Oxygenation 2 - module 15

Question 1

The nurse is providing care to a client who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism?
A) The ability to cough
B) Filtration and humidification of inspired air
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages

Answer 1

B) Filtration and humidification of inspired air

Rationale:

When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

Question 2

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis. Which effects does the nurse anticipate based on this diagnosis? 
 Select all that apply.
A) Increased CO2
B) Vasoconstriction 
C) Decreased O2
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate

Answer 2

A) Increased CO2
E) Increased pulse rate

Rationale:

Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO2 causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O2.

Question 3

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations indicate the client’s perfusion is affected? 
Select all that apply.
A) Bounding pulse 
B) Pink nail beds
C) Acrocyanosis 
D) Confusion 
E) Wheezing

Answer 3

C) Acrocyanosis
D) Confusion

Rationale:

A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.

Question 4

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothroax. Which interventions are appropriate for this client?
Select all that apply.
A) Elevate head of the bed
B) Administer a high rate of oxygen by nasal cannula
C) Prepare for a chest tube insertion
D) Administer prescribed antihypertensive medications
E) Administer intravenous caffeine per order

Answer 4

A) Elevate head of the bed
C) Prepare for a chest tube insertion

Rationale:

The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client’s dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

Question 5

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse?
A) Narrow bronchi
B) Narrow trachea passages
C) Blocked large airway passages
D) Inflamed pleural surfaces

Answer 5

C) Blocked large airway passages

Rationale:

The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.

Question 6

The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder. Which laboratory finding would be most significant for this client? 
A) Hemoglobin level 12 mg/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32

Answer 6

D) Blood pH 7.32

Rationale:

Normal blood pH is 7.35–7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.

Question 7

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client?  
A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask

Answer 7

B) Nasal cannula

Rationale:

The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

Question 8

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate?
A) Encourage strenuous activity.
B) Consult a dietitian for low-calorie meals.
C) Consult physical therapy for endurance and musculoskeletal function.
D) Encourage dependence with activities of daily living.

Answer 8

C) Consult physical therapy for endurance and musculoskeletal function.

Rationale:

The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with physical therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living. It will often be appropriate to cluster this client’s care to allow for periods of rest.

Question 9

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? 
A) Inhaled short-acting beta-agonists
B) Oral corticosteroids 
C) Inhaled long-acting beta-agonists
D) Oral anticholinergics

Answer 9

A) Inhaled short-acting beta-agonists

Rationale:

The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.

Question 10

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?
A) Notify the healthcare provider of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
D) Continue to monitor the newborn per facility policy.

Answer 10

D) Continue to monitor the newborn per facility policy.

Rationale:

A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.

Question 11

The nursing student is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis

Answer 11

A) Excessive rapid breathing
C) Rapid breathing at rest
D) Shallow breathing

Rationale:

Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.

Question 12

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?
A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client’s thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Answer 12

B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.

Rationale:

The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client’s physician should be notified immediately on the client’s arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client’s thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client’s breath sounds with the use of a stethoscope is appropriate.

Question 13

The nurse is providing care to clients on a medical-surgical unit. Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation?
Select all that apply.
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Prescribing bronchodilators
E) Monitoring activity intolerance

Answer 13

A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
E) Monitoring activity intolerance

Rationale:

Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

Question 14

The nurse is providing care to a client in a medical-surgical unit. The client’s arterial blood gas analysis is as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which acid-base imbalance is this client experiencing based on this data? 
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic alkalosis
D) Metabolic acidosis

Answer 14

A) Respiratory acidosis

Rationale:

An arterial blood gas analysis is often prescribed for client’s experiencing alterations in oxygenation. Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH lower than 7.35 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis is present. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal.

Question 15

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis? 
A) Fluid imbalance 
B) Hypertension 
C) Bradycardia 
D) Dyspnea

Answer 15

D) Dyspnea

Rationale:

Dyspnea is a clinical manifestation that clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.

Question 16

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the client’s family on the disease progress, in which order will the nurse present the material? 
A)	Initiation of ARDS
B)	Onset of pulmonary edema
C) End-stage ARDS
D)	Alveolar collapse

Answer 16

A) Initiation of ARDS
B) Onset of pulmonary edema
D) Alveolar collapse
C) End-stage ARDS

Rationale:

ARDS begins with inflammatory cellular responses and biochemical mediators that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes of death in ARDS.

Question 17

The nurse is providing care to a client with an infected leg wound. The client is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The client states to the nurse, “I am having trouble breathing.” Based on this data, which does the nurse suspect the client is experiencing?
A) Allergic response from antibiotic therapy
B) Deep vein thrombosis
C) Acute respiratory distress syndrome
D) Anemia

Answer 17

C) Acute respiratory distress syndrome

Rationale:

Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.

Question 18

While performing nasotracheal suctioning, the nurse notes the older adult client is moving the head around and pulling at the nurse’s hand to remove the suction catheter. Which actions by the nurse are appropriate?
Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Hyperinflate the client’s lungs
D) Apply restraints to the client’s arms and legs
E) Hyperoxygenate the client

Answer 18

A) Remove the suction catheter
C) Hyperinflate the client’s lungs
E) Hyperoxygenate the client

Rationale:

The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client’s lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.

Question 19

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client? 
A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output

Answer 19

B) Impaired Spontaneous Ventilation

Rationale:

A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.

Question 20

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client?
Select all that apply.
A) Increase percentage of oxygen being provided through the ventilator.
B) Place in the Fowler position.
C) Provide morning care during the weaning procedures.
D) Begin weaning procedures in the morning.
E) Medicate with morphine for pain as needed.

Answer 20

B) Place in the Fowler position.
D) Begin weaning procedures in the morning.

Rationale:

Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.

Question 21

A client receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate?
Select all that apply.
A) Explain about care areas specifically designed for long-term ventilatory support.
B) Dim the lights and reduce distracting noise, such as the television.
C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.

Answer 21

C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.

Rationale:

A critical illness creates anxiety for any client. For the client with ARDS, anxiety is compounded by intubation and mechanical ventilation. To reduce this client’s anxiety, the nurse should encourage the family to visit and participate in care. The nurse should also remain with the client as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. Explaining that there are care areas designed for long-term ventilatory support could increase the client’s anxiety. The nurse should provide distractions such as television or radio and not dim the lights or turn off the television, which could also increase the client’s anxiety.

Question 22

The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the parents that the newborn is improving. Which data supports the nurse’s assessment of the newborn’s condition?
A) Increased PCO2
B) Oxygen saturation of 92%
C) Pulmonary vascular resistance increases
D) Less than 1 mL/kg/hour urine output

Answer 22

B) Oxygen saturation of 92%

Rationale:

An expected outcome for a client being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving. Increased PCO2 and pulmonary vascular resistance are indicative of continued distress. Urine output of less than 1 mL/kg/hour is an abnormal finding and does not support that the newborn is improving.

Question 23

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? 
Select all that apply.
A) Septic shock
B) Viral pneumonia
C) Aspirin overdose
D) Head injury
E) Angioplasty

Answer 23

A) Septic shock
B) Viral pneumonia
C) Aspirin overdose
D) Head injury

Rationale:

ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. Angioplasty, a percutaneous interventions, does not lead to the development of ARDS. However, undergoing an open heart surgery with cardiopulmonary bypass could lead to the development of ARDS.

Question 24

The nurse caring for a client admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS? 
A) Intercostal retractions
B) Cyanosis
C) Tachypnea
D) Tachycardia

Answer 24

C) Tachypnea

Rationale:

Dyspnea and tachypnea are early clinical manifestations of ARDS. As the distress progresses, the client would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. Cyanosis is a late manifestation.

Question 25

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygen therapy?
A) Oxygen via a nasal cannula
B) Mechanical ventilation
C) Oxygen via a facial mask
D) Oxygen via a venturi mask

Answer 25

B) Mechanical ventilation

Rationale:

With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the percentage of oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than 60 mmHg and oxygen saturation of approximately 90%. It is important to remember that mechanical ventilation does not cure ARDS; it simply supports respiratory function while the underlying problem is identified and treated.

Question 26

The nurse in the intensive care unit (ICU) is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mmHg, and oxygen saturation 82%. The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation? 
A) Blood pressure 90/60 mmHg
B) Urine output 25mL/hr
C) Heart rate 110 bpm
D) Oxygen saturation 90%

Answer 26

B) Urine output 25mL/hr

Rationale:

Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client’s urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.

Question 27

The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse?
Select all that apply.
A) Retractions and fatigue
B) Tachycardia and tachypnea
C) Inaudible breath sounds
D) Diffuse wheezing and the use of accessory muscles when inhaling
E) Reduced wheezing and an ineffective cough

Answer 27

C) Inaudible breath sounds
E) Reduced wheezing and an ineffective cough

Rationale:

Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure. During an asthma attack, tachycardia, tachypnea, and prolonged expirations are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing and the use of accessory muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still occurring; therefore, they do not require the most urgent action. Retractions and fatigue are also a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging.

Question 28

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift would the nurse recommend for this client? 
A) A basket of flowers
B) A stuffed animal
C) Fruit and candy
D) A book

Answer 28

D) A book

Rationale:

A client with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust and much, such as a stuffed animal, should be avoided. Objects void of irritants, such as a book, would be an appropriate gift.

Question 29

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching?
A) “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
B) “We will replace the carpet in our child’s bedroom with tile.”
C) “We’ll keep the plants in our child’s room dusted.”
D) “We’re glad the dog can continue to sleep in our child’s room.”

Answer 29

B) “We will replace the carpet in our child’s bedroom with tile.”

Rationale:

Control of dust in the child’s bedroom is an important aspect of environmental control for asthma management, and replacing the carpeting in the child’s bedroom with tile flooring will reduce dust. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Question 30

An older adult client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?  
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance

Answer 30

C) Ineffective Breathing Pattern

Rationale:

The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.

Question 31

A client asks why asthma medication is needed even though the client’s last attack was several months ago. Which response by the nurse is appropriate?
A) “The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack.”
B) “The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him.”
C) “The medication is still needed to decrease inflammation in your airways and help prevent an attack.”
D) “The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it.”

Answer 31

C) “The medication is still needed to decrease inflammation in your airways and help prevent an attack.”

Rationale:

Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. Long-term treatment of asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be severely damaged is nontherapeutic; the inability to prevent an acute attack in this client is not true. The nurse is able to answer the client’s question; it does not need to be referred to the physician.

Question 32

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this client’s teaching?
Select all that apply.
A) Take no more than the prescribed number of doses each day.
B) Rinse the mouth after taking this medication.
C) Take on an empty stomach.
D) Take with meals or a full glass of water.
E) Use hard candy or drink extra fluids to help with a dry mouth.

Answer 32

A) Take no more than the prescribed number of doses each day.
E) Use hard candy or drink extra fluids to help with a dry mouth.

Rationale:

Appropriate teaching for a client prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose and the use of hard candy or extra fluids to decrease dry mouth. The mouth does not need to be rinsed after taking this medication. This medication does not need to be taken with meals or a full glass of water, or on an empty stomach.

Question 33

The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care?
Select all that apply.
A) Referring to a peer-lead support group
B) Teaching the parents how to administer maintenance medication prior to teaching the client
C) Assessing peer-support when planning care
D) Collaborating with teachers for support in the school setting
E) Telling the client to avoid medication while at school

Answer 33

A) Referring to a peer-lead support group
C) Assessing peer-support when planning care
D) Collaborating with teachers for support in the school setting

Rationale:

Age-appropriate, evidence-based interventions for a young adolescent client diagnosed with asthmas include referral to a peer-lead support group, assessing peer-support of the client, and collaborating with teachers to ensure the client has the necessary support in the school setting. While it is appropriate to include the parents in the educational process, the client should be taught how to administer medications prior to teaching the parents. Avoiding medication administration while in school could lead to an acute asthma attack.

Question 34

The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding?
A) “The medication widens the airways because it acts on the parasympathetic nervous system.”
B) “The medication widens the airways because it stimulates the fight-or-flight response of the nervous system.”
C) “The medication widens the airways because it decreases the production of histamine that narrows the airways.”
D) “The medication widens the airways because it decreases the production of mucous that narrows the airways.”

Answer 34

B) “The medication widens the airways because it stimulates the fight-or-flight response of the nervous system.”

Rationale:

During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs. Bronchodilators act on the sympathetic nervous system, not the parasympathetic nervous system. Bronchodilators do not decrease the production of mucus or the production of histamine.

Question 35

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention? 
Select all that apply.
A) Shallow respirations
B) Slightly diminished breath sounds
C) Decreased wheezing
D) Increased crackles
E) Increased respiratory rate

Answer 35

A) Shallow respirations
C) Decreased wheezing

Rationale:

Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary. Increased crackles are usually associated with heart failure and are not an indication of exhaustion. An increased respiratory rate indicates respiratory compromise, but not exhaustion.

Question 36

The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate?
A) Attempt to clear the obstruction by delivering back blows and chest thrusts.
B) Attempt to clear the obstruction by delivering back blows.
C) Attempt to clear the obstruction by delivering back blows and abdominal thrusts.
D) Attempt to clear the obstruction by delivering abdominal thrusts.

Answer 36

A) Attempt to clear the obstruction by delivering back blows and chest thrusts.

Rationale:

When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children.

Question 37

The nurse is providing care to a newly diagnosed with asthma. When developing the client’s plan of care, which intervention would be most appropriate to promote airway clearance?
A) Provide adequate rest periods.
B) Reduce excessive stimuli.
C) Assist with activities of daily living
D) Place in Fowler position.

Answer 37

D) Place in Fowler position.

Rationale:

Placing the client in Fowler position facilitates breathing and lung expansion, promoting airway clearance. Providing adequate rest periods prevents fatigue and reduces oxygen demands. Reducing excessive stimuli promotes rest. Assisting with activities of daily living conserves energy and reduces oxygen demands.

Question 38

Which assessment finding supports the nurse’s suspicion that a client is experiencing chronic obstructive pulmonary disease (COPD)?
A) Dysrhythmias
B) Cyanotic nail beds
C) Clubbing of the fingers
D) Cough in the morning producing clear sputum

Answer 38

D) Cough in the morning producing clear sputum

Rationale:

The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the client develops an infection, in which case the sputum would become yellow or green in color. With the progression of COPD, the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading to the development of cyanotic nail beds and clubbing of the fingertips. Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias.

Question 39

The nurse is providing care to a client diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client? 
A) Tachycardia
B) Cough
C) Barrel chest
D) Wheezing

Answer 39

C) Barrel chest

Rationale:

Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded. While coughing, wheezing, and tachycardia may also be experienced by a client diagnosed with COPD, these are not specific to COPD caused by emphysema.

Question 40

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the client’s history support the current diagnosis?
Select all that apply.
A) Working in an industrial environment
B) Working in an office setting with air conditioning
C) History of asthma
D) Current cigarette smoking
E) Playing golf several times a week

Answer 40

A) Working in an industrial environment
C) History of asthma
D) Current cigarette smoking

Rationale:

Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.

Question 41

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client?
A) Have the adult child of the client translate during the assessment process
B) Encourage aerobic activity
C) Encourage the client to write down questions prior to seeing the healthcare provider
D) Obtain educational materials about smoking cessation written in Spanish.

Answer 41

D) Obtain educational materials about smoking cessation written in Spanish.

Rationale:

A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client’s native language, Spanish. Relatives should not be used as a medical interpreter due to the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English speaking client but will not be appropriate for a Spanish speaking client being treated in an English speaking healthcare environment.

Question 42

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minutes, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this client? 
A) Ineffective Coping
B) Ineffective Airway Clearance
C) Anxiety
D) Ineffective Breathing Pattern

Answer 42

D) Ineffective Breathing Pattern

Rationale:

The client’s respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.

Question 43

The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD. Which interventions are appropriate in order to control the client’s breathing pattern?
Select all that apply.
A) Instruct in pursed-lip breathing.
B) Teach visualization and meditation.
C) Deep breathing and coughing every hour.
D) Instruct in abdominal breathing.
E) Provide oxygen 2 liters nasal cannula.

Answer 43

A) Instruct in pursed-lip breathing.
B) Teach visualization and meditation.
D) Instruct in abdominal breathing.

Rationale:

Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client’s breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.

Question 44

A client diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this client?
A) Antibiotic therapy
B) Nonsteroidal anti-inflammatory agents
C) Oxygen by nasal cannula at 3-4 liters/minute
D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

Answer 44

C) Oxygen by nasal cannula at 3-4 liters/minute

Rationale:

The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a client with COPD because the client’s breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute, with close assessments of the client’s breathing status. The order for antibiotic therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this client.

Question 45

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this client is Imbalanced Nutrition: Less than Body Requirements. Which interventions are appropriate for this nursing diagnosis?
Select all that apply.
A) Encourage a diet high in protein and fats.
B) Keep snacks to a minimum.
C) Provide frequent small meals with between meal supplements.
D) Encourage carbohydrate-rich foods to provide needed calories for energy.
E) Suggest the client eat 3 meals per day to maintain energy needs.

Answer 45

A) Encourage a diet high in protein and fats.
C) Provide frequent small meals with between meal supplements.

Rationale:

A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Frequent small meals help maintain intake and reduce fatigue associated with eating. Carbohydrate-rich foods would increase the client’s carbon dioxide production and worsen the symptoms of the disease. The client should be encouraged to eat frequent small meals, not 3 meals a day. The client should be encouraged to eat frequent snacks, not limit snacks.

Question 46

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this client has been effective?
A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.
B) Client needs assistance with morning care and meals due to shortness of breath.
C) Client states family members are discussing admission to a nursing home for continuing care.
D) Client leaves hospital unit to smoke outside 4 times a day.

Answer 46

A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.

Rationale:

Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client’s ability to maintain adequate oxygenation and perform activities of daily living. The client’s leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.

Question 47

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the client’s breathing pattern? Select all that apply.
A) Provide adequate rest periods.
B) Assist with ADLs.
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer a cough suppressant

Answer 47

A) Provide adequate rest periods.
B) Assist with ADLs.
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.

Rationale:

Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.

Question 48

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) is educating the client on effective coughing techniques. Which statement made by the client indicates a need for further teaching?
A) “I should inhale by sniffing.”
B) “I should avoid aerosol sprays.”
C) “I should limit my fluid intake to 1-1.5 quarts daily.”
D) “I should get a flu vaccine every year.”

Answer 48

C) “I should limit my fluid intake to 1-1.5 quarts daily.”

Rationale:

Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.

Question 49

The nurse on the medical unit is admitting a client with chronic obstructive pulmonary disease (COPD). Which prescription does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?
A) A broad-spectrum antibiotic
B) A bronchodilator 
C) A corticosteroid
D) An influenza vaccine

Answer 49

D) An influenza vaccine

Rationale:

An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when asthma is a major component of COPD. It improves symptoms and exercise tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an infection.

Question 50

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). The client’s family ask how their loved on got this disease. Which risk factors for COPD will the nurse include in the teaching session? 
A) Asthma and bronchitis
B) Asthma and emphysema
C) Bronchitis and emphysema
D) Emphysema and atelectasis

Answer 50

C) Bronchitis and emphysema

Rationale:

Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Although the COPD complex can also include asthma, small airways disease, and narrowing of small bronchioles, it is more commonly known to include bronchitis and emphysema.

Question 51

The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. Based on this data, which diagnosis does the nurse anticipate?
A) Meningitis
B) Respiratory syncytial virus (RSV) bronchiolitis
C) Bronchitis
D) The common cold

Answer 51

B) Respiratory syncytial virus (RSV) bronchiolitis

Rationale:

The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.

Question 52

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate?
A) “There is a higher risk in children who are being breastfed.”
B) “There is no way to avoid the illness.”
C) “There is a higher risk in children who are exposed to secondary cigarette smoke.”
D) “It is seen more frequently in children who do not attend daycare.”

Answer 52

C) “There is a higher risk in children who are exposed to secondary cigarette smoke.”

Rationale:

Risk for RSV is higher when the parent or caregiver smokes. Tobacco smoke increases mucus production and reduces the action of cilia within the airway passages. Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.

Question 53

The nurse observes a toddler-age client, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate?
A) Assist the child to clear the nasal passages.
B) Limit fluids.
C) Suction the airway to relieve the obstruction.
D) Lay the child on his back.

Answer 53

C) Suction the airway to relieve the obstruction.

Rationale:

Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child’s ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.

Question 54

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant?
A) Acute Pain
B) Ineffective Tissue Perfusion
C) Activity Intolerance
D) Decreased Cardiac Output

Answer 54

C) Activity Intolerance

Rationale:

Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.

Question 55

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis with the nursing diagnosis of Impaired Gas Exchange. Which interventions should be included in the child’s plan of care?
Select all that apply.
A) Weigh daily.
B) Monitor vital signs and pulse oximetry.
C) Administer oxygen as prescribed.
D) Weigh diapers.
E) Provide frequent rest periods.

Answer 55

B) Monitor vital signs and pulse oximetry.
C) Administer oxygen as prescribed.

Rationale:

Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.

Question 56

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? 
Select all that apply.
A) An advanced practice nurse
B) A dietitian
C) The primary healthcare provider
D) A respiratory therapist
E) A play therapist

Answer 56

B) A dietitian
D) A respiratory therapist

Rationale:

Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client’s endotracheal tube and ventilation.

Question 57

The nurse is providing care to a client with respiratory syncytial virus (RSV). The client’s condition is not severe and there is no history of immune compromise. Which pharmacologic therapies does the nurse anticipate based on this data? Select all that apply.
A) Nebulized epinephrine
B) Ribavirin
C) Systemic corticosteroids
D) Antibiotics
E) Antipyretics

Answer 57

A) Nebulized epinephrine
C) Systemic corticosteroids
E) Antipyretics

Rationale:

Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.

Question 58

Which interventions would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis?
Select all that apply.
A) Do not smoke, and avoid all secondhand smoke around the child.
B) Practice frequent hand washing.
C) Encourage physical activity and play.
D) Consider alternatives to sending the child to daycare.
E) Ensure an adequate nutritional intake.

Answer 58

A) Do not smoke, and avoid all secondhand smoke around the child.
D) Consider alternatives to sending the child to daycare.

Rationale:

The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.

Question 59

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicate that treatment has been effective?
A) Client ingesting small amounts of clear fluids when encouraged
B) Client resting in bed with limited interest in play or activities
C) Client respiratory rate within normal limits for age
D) Client coughing copious amounts of green sputum and requires occasional suctioning.

Answer 59

C) Client respiratory rate within normal limits for age

Rationale:

Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client’s age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.

Question 60

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). The nurse is aware that which action is the best way to prevent RSV?
A) Hand washing
B) Monitoring temperature
C) Administering antibiotics
D) Limiting fluid intake

Answer 60

A) Hand washing

Rationale:

According to the Center for Disease Control and Prevention (CDC), the best way to prevent RSV is through good hand hygiene and infection-control measures. This can be accomplished through frequent washing of hands with soap and water and avoiding sharing items such as food, cups, or utensils with infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when infection is suspected. There is no indication of the need to limit fluids, which could potentially produce other complications.

Question 61

The student nurse attends a workshop on culture and diversity with regards to respiratory syncytial virus (RSV). Which statement made by the student at the end of the workshop indicates understanding of the information presented?
A) “RSV is the major cause of hospitalization for Alaskan Native infants.”
B) “RSV is the major cause of hospitalization for African-American infants.”
C) “RSV is the major cause of hospitalization for Native American infants.”
D) “RSV is the major cause of hospitalization for Asian-American infants.”

Answer 61

A) “RSV is the major cause of hospitalization for Alaskan Native infants.”

Rationale:

According to the National Center for Preparedness, Detection, and Control of Infectious Diseases, RSV is a major cause of hospitalization among Alaskan Native infants and is responsible for one-third of hospitalizations of children younger than 3 years in Alaska. Alaskan children hospitalized with RSV at any age are at a high risk for rehospitalization as a result of respiratory infection. Alaskan Native children living in rural areas have a higher rate of chronic lung disease; however, the relationship between RSV and chronic lung disease remains unclear.

Question 62

The nurse working in the emergency department (ED) is assessing an infant client. Whch findings support the diagnosis of respiratory syncytial virus (RSV)?
Select all that apply.
A) Rhinorrhea
B) Irritability
C) Grunting
D) Bradypnea
E) Tachypnea

Answer 62

A) Rhinorrhea
B) Irritability
C) Grunting
E) Tachypnea

Rationale:

The typical clinical presentation in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea (drainage of mucus from the nose), cough, irritability, and a low-grade fever for 1-3 days. Copious mucous secretions occur in the lung fields and nasal passages and are usually green in color. The fever can lead to dehydration. Other clinical manifestations include, but are not limited to, tachypnea, wheezing, and grunting.

Question 63

The nurse is developing a plan of care for a toddler-age client diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client? 
A) Offer small, frequent meals.
B) Encourage to ambulate frequently.
C) Encourage oral intake.
D) Monitor intake and output.

Answer 63

B) Encourage to ambulate frequently.

Rationale:

It would not be appropriate to encourage frequent ambulation. Nursing interventions should be introduced in an effort to reduce fatigue, such as allowing rest periods. All other interventions are appropriate for this client.

Question 64

The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate?
A) “You should the baby with you at all times to assess for apnea.”
B) “There is no one cause for the syndrome; the best thing is to keep the baby healthy.”
C) “It is recommended that you place your baby in a face-down position for sleep.”
D) “SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby.”

Answer 64

B) “There is no one cause for the syndrome; the best thing is to keep the baby healthy.”

Rationale:

The best intervention would be for the nurse to explain that there is no single cause for the syndrome and to instruct the mother to keep the baby healthy. According to one theory for the syndrome, a face-down position could encourage a reduction in respirations and increase the risk for SIDS. The nurse should instruct the mother to position the baby face-up for sleep. Immunizations and newborn apnea have not been found to be associated with the syndrome.

Question 65

The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS) with their newborn son. What should be included in these instructions?
Select all that apply.
A) There is nothing that can be done, so requirements for toys and bedding are of no consequence.
B) Instruct that it is more common in babies from ages 6 months to 18 months.
C) Avoid placing the baby in the prone or side-lying position for sleep.
D) Remind the parents that the syndrome is more common in females than males, and that they have a male child.
E) Do not smoke near the child and reduce all exposure to secondhand smoke.

Answer 65

C) Avoid placing the baby in the prone or side-lying position for sleep.
E) Do not smoke near the child and reduce all exposure to secondhand smoke.

Rationale:

The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand smoke to reduce the child’s risk of SIDS. Sleeping in the prone or side-lying position is a risk factor for the syndrome. Other risk factors for SIDS include being male, being 2-4 months of age, having loose bedding and toys that could occlude the airway, and being exposed to smoke or having a mother who smoked during pregnancy.

Question 66

When assessing the risk of a newborn for sudden infant death syndrome (SIDS), which are risk factors that the nurse should consider? 
Select all that apply.
A) Race
B) Gender
C) Father's age
D) Age
E) Eye color

Answer 66

A) Race
B) Gender
D) Age

Rationale:

SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic Blacks, non-Hispanic Whites, Asian or Pacific Islanders, and Hispanics. It is more common in males than in females. SIDS is most common in infants between 2 and 4 months of age. Father’s age and infant eye color are not related to the risk of SIDS.

Question 67

The nurse is providing care for an African-American male infant who is two months of age. The infant is brought to the appointment by the mother. When reinforcing instructions regarding reducing the infant’s risk for sudden infant death syndrome (SIDS), which teaching point is the most appropriate for the nurse to include when teaching the infant’s mother?
A) Instruct on side-lying and face-down positions when in the crib.
B) Instruct on face-up position when in the crib.
C) Ensure adequate nutritional intake for the mother and newborn.
D) Encourage good hand washing.

Answer 67

B) Instruct on face-up position when in the crib.

Rationale:

Rates for SIDS are highest for African-American children. The nurse should instruct the mother to place the baby in the face-up position when in the crib. Side-lying and face-down positions are associated with a higher risk of the syndrome and should not be instructed. Although important, good hand washing and adequate nutrition are not interventions that would assist in preventing SIDS.

Question 68

The nurse is planning care for a baby of African-American descent born to a mother who smoked during the pregnancy. Which nursing diagnosis would be appropriate for this baby?
A) Risk for Sudden Infant Death Syndrome (SIDS)
B) Readiness for Enhanced Parenting
C) Anxiety
D) Deficient Knowledge

Answer 68

A) Risk for Sudden Infant Death Syndrome (SIDS)

Rationale:

The most important nursing diagnosis for the baby at this time is Risk for SIDS. Babies of African-American descent have twice the risk of SIDS than babies of Caucasian descent. Another risk factor is that the mother smoked during the pregnancy. Deficient Knowledge, Readiness for Enhanced Parenting, and Anxiety are appropriate nursing diagnoses for the mother, not the baby.

Question 69

The nurse is planning care for a new mother of African-American descent who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby?
Select all that apply.
A) Information on bottle-feeding the infant
B) Reasons why the child should sleep with others
C) Ages at which the child should receive immunizations
D) Using bedding that is firm
E) Smoking cessation information

Answer 69

D) Using bedding that is firm
E) Smoking cessation information

Rationale:

The plan of care to decrease the child’s risk of SIDS should include habits to lower the risk of SIDS, one of which is smoking cessation. The nurse should also instruct the mother to use bedding that is firm. The method of feeding is not associated with the syndrome; however, the risk is decreased with breastfeeding not bottle feeding. While age-approprorate immunizations are important for the overall health of the baby, this intervention does not specifically reduce the risk for SIDS. Sleeping with others will increase the child’s risk of the syndrome and should not be in the plan of care.

Question 70

The nurse is placing a newborn baby in the nursery crib with the baby’s back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. Which action by the nurse is appropriate?
A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS).
B) Place the baby on the stomach.
C) Suggest the mother place the baby on the stomach when at home.
D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.

Answer 70

A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS).

Rationale:

The nurse needs to model protective behavior for the mother to use when the baby is taken home. The nurse should instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome. The nurse should not place the baby on the stomach or suggest that the mother place the baby on the stomach when at home. Placing the baby on the back does not necessarily make it easier to provide care.

Question 71

The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse are appropriate?
A) Advising the parents that an autopsy is not necessary.
B) Sheltering the parents from their grief by not giving them any personal items of the infant, such as footprints.
C) Interviewing the parents to determine the cause of the SIDS incident.
D) Allowing the parents to hold, touch, and rock the infant.

Answer 71

D) Allowing the parents to hold, touch, and rock the infant.

Rationale:

The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy, even though a specific cause of death may not be identified for SIDS.

Question 72

The nurse is evaluating care provided to a new mother whose infant is at risk for sudden death syndrome (SIDS). Which statement by the mother indicates teaching has been effective?
A) “I need to purchase loose-fitting sheets and blankets for the bed.”
B) “I plan to quit smoking.”
C) “I will place my baby in a side-lying position for sleep.”
D) “I will bottle-feed my baby since breastfeeding is a risk factor for SIDS.”

Answer 72

B) “I plan to quit smoking.”

Rationale:

If the mother of an infant at risk for SIDS expresses her plan to quit smoking, the nursing care would have been effective. Loose-fitting sheets and blankets are associated with an increased risk for the syndrome. The prone and side-lying positions increase the risk for the syndrome. The feeding method is not implicated with the syndrome and would not be used to evaluate the plan of care for an infant at risk for SIDS.

Question 73

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which should the nurse include when presenting significant stressors that contribute to SIDS?
Select all that apply.
A) Prone sleeping
B) Side sleeping
C) Face-down sleeping
D) Bed sharing
E) Supine sleeping

Answer 73

A) Prone sleeping
B) Side sleeping
C) Face-down sleeping
D) Bed sharing

Rationale:

Significant stressors contributing to SIDS are prone or side sleeping, face-down sleeping, and bed sharing. Infants in the prone or side-lying positions are vulnerable because the brainstem abnormality compromises their protective reflexes, such as arousal and head turning, when experiencing asphyxia. Supine sleeping is a method to decrease the risk for SIDS.

Question 74

The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants?
A) American Indians
B) African-Americans
C) Asians
D) Hispanics

Answer 74

A) American Indians

Rationale:

According to the Health Resources Services Administration, rates of SIDS are highest for African-Americans and American Indians and lowest for Asians and Hispanics. In 2008, the rate of SIDS among African-Americans was more than twice that of Caucasians, and the rate among American Indians was more than three times greater than that among Caucasians.

Question 75

The nurse working in the emergency department provides care to an infant who arrived in cardiac and respiratory arrest. Resuscitative efforts failed and the infant’s cause of death is sudden infant death syndrome (SIDS). The parents are grieving and will need collaborative interventions. Which interventions does the nurse plan for when providing care to these parents? 
Select all that apply. 
A) A psychosocial assessment
B) A grief counselor referral
C) A psychotherapist referral
D) A visit from the chaplain
E) A social services consult

Answer 75

A) A psychosocial assessment
B) A grief counselor referral
C) A psychotherapist referral
D) A visit from the chaplain

Rationale:
Collaborative care for the parents may include grief counselors, chaplains and religious leaders, nurses (including school nurses working with older children who lose a sibling), and psychotherapists. In particular, the parents’ grief will be acute, and they should receive a psychosocial assessment at each healthcare interaction. A social services consult is necessary for incidences of child abuse and is not appropriate for an infant who died from SIDS.

Question 76

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which interventions are appropriate to decrease an infant’s risk for SIDS?
Select all that apply.
A) Using firm bedding
B) Ensuring the room temperature is at least 80 degrees F at all times
C) Avoiding smoking around infants
D) Recommending bed sharing
E) Placing the infant in a prone-position for sleeping

Answer 76

A) Using firm bedding
C) Avoiding smoking around infants

Rationale:

Interventions that are appropriate to decrease the risk of SIDS include using firm bedding and avoiding smoking around infants. Other interventions that are appropriate include avoiding overheating, educating on the risk of bed sharing, and placing the infant in a supine position, not a prone position, for sleeping.

Question 77

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply.
A) Increased CO2
B) Vasoconstriction
C) Decreased O2
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate

Answer 77

A) Increased CO2
C) Decreased O2
E) Increased pulse rate

Rationale:

Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). Vasodilation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.