD andis a carbon dioxide retainer. The other interventions do not address the client's hypoxia,which is the priority. DIF: Applying/Application REF: 563 KEY: Oxygen therapy| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation

*Therapies 28. A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO 2 = 62 mm Hg PaO 2 = 46 mm Hg HCO 3 - = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first?* a. Administer a short-acting beta 2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

"*ANS: C* Long-acting beta 2 agonist medications will help prevent an acute asthma attack becausethey are long acting. The client will take this medication every day for best effect. The clientdoes not have to always keep this medication with him or her because it is not used as arescue medication. This is not the medication the client will use during an acute asthmaattack because it does not have an immediate onset of action. The client will not be weanedoff this medication because this is likely to be one of his or her daily medications. DIF: Applying/Application REF: 554 KEY: Medication| patient education MSC: Integrated Process: Teaching/Learning

*Therapies 3. After teaching a client who is prescribed a long-acting beta 2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?* a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."

*ANS: B* To perform diaphragmatic breathing correctly, the client should place his or her hands onhis or her abdomen to create resistance. This type of breathing cannot be performedeffectively while lying on the side or with hands over the head. This type of breathing wouldnot be as effective lying prone. DIF: Applying/Application REF: 562 KEY: Respiratory distress/failure| patient education MSC: Integrated Process: Teaching/Learning

*Therapies 4. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching?* a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

*ANS: B* Many clients experience changes in taste after surgery. The nurse should identify foods thatthe client wants to eat to ensure the client maintains necessary nutrition. Although the nurseshould collaborate with the speech therapist and dietitian to ensure appropriate replacementof protein, calories, and water, the other responses do not address the client's concerns. DIF: Applying/Application REF: 533 KEY: Surgical care| nutrition MSC: Integrated Process: Communication and Documentation

*Therapies 9. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?* a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important after surgery."

*ANS:* 45 pack-years 66 (current age) - 16 (year started smoking) = 50 years of smoking. (40 years × 1 pack per day) + (10 years × 0.5 pack per day) = 45 pack-years. DIF: Applying/Application REF: 495 KEY: Smoking cessation MSC: Integrated Process: Nursing Process: Assessment

*1. A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years*

*ANS: B, D, E* Conditions that place clients at higher risk of developing PE include prolonged immobility,central venous catheters, surgery, obesity, advancing age, conditions that increase bloodclotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction andasthma pose no risk for PE. DIF: Remembering/Knowledge REF: 604 KEY: Pulmonary embolism| nursing assessment| clotting| thromboembolic event MSC: Integrated Process: Nursing Process: Assessment

*1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)* a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

*ANS: A, C, D, E* Clients over 65 years of age and any client (no matter what age) with a chronic healthcondition would be considered a priority for a pneumonia vaccination. Having acholecystectomy a year ago does not qualify as a chronic health condition. DIF: Understanding/Comprehension REF: 589 KEY: Vaccinations| chronic illness| older adults| health promotion MSC: Integrated Process: Nursing Process: Implementation

*1. A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)* a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

*ANS: C* The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse. DIF: Applying/Application REF: 619 KEY: Mechanical ventilation| oral care| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation

*10. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?* a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

*ANS: D* The upper peak airway pressure limit alarm will sound when the airway pressure reaches apreset maximum. This is critical to prevent damage to the lungs. Alarms should never beturned off. Initiating spontaneous breathing is important for some modes of ventilation butnot others. Adequate humidification is important but does not take priority over preventinginjury. DIF: Applying/Application REF: 619 KEY: Mechanical ventilation| respiratory system| equipment safety MSC: Integrated Process: Nursing Process: Implementation

*11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?* a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

*ANS: A* Goals for treatment of community-acquired pneumonia include initiating antibiotics prior toinpatient admission or within 6 hours of presentation to the ED. Timely collection of bloodcultures, chest x-ray, and pulse oximetry are important as well but do not coincide withestablished goals. DIF: Evaluating/Synthesis REF: 590 KEY: Infection| pneumonia| core measures MSC: Integrated Process: Nursing Process: Assessment

*11. The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?* a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

*ANS: C* INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin). DIF: Evaluating/Synthesis REF: 597 KEY: Antibiotics| anti-tuberculosis agents| medication-food interactions| patient education MSC: Integrated Process: Nursing Process: Evaluation

*12. A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?* a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

*ANS: B* Having a bag-valve-mask device is critical in case the client needs manual breathing. Therespiratory therapist is usually primarily responsible for setting up the ventilator, althoughthe nurse should know and check the settings. Personal protective equipment is important,but ensuring client safety takes priority. The client may or may not need suctioning onarrival. DIF: Applying/Application REF: 615 KEY: Mechanical ventilation| patient safety| critical rescue MSC: Integrated Process: Nursing Process: Implementation

*13. A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?* a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

*ANS: D* Stress ulcers occur in many clients who are receiving mechanical ventilation, and oftenprophylactic medications are used to prevent them. Frequently used medications includeantacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blockingagent. DIF: Understanding/Comprehension REF: 621 KEY: Mechanical ventilation| histamine blocker| communication MSC: Integrated Process: Teaching/Learning

*14. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?* a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

*ANS: B* This client has manifestations of early inhalation anthrax. For treatment, after IV antibioticsare finished, oral antibiotics are continued for at least 60 days. Sputum cultures are notneeded. Anthrax is not transmissible from person to person, so Standard Precautions areadequate. Directly observed therapy is often used for tuberculosis. DIF: Applying/Application REF: 600 KEY: Anthrax| antibiotics| Standard Precautions| Transmission-Based Precautions| patient education MSC: Integrated Process: Teaching/Learning

*14. A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?* a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

*ANS: A* The nurse needs to obtain further information about the spouse's specific fears so they canbe addressed. This will decrease stress and permit visitation, which will be beneficial forboth client and spouse. Precautions for TB prevent transmission to all who come intocontact with the client. Explaining isolation precautions and what to do when entering theroom will be helpful, but this is too narrow in scope to be the best answer. Telling thespouse it's safe to visit is demeaning of the spouse's feelings. DIF: Applying/Application REF: 599 KEY: Psychosocial response| therapeutic communication| communication| caring MSC: Integrated Process: Caring

*15. A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?* a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

*ANS: D* Directly observed therapy is often utilized for managing clients with TB in the community.Meals on Wheels, job retraining, and home therapy may or may not be appropriate. DIF: Applying/Application REF: 599 KEY: Anti-tuberculosis agents| referrals| infection| interdisciplinary team MSC: Integrated Process: Communication and Documentation

*16. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?* a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

*ANS: B* Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foodshigh in vitamin K thus interfere with its action and need to be eaten in moderate, consistentamounts. The chef's salad most likely has too many leafy green vegetables, which containhigh amounts of vitamin K. The other selections, while not particularly healthy, will notinterfere with the medication's mechanism of action. DIF: Evaluating/Synthesis REF: 607 KEY: Patient education| anticoagulants| nursing process evaluation MSC: Integrated Process: Nursing Process: Evaluation

*16. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?* a. Hamburger and French fries b. Large chef's salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

*ANS: B* Polymerase chain reaction testing is used to diagnose pertussis, which this client is showingmanifestations of. Hospitalization may or may not be needed but is not the most importantaction. The client may or may not be able to produce sputum, but sputum cultures for thisdisease must be obtained via deep suctioning. Blood cultures will be negative. DIF: Remembering/Knowledge REF: 600 KEY: Laboratory values| infection| respiratory system MSC: Integrated Process: Nursing Process: Implementation

*17. A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?* a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

*ANS: D* "Valley fever," or coccidioidomycosis, is a fungal infection. Many people do not needtreatment and the disease resolves on its own. However, the presence of joint and musclepain indicates a moderate infection that needs treatment with antifungal medications. IVamphotericin is reserved for pregnant women and those with severe infection.Anti-inflammatory medications may be used to treat muscle aches and pain but are not usedlong term. DIF: Applying/Application REF: 601 KEY: Infection| fungal infection| anti-fungal medications| patient education MSC: Integrated Process: Teaching/Learning

*18. A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?* a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

"*ANS: B* Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The otheractions are appropriate. DIF: Applying/Application REF: 607 KEY: Anticoagulants| medication administration MSC: Integrated Process: Communication and Documentation

*18. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?* a. Assessing the client's platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

*ANS: C* Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,including PE. A client with no known risk factors for this disorder should be referred fortesting. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature. DIF: Applying/Application REF: 605 KEY: Pulmonary embolism| thrombotic events| patient education| genetic testing MSC: Integrated Process: Teaching/Learning

*2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?* a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

*ANS: A, B, C* Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalationanthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tractinfections and other common infections. DIF: Remembering/Knowledge REF: 600 KEY: Antibiotics| anthrax| emergency preparedness plan MSC: Integrated Process: Nursing Process: Implementation

*2. A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.)* a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

*ANS: C, D, E* Health promotion measures for clients to prevent thromboembolic events such as PE includemaintaining a healthy weight, exercising on a regular basis, and not smoking. Avoidingalcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions butdo not relate to the prevention of PE. DIF: Understanding/Comprehension REF: 604 KEY: Pulmonary embolism| patient education| clotting| thromboembolic event| lifestyle choices MSC: Integrated Process: Teaching/Learning

*2. When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)* a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

*ANS: A* Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamicinstability. The nurse knows this drug is the priority, although heparin may be startedinitially. Enoxaparin and warfarin are not indicated in this setting. DIF: Remembering/Knowledge REF: 606 KEY: Pulmonary embolism| thromboembolic event| anticoagulants MSC: Integrated Process: Nursing Process: Analysis

*20. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?* a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

*ANS: C* This "allergy test" is actually a positive tuberculosis test. The client should be placed onAirborne Precautions immediately. The other options do not take priority over preventingthe spread of the disease. DIF: Applying/Application REF: 595 KEY: Infection| Transmission-Based Precautions| nursing implementation MSC: Integrated Process: Nursing Process: Implementation

*20. A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority?* a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

*ANS: D* Refractory hypoxemia is hypoxemia that persists even with the administration of 100%oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompanyrestrictive airway disease and is not caused by the use of mechanical ventilation or by beingweaned from oxygen. DIF: Understanding/Comprehension REF: 612 KEY: Respiratory disorders| respiratory system| pathophysiology MSC: Integrated Process: Teaching/Learning

*22. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?* a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

*ANS: B* This client has manifestations of pulmonary embolism (PE); however, many conditions cancause the client's presentation. The gold standard for diagnosing a PE is pulmonaryangiography. The nurse should facilitate this test as soon as possible. The client does nothave wheezing, so a respiratory treatment is not needed. The client is not unstable enough toneed intubation and mechanical ventilation. IV anticoagulants are not given without adiagnosis of PE. DIF: Analyzing/Analysis REF: 605 KEY: Pulmonary embolism| thromboembolic event| laboratory values| respiratory system| clotting MSC: Integrated Process: Nursing Process: Implementation

*23. A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened "Can't catch my breath" pH: 7.12 PaCO 2 : 28 mm Hg PaO 2 : 58 mm Hg SaO 2 : 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?* a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

"*ANS: C* A large blood clot in the lungs will significantly impair gas exchange and oxygenation.Unless the clot is dissolved, this process will continue unabated. Hyperventilation caninterfere with oxygenation by shallow breathing, but there is no evidence that the client ishyperventilating, and this is also not the most precise physiologic answer. Respiratorydistress syndrome can occur, but this is not as likely. The client may need to bemechanically ventilated, but without concrete data on FiO 2 and SaO 2 , the nurse cannotmake that judgment. DIF: Applying/Application REF: 603 KEY: Pulmonary embolism| thromboembolic event| respiratory system| oxygen saturation MSC: Integrated Process: Teaching/Learning

*3. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?* a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

*ANS: A, B, C, E* Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegatecomfort measures, give simple explanations the client will understand, and stay with theclient. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medicationsare not used routinely because they can contribute to hypoxia. If the client's anxiety isinterfering with diagnostic testing or treatment, they can be used, but there is no evidencethat this is the case. DIF: Applying/Application REF: 609 KEY: Pulmonary embolism| thromboembolic events| psychosocial response| anxiety| support MSC: Integrated Process: Nursing Process: Implementation

*3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)* a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

*ANS: A, B, C, D* The client with an empyema is often treated with chest tube insertion, which facilitatesobtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurseshould perform frequent respiratory system assessments. Antipyretic medications are alsoused. Suction is only used when needed and is not done deeply to prevent tissue injury. DIF: Applying/Application REF: 599 KEY: Respiratory system| chest tubes| infection| respiratory assessment MSC: Integrated Process: Nursing Process: Implementation

*4. A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)* a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

*ANS: B* For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstratethe heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is toolow. The heparin rate needs to be increased. Warfarin is not indicated in this situation. DIF: Applying/Application REF: 606 KEY: Pulmonary embolism| thromboembolic events| anticoagulants| laboratory values MSC: Integrated Process: Nursing Process: Analysis

*4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?* a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

*ANS: A, B, C, D* The "ventilator bundle" is a group of care measures to prevent ventilator-associatedpneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcermedications, elevating the head of the bed, providing frequent oral care per policy,preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done asneeded. DIF: Remembering/Knowledge REF: 621 KEY: Mechanical ventilation| respiratory system| core measures| infection control| pneumonia MSC: Integrated Process: Nursing Process: Implementation

*4. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)* a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

*ANS: B* Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However,clients with a variation in the CYP2C19 gene do not metabolize warfarin well and havehigher blood levels and more side effects. This client is a poor candidate for warfarintherapy, and the prescriber will most likely order an IVC filter device to be implanted. Thenurse should prepare to do preoperative teaching on this procedure. It would be impossibleto eliminate all vitamin K from the diet. A chronic illness support group may be needed, butthis is not the best intervention as it is not as specific to the client as the IVC filter. Asoft-bristled toothbrush is a safety measure for clients on anticoagulation therapy. DIF: Applying/Application REF: 608 KEY: Pulmonary embolism| thromboembolic events| patient education| genetic alterations MSC: Integrated Process: Nursing Process: Analysis

*5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?* a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

*ANS: B* This platelet count is low and could indicate heparin-induced thrombocytopenia. The othervalues are normal for either gender. DIF: Applying/Application REF: 609 KEY: Anticoagulants| laboratory values MSC: Integrated Process: Nursing Process: Assessment

*6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?* a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm 3 d. White blood cell count: 8.7/mm 3

*ANS: A, B, D* Age-related changes that increase the difficulty of weaning older adults from mechanicalventilation include increased stiffness of the chest wall, decreased muscle strength, and lesselasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensoryacuity. DIF: Remembering/Knowledge REF: 622 KEY: Mechanical ventilation| older adult MSC: Integrated Process: Nursing Process: Analysis

*6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)* a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

*ANS: A* Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factorscan interfere, producing normal or near-normal readings in the setting of hypoxia. The nurseshould conduct a more thorough assessment. The other actions are not appropriate for ahypoxic client. DIF: Applying/Application REF: 605 KEY: Respiratory assessment| respiratory system| oxygen saturation| hypoxia MSC: Integrated Process: Nursing Process: Assessment

*7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?* a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

*ANS: A* The treatment regimen for TB ranges from 6 to 12 months, making adherence problematicfor many people. The nurse should stress the absolute importance of following the treatmentplan for the entire duration of prescribed therapy. The other options are appropriate topics toeducate this client on but do not take priority. DIF: Applying/Application REF: 597 KEY: Patient education| infection| antibiotics| tuberculosis MSC: Integrated Process: Teaching/Learning

*8. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?* a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

*ANS: C* Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causeshypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. Thenurse should also have adequate sedation during the procedure and monitor the client'soxygen saturation, but these do not take priority. Finding another provider is not appropriateat this time. DIF: Applying/Application REF: 615 KEY: Respiratory system| intubation| oxygenation MSC: Integrated Process: Nursing Process: Implementation

*8. A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?* a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

*ANS: D* Inhalation anthrax is rare and is an occupational hazard among people who work withanimal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalationanthrax seen in someone without an occupational risk is considered a bioterrorism event andmust be reported to authorities immediately. The other questions are appropriate for anyonewith an infection. DIF: Applying/Application REF: 599 KEY: Infection| nursing assessment| anthrax| bioterrorism MSC: Integrated Process: Nursing Process: Assessment

*9. A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?* a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"

*ANS: C* When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (mostcommon cause), obstruction (often by secretions), pneumothorax, and equipment problems.The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tubeis still correctly placed. If this assessment is normal, the nurse would follow the mnemonicand assess the patency of the tube and connections and perform suction. DIF: Applying/Application REF: 616 KEY: Mechanical ventilation| respiratory assessment| equipment safety| critical rescue MSC: Integrated Process: Nursing Process: Assessment

*9. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?* a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

*ANS:* 660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg × 6 mL/kg = 660 mL. DIF: Applying/Application REF: 614 KEY: Mechanical ventilation| respiratory system| injury prevention MSC: Integrated Process: Nursing Process: Analysis

*COMPLETION 1. A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL*

*ANS: C* Oral colonization by gram-negative bacteria is a risk factor for healthcare-associatedpneumonia. Good, frequent oral care can help prevent this from developing and is a task thatcan be delegated to the UAP. Encouraging good nutrition is important, but this will notprevent pneumonia. Monitoring temperature and reporting new cough in clients is importantto detect the onset of possible pneumonia but do not prevent it. DIF: Applying/Application REF: 590 KEY: Delegation| oral care| pneumonia| older adult| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation

*Control 10. A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?* a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

*ANS: A* The nurse needs to determine the cause of the agitation. The inability to communicate oftenmakes clients anxious, even to the point of panic. Pain and confusion can also causeagitation. Once the nurse determines the cause of the agitation, he or she can implementmeasures to relieve the underlying cause. Reassurance is also important but may not addressthe etiology of the agitation. Restraints and more sedation may be necessary, but not as afirst step. DIF: Applying/Application REF: 618 KEY: Mechanical ventilation| psychosocial response| anxiety| communication| nursing assessment MSC: Integrated Process: Nursing Process: Assessment

*Control 12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?* a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

*ANS: A* All actions are appropriate for this client who has manifestations of pneumonia. However,airway and breathing come first, so begin oxygen administration and titrate it to maintainsaturations greater than 95%. Start the IV and collect a sputum culture, and then beginantibiotics. DIF: Analyzing/Analysis REF: 593 KEY: Pneumonia| antibiotics| oxygen therapy MSC: Integrated Process: Nursing Process: Analysis

*Control 21. A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm 3 PaO 2 on room air 65 mm Hg What action by the nurse is the priority?* a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

*ANS: A, B, D, E* There are many basic care measures that can be employed for the client who is on aventilator. Allowing visitation, providing a means of communication, massaging the client'sskin, and routinely turning and repositioning the client are some of them. Keeping the TVon will interfere with sleep and rest. DIF: Applying/Application REF: 619 KEY: Comfort measures| mechanical ventilation MSC: Integrated Process: Nursing Process: Implementation

*Control 5. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)* a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

*ANS: B* This client has manifestations of a pulmonary embolism, and the most critical action is tonotify the Rapid Response Team for speedy diagnosis and treatment. The other actions areappropriate also but are not the priority. DIF: Remembering/Knowledge REF: 605 KEY: Critical rescue| Rapid Response Team| thromboembolic event| pulmonary embolism MSC: Integrated Process: Communication and Documentation

*MULTIPLE CHOICE 1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?* a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

"*ANS: B* INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection. DIF: Analyzing/Analysis REF: 597 KEY: Infection| anti-tuberculosis agents| laboratory values| communication MSC: Integrated Process: Nursing Process: Analysis

*Therapies 13. A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately?* a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm 3 d. White blood cell (WBC) count: 12,500/mm 3

*ANS: C* The priority for any chest trauma client is airway, breathing, circulation. The nurse firstensures the client has a patent airway. Assessing respiratory rate and applying oxygen arenext, followed by inserting IVs. DIF: Remembering/Knowledge REF: 622 KEY: Emergency nursing| primary survey| medical emergencies| trauma| respiratory assessment MSC: Integrated Process: Nursing Process: Assessment

*Therapies 15. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?* a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

*ANS: B* Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foodshigh in vitamin K thus interfere with its action and need to be eaten in moderate, consistentamounts. A vegetarian may have trouble maintaining this diet. The nurse should explore thispossibility with the client. The other options are not related. DIF: Applying/Application REF: 607 KEY: Anticoagulants| patient education| medication safety MSC: Integrated Process: Nursing Process: Assessment

*Therapies 17. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?* a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

*ANS: A* Allow the client with respiratory problems to assume a position of comfort if it does notinterfere with care. Often the client will choose a more upright position, which alsoimproves oxygenation. The other options are less effective comfort measures. DIF: Applying/Application REF: 612 KEY: Respiratory system| nonpharmacologic pain management| comfort measures MSC: Integrated Process: Nursing Process: Implementation

*Therapies 19. A client in the emergency department has several broken ribs. What care measure will best promote comfort?* a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

*ANS: B* Odynophagia is painful swallowing. The nurse should assess the client for this either byasking or by having the client attempt to drink water. It is not related to specific foods and isnot assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but itwould be a serious situation. DIF: Applying/Application REF: 584 KEY: Infection| respiratory system| respiratory disorders| respiratory assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment

*Therapies 19. A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate?* a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.

*ANS: D* This client has manifestations of flail chest and, with the other signs, needs to be intubatedand mechanically ventilated immediately. The nurse does not have time to administeroxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after theclient is intubated. DIF: Applying/Application REF: 614 KEY: Trauma| respiratory system| respiratory disorders| mechanical ventilation MSC: Integrated Process: Nursing Process: Implementation

*Therapies 21. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?* a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

*ANS: B, C* Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time.The BUN and WBC count are normal. The sodium level is low, but that is not related to thisclient's problem. DIF: Analyzing/Analysis REF: 597 KEY: Laboratory values| anti-tuberculosis agents| liver disorders MSC: Integrated Process: Nursing Process: Analysis

*Therapies 3. A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)* a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm 3

*ANS: C* Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms.Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. Thedrug must be shaken well because it has a tendency to separate easily. Poor technique on theclient's part allows the drug to escape through the nose and mouth. DIF: Applying/Application REF: 554 KEY: Medication| patient education MSC: Integrated Process: Teaching/Learning

*Therapies 7. After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?* a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."