midterm Flashcards
The nurse is admitting a patient with acute shortness of breath. What actions should the nurse take during the initial assessment of the patient?
Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
The nurse is preparing a patient with a right-sided pleural effusion for a thoracentesis. Which position should the nurse position the patient?
Sitting upright with the arms supported on an over bed table
Rationale:The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
The nurse is auscultating a patient’s lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
Expiratory wheezes in both lungs
The nurse is palpating the posterior chest of a patient while the patient says “99” and notes that no vibration is felt. What information should the nurse document?
Absent tactile fremitus (the palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall) an increase in tactile fremitus indicates denser or inflamed lung tissue
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.
The nurse is caring for a patient with respiratory disease and observes that the patient’s SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. What actions should the nurse take next?
Nurse should administer the PRN supplemental O2.
The nurse is assessing the respiratory system of an older-adult patient. What findings would indicate that the nurse should take immediate action?
Crackles are heard from the lung bases to the midline.
Rationale: Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. What assessment information best supports this diagnosis?
Weak, nonproductive cough effort.
the weak, nonproductive cough indicates that the client is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
The nurse is conducting a chest assessment on a patient with pneumococcal pneumonia. Which assessment findings should the nurse expect to assess?
Increased tactile fremitus.
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.
The nurse is providing teaching to a patient with pneumonia. What education should the nurse ensure to include in the discharge instructions?
“I will continue to do the deep-breathing and coughing exercises at home.”
Clients should continue to cough and deep breathe after discharge for up to 6-8 weeks. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumonia and influenza vaccines can be given at the same time.
What nursing actions are most effective in preventing aspiration pneumonia in patients who are at risk?
Place clients with altered consciousness in side-lying position.
The risk for aspiration is decreased when clients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized clients but will not decrease the risk for aspiration in clients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immuno-compromised clients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated clients but not for all clients receiving enteral feedings.
The nurse is developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking. What information should the nurse include in the plan of care?
Options for smoking cessation.
Because smoking is the major cause of lung cancer, the most important role for the nurse is educating clients about the benefits of and means of smoking cessation. Early screening of at-risk clients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in clients who have lung cancer but not to reduce risk for developing tumours.
The nurse is assessing a patient who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. What actions should the nurse anticipate?
Intersertation of chest tube with a chest drainage system.
The client’s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the client’s clinical manifestations are not consistent with these problems.
What patients would benefit from education and encouragement to use an incentive spirometry and why?
The spirometer is a device used to help you keep your lungs healthy. Take your time so you do not get dizzy or light-headed. If you are in pain, you may need to take pain medicine before doing incentive spirometry.
The nurse caring for a patient with pneumonia has a fever of 38.4°C (101.1°F), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. What nursing diagnoses are a priority?
Ineffective breathing pattern related to respiratory muscle fatigue
The nurse is caring for a patient with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. What actions should the nurse implement with priority?
Elevate the head of the bed to 45-60 degrees. The client has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).
The nurse is caring for a patient with pneumonia who has symptoms of a sharp pain “whenever I take a deep breath.” What actions should the nurse take next?
Listen to client’s lungs.
The client’s statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub or decreased breath sounds. Assessment should occur before administration of pain medications. The client is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
The nurse is caring for a patient with chronic bronchitis who has a new prescription for a combined fluticasone and salmeterol inhaler and the patient asks the nurse the purpose of using two drugs. How should the nurse respond?
The combination of two drugs work together to block the effects of histamine on the bronchioles. Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. The two-drug combination of salmeterol and fluticasone is not used during an acute attack because the medications do not work rapidly.
The nurse has completed patient teaching about the administration of salmeterol using a metered-dose inhaler (MDI). What would they include?
The patient attaches a spacer before using the MDI. Spacers can improve the delivery of medication to the lower airways. The other client actions indicate a need for further teaching.
What information should the nurse include when teaching the patient with asthma about the prescribed medications?
Tremors are an expected adverse effect of rapidly acting bronchodilators.
Tremors are a common adverse effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The client should hold the breath for 10 seconds after using inhalers.
the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. What findings are the best indicator that the therapy has been effective?
Oxygen saturation is >92%.
The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The other client data may occur when the client is too fatigued to continue with the increased work of breathing required in an asthma attack.
The nurse is caring for a patient with chronic bronchitis who has a nursing diagnosis of impaired breathing pattern related to anxiety. What nursing actions should be included in the plan of care?
Teach the client how to effectively use purse lip breathing.
Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the client requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who has a nursing diagnosis of imbalanced nutrition: less than body requirements. What interventions are best to address this problem?
Offer high calorie snacks between meals and at bedtime.
Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Clients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.
The nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). What information will help most in confirming a diagnosis of chronic bronchitis?
The client complains about a productive cough every winter for 3 months.
A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.
What assessment findings 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 ocimetry reading of 91%.
For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
