Respiratory System
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
A patient who is complaining of a sore throat and has a muffled voice
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?
Administer PRN supplemental oxygen
A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse take next?
Administer a bronchodilator and recheck the peak flow
Which action should the nurse take first when a patient develops epistaxis?
Apply squeezing pressure to the nostrils for 10 minutes
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
Appropriate use of cough suppressants
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrasinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
Ask the patient whether medications have been taken as directed
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?
Continue to monitor the collection device
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?
Diffuse crackles in the lungs
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?
Flushing and dizziness
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?
Frequent use of an incentive spirometer
A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate?
Have the patient add dietary salt to meals
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
Identifying and avoiding environmental triggers are the best way to prevent symptoms
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
Increased tactile fremitus
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
Inspiratory crackles at the bases
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first?
Instruct the patient to use the prescribed albuterol (Ventolin HFA)
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first?
Methylprednisolone (Solu-Medrol) 60 mg IV
A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first?
Notify the health care provider
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching?
O2 use can improve the patient's prognosis and quality of life
The nurse administers prescribed therapies for a patient with cor pulmonate and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?
Observe for distended neck veins
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Obtain O2 saturation using pulse oximetry
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
Paradoxical chest movement
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?
Patient reports a decrease in exertional dyspnea
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Perform chest physiotherapy every 4 hours
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?
Peripheral edema
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Place a patient with altered consciousness in a side-lying position
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?
Placing the patient on droplet precautions in a private hospital room
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
Position the patient sitting up on the right side of the bed
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
Pulse oximetry reading of 92%
Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
Reduced excursion
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
Require use of protective equipment
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical / vocational nurse (LPN / LVN) caring for a patient with a permanent tracheostomy?
Suction the tracheostomy when directed
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?
Tape a nonporous dressing on three sides over the wound
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
Teaching patients about the need for adult pertussis immunizations
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?
The epoprostenol (Flolan) infusion is disconnected
The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?
The oxygen saturation is 89%
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy?
The patient takes propranolol (Inderal) for hypertension
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
UAP lower the head of the patient's bed to 15 degrees
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
Use of accessory muscles in breathing
A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?
Withhold bronchodilators for 6 to 12 hours before the examination
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?
pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?
pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse?
"Can you tell me what it is that makes you think you will die so soon?"
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask?
"Have you taken any bronchodilators today?"
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?
"How much alcohol do you drink in an average week?"
The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective?
"I can have ice cream as a snack every day."
The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?
"I can use nasal decongestant spray until congestion is gone."
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?
"I must keep the stoma covered with an occlusive dressing."
The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?
"I will call the health care provider right away if I develop a fever."
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
"I will continue to do deep breathing and coughing exercises at home."
The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?
"I will elevate my head for 48 hours to minimize swelling."
The nurse teaches a patient about pulmonary spirometry testing. Which statement, if made by the patient, indicates teaching was effective?
"I will inhale deeply and blow out hard during the test."
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?
"I will need to buy a water bottle to carry with me."
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
"I will use the incentive spirometer every hour or two during the day."
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
"I've been using my albuterol inhaler more frequently over the last 4 days."
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
"My spouse will sleep in another room."
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?
"Tell me what you know about the treatments available."
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)?
"Use the bronchodilator before you start to exercise."
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best?
"Would you like more information to help you with that decision?"
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse?
"You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration."
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?
- a 76-year-old nursing home resident - a 36-year-old female patient who is pregnant -a 30-year-old patient who take corticosteroids for rheumatoid arthritis
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?
- age - blood pressure - respiratory rate - presence of confusion - blood urea nitrogen (BUN) level
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?
- decongestants can be used to relieve swelling - taking a hot shower will increase sinus drainage and decrease pain - saline nasal spray can be made at home and used to wash out secretions - you will be more comfortable if you keep your head in an upright position
The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions?
- obtain the O2 saturation - check the patient's pulse rate - notify the health care provider - document the change in status
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
400mL of blood in the collection chamber
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
After change-of-shift report, which patient should the nurse assess first?
A 64-year-old with lung cancer and trachea deviation after subclavian catheter insertion
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?
A patient with a respiratory rate of 38 breaths/min
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
A surgical face mask is applied before visiting the patient
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?
Administer the prescribed morphine
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
Allergy to shellfish
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
Arrange for a daily meal and drug administration at a community center
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Arrange for the patient's caregiver to be present during the teaching
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Assess the ability to swallow before using the fenestrated tube
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Assist the patient to splint the chest when coughing
After a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
Attempt to reinsert the tracheostomy tube with the obturator in place
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next?
Auscultate anterior and posterior breath sounds bilaterally
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?
Auscultate for breath sounds
Which assessment finding indicates that the nurse should take immediate action for an older patient?
Bilateral basilar crackles
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Blood cultures from two sites
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
Briefly ask specific questions about this episode of respiratory distress
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
Chest tube connected to suction
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate?
Chronic low self-esteem related to physical dependence
After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?
Clear nasal drainage
Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider?
Cough productive of bloody, purulent mucus
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
Discontinuous, high-pitched sounds of short duration during inspiration
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
Document the amount of drainage every 8 hours
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?
Elevate the head of the bed to a semi-Fowler's position
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation?
Encourage the patient to situ up at the bed-side chair and lean forward
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?
Explain that orange discolored urine and tears are normal while taking this medication
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?
Give the prescribed albuterol (Ventolin HFA) before the therapy
A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?
Have the patient occlude the left nare and blow the nose
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?
Impaired gas exchange related to respiratory congestion
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important?
Keep the air entrainment ports clean and unobstructed
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure?
Keep the patient NPO until the gag reflex returns
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?
Keep the patient in semi-Fowler's position
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
Kussmaul Respirations
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP?)
Label specimens obtained during percutaneous lung biopsy
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?
Listen to the patient's breath sounds
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?
Maintain the pulse oximetry level at 90% or greater
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Medication the patient with prescribed morphine
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
O2 saturation is 88%
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?
O2 saturation is >90%.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care?
Offer high-calorie protein snacks between meals and at bedtime
A patient who has just been admitted with community-acquired pneumonoccocal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
Piperacillin / Tazobactam (Zosyn)
A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next?
Place the patient on high-flow oxygen
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Put on sterile gloves and use a sterile catheter to suction
Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?
Resources for support in smoking cessation
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
Respirations are 36 breaths / min
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching?
Self-administration of inhaled corticosteroids
The nurse prepares a patient with a left-sided pearl effusion for a thoracentesis. How should the nurse position the patient?
Sitting upright with the arms supported on an over bed table
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?
Sputum smears for acid-fast bacilli are negative
A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
Start an IV so contrast media may be given
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?
Teach about the need for prolonged antibiotic therapy after discharge from the hospital
The nurse is caring for a patient who has acute pharyngitis cause by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?
Teach patient to "swish and swallow" prescribed oral nystatin
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement?
Teach the patient about administration of insulin
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
Teach the patient about providing specimens for 3 consecutive days
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?
Teach the patient how to use pursed-lip breathing
A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective?
Teach the patient to use the Flutter airway clearance device
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?
The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?
The patient asks how to clean the tracheostomy stoma and tube
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
The patient is being treated with anti-retrovirals for HIV infection
The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?
The patient puffs up the cheeks while exhaling
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful?
The patient rapidly inhales the medication
The nurse teaches a new patient how to administer formoterol (Perforoomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching?
The patient removes the facial mask when misting stops
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis?
The patient reports a productive cough for 3 months every winter
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline?
The patient take cimetidine (Tagamet HB) daily
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful?
The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone
The nurse completes an admission assessment on a patient with asthma. Which information given by patient indicates a need for a change in therapy?
The patient's only medications are albuterol (Ventolin HFAI) and salmeterol (Serevent)
A patient with right lower lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
The patient's white blood cell (WBC) count is 9000/µL.
The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates a need to review respiratory assessment skills?
The student listens during the inspiratory phase, then moves the stethoscope
Which information will the nurse include in the asthma teaching plan for a patient being discharged?
Tremors are an expected side effect of rapidly acting bronchodilators
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?
Use a hand-held manometer to measure cuff pressure
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
Use a swab to obtain a sample for a rapid strep antigen test
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
Use and side effects of isoniazid
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?
Walk 15 to 20 minute a day at least 3 times / week
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
Weak cough effort
An older patient is receiving standard Multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
Yellow-tinged sclera
After the nurse has received change-of-shift report, which patient should the nurse assess first?
a patient with possible lung cancer who has just returned after bronchoscopy
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (select all that apply)?
allergy to shellfish, elevated serum creatinine level
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about
α1-antitrypsin testing.
