Chapter 30 Flashcards
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
d.
A 27-year-old client with a heart rate of 120 beats/min
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. 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
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.
b.
Ask about medications the client is currently taking.
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client’s history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.
DIF: Applying/Application REF: 553
After teaching a client who is prescribed a long-acting beta2 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.”
c.
“I will take this medication every morning to help prevent an acute attack.”
Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.
DIF: Applying/Application REF: 554
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.
b.
The client places his or her hands on his or her abdomen.
To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.
DIF: Applying/Application REF: 562
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
c.
Omelet, soft whole wheat bread
Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.
DIF: Applying/Application REF: 576
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?”
c.
“It is unlikely you will become addicted when taking medicine for pain.”
Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication.
DIF: Applying/Application REF: 576
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.”
c.
“I will use the drug when I have an asthma attack.”
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. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client’s part allows the drug to escape through the nose and mouth.
DIF: Applying/Application REF: 554
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.”
c.
“Share any thoughts and feelings that cause you to limit social activities.”
Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.
DIF: Applying/Application REF: 561
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.”
c.
“Eat a well-balanced, nutritious diet.”
Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.
DIF: Applying/Application REF: 567
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.
b.
Cover the insertion site with sterile gauze.
Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.
DIF: Applying/Application REF: 578
KEY: Drains| surgical care
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.
a.
Encourage oral rinsing after fluticasone administration.
The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.
DIF: Applying/Application REF: 554
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.
c.
Keep the client isolated from other clients with cystic fibrosis.
Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures 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 client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.
DIF: Applying/Application REF: 568
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.
d.
Administer pain medication and encourage the client to take deep breaths.
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client’s discomfort and need to take deep breaths to prevent complications.
DIF: Applying/Application REF: 580
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
d.
When the tube becomes disconnected from the drainage system
Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the client’s risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the client’s risk for a pneumothorax.
DIF: Applying/Application REF: 578
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
a.
Increased pulmonary pressure creating a higher workload on the right side of the heart
Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.
DIF: Remembering/Knowledge REF: 58
