PATHOPHYSIOLOGY

Question 1

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction?
A/ “We need to encourage our child to drink fluids.”
B/ “Coughing spells may be triggered by dust or smoke.”
C/ “Vomiting may occur when our child has coughing episodes.”
D/ “We need to maintain droplet precautions and a quiet environment for at least 2 weeks.”

Answer 1

D/ “We need to maintain droplet precautions and a quiet environment for at least 2 weeks.”

Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

Question 2

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent?
A/ Monitor the infant for a fever.
B/ Bring the infant back to the clinic.
C/ Apply a hot pack to the injection site.
D/ Apply a cold pack to the injection site.

Answer 2

D/ Apply a cold pack to the injection site.

On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.

Question 3

A child is scheduled to receive inactivated polio vaccine (IPV), and the nurse preparing to administer the vaccine reviews the child’s record. The nurse questions the administration of IPV if which is documented in the child’s record?
A/ Recent recovery from a cold
B/ A history of frequent respiratory infections
C/ A history of an anaphylactic reaction to neomycin
D/ A local reaction at the site of injection of a previous IPV

Answer 3

C/ A history of an anaphylactic reaction to neomycin

Inactivated poliovirus vaccine (IPV) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV.

Question 4

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance?
A/ Eggs
B/ Penicillin
C/ Sulfonamides
D/ A previous dose of hepatitis B vaccine or component

Answer 4

D/ Previous reaction to Hep B

A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

Question 5

The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents about the care of the child. Which instruction should the nurse give to the parents?
A/ Maintain the child on bed rest for 2 weeks.
B/ Maintain respiratory precautions for 1 week.
C/ Notify the health care provider (HCP) if the child develops a fever.
D/ Notify the HCP if the child develops abdominal pain or left shoulder pain.

Answer 5

D/ Notify the HCP if the child develops abdominal pain or left shoulder pain.

Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves.

Question 6

The clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5- year-old child. The nurse should administer this vaccine by which best route and in which
best site?
A/ Subcutaneously in the gluteal muscle
B/ Intramuscularly in the deltoid muscle
C/ Subcutaneously in the outer aspect of the upper arm
D/ Intramuscularly in the anterolateral aspect of the thigh

Answer 6

C/ Subcutaneously in the outer aspect of the upper arm

Measles, mumps, rubella (MMR) vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. MMR vaccine is not administered by the intramuscular route.

Question 7

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions?
A/ Enteric
B/ Airborne
C/ Protective 
D/ Neutropenic

Answer 7

B/ Airborne

Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled.

Question 8

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine?
SELECT ALL THAT APPLY

A/ Child has symptoms of a cold
B/ Previous anaphylaxis to the vaccine
C/ Mother reports child is having intermittent episodes of diarrhea
D/ Mother reports Child has not had an appetite today and has been fussy
E/ The child has a disorder that caused a severely deficient immune system
F/ Mother reports that the child has recently been exposed to an infectious disease

Answer 8

B/ Previous anaphylaxis to the vaccine
E/ The child has a disorder that caused a severely deficient immune system

The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine.

Question 9

What are the 3 C’s of Rubeola (Measles)?

Answer 9

Coryza (Inflammation of nose membranes)
Cough
Conjunctivitis

Question 10

An infant is admitted to the hospital with the diagnosis of German Measles (Rubella). The nurse about to admit the infant knows the baby will have which of the following characteristics of the German Measles?
SELECT ALL THAT APPLY

1/ High-grade fever
2/ Pinkish-red maculopapular rash on their face
3/ Anorexia
4/ Lesions on the genitals and rectum
5/ Petechiae on the soft palate
6/ Jaw and/or ear pain aggravated by chewing

Answer 10

2/ Pinkish-red maculopapular rash on their face
5/ Petechiae on the soft palate

Signs and symptoms of Rubella or “German Measles” are a low-grade fever, malaise, pinkish-red maculopapular rash that begins on the face and spreads to the body in 1-3 days. They may also have petechiae on their soft palate in their mouth. These patients need to be isolated from pregnant women, and placed on airborne and droplet precautions.

Anorexia, Jaw and ear pain are associated with Mumps.
Lesions are a symptoms of chickenpox, along with anorexia.

Question 11

A toddler is diagnosed with Mumps after visiting their daycare. The mother dose not understand how her child became infected. The nurses suspects which one of the following scenarios probably lead to her contraction of Mumps?
A/ Playing in a dusty sandbox with another child
B/ Painting alongside another child with a respiratory infection
C/ Visiting the doctors office the previous day, and touching the magazines on the shelf in the waiting room
D/ Sharing a drink with another toddler in the daycare.

Answer 11

D/ Sharing a drink.

Mumps is spread through direct contact with infected saliva. Whether by direct contact or droplet. Mumps is communicable by a host immediately before and after their parotid glands swell. Common symptoms include:
Fever
Headache
Anorexia
Jaw or ear pain that worsens when eating
Inflammation of the testes

Question 12

A nurse is caring for a 9-year-old with chickenpox and recalls her pathophysiology class were she learned the infectious agent that causes Chicken pox is:
A/ Paramyxovirus
B/ Varicella Zoster virus
C/ Herpes Simplex 1
D/ Human Herpesvirus type 6

Answer 12

B/ Varicella-Zoster virus

Human Herpesvirus type 6 is associated with Roseola, Paramyxovirus is associated with the Measles, and Herpes simplex 1 is associated with oral sores.

Question 13

A 3-year-old comes to the emerge with a loud barking cough, is highly irritable, and hasn't eaten any food in the past 36 hours. What diagnosis can the nurse expect?
A/ Viral Bronchitis
B/ Pneumonia 
C/ Pertussis
D/ Laryngitis

Answer 13

C/ Pertussis

The trademark sign of pertussis is a loud barking/whooping cough and an audible inspiration. The patient may also experience coughing spasms when exposed to smoke, dust, or sudden changes in temperature. Treatment includes antimicrobial therapy, hydration, reduction of environmental stimuli that increases coughing, humidified oxygen.

Viral bronchitis would not likely have anorexia as a symptom. Pneumonia is associated with fever and purulent sputum, and laryngitis is associated with a severely sore throat and a hoarse voice.

Question 14

When assessing a 7 year old, the nurses the following:
89 HR
24 respirations per minute
38.4 degrees 
Neck swelling
Sore reddened throat
foul-smelling purulent nasal discharge.

Based on these findings, what does the nurse expect?
A/ Pertussis
B/ Poliomyelitis
C/ Diphtheria
D/ Scarlet Fever

Answer 14

C/ Diphtheria

Characterized by
○ Low-grade fever
○ Malaise
○ Sore Throat
○ Foul-smelling, mucopurulent nasal discharge
○ Dense pseudomembrane formation in the throat that may interfere with eating, drinking, and breathing
AND Lymphadenitis, neck edema or “Bull neck”

Treatment includes: Strict isolation, diphtheria antitoxin, bedrest, antibiotics, suctioning, and possible tracheostomy.

Question 15

Which of the following are complications of Poliomyelitis? SELECT ALL THAT APPLY

A/ Coma
B/ Respiratory Paralysis
C/ Central Nervous System Paralysis
D/ Dense Pseudomembranous formation in the throat
E/ Neurological deficits

Answer 15

B/ Respiratory Paralysis
C/ Central Nervous System Paralysis

D/ Dense Pseudomembranous formation in the throat.. is associated with Diphtheria.

A/ and D/ are unrelated.

Question 16

During an assessment of a child in a rural health clinic in northern Ontario. The nurse notes the following information during assessment:
Abrupt fever of 39.1 that started 7 hours ago
Flushed red cheeks
Vomiting
Malaise
Red and rough rash in axillary region and to their neck
Reddened tonsils and covered in exudate

Based on these findings, the nurse suspects which infectious disease?

Answer 16

Scarlet fever

Distinguishing signs include an abrupt fever, with rough-red rash that appears first under the arms and on the neck and groin. Eventually rash spreads to entire body.
Tonsils that are red and covered in exudate, along with a swollen pharynx is a clinical sign.

Question 17

A 23-year-old law student comes to her university clinic complaining of:
Fever 
malaise and severe fatigue
headache
Abdominal pain
and a sore throat
Upon further investigation, the nurse notes possible liver enlargement. Due to these findings, what may the nurse suspect is infecting this student?
A/ Rickettsia Rickettsii
B/ Epstein-Barr Virus
C/ Group A Beta-hemolytic streptococci
D/ Enterovirus

Answer 17

B/ Epstein Barr Virus (Mono)

Along with those symptoms the patient will likely also have swollen lymph nodes, and could have a macular rash on their trunk.

A/ Rickettsia Rickettsii is associated with Rocky Mountain Spotted Fever

C/ Group A Beta-hemolytic streptococci is associated with Scarlet Fever

D/ Enterovirus is associated with Poliomyelitis

Question 18

What is the cardinal sign of Rocky Mountain Spotted fever? and How does one become infected with it?

Answer 18

Muscle pain (myalgia)

Infection occurs through the bite of an infected tick

Question 19

Which of the following people are at a higher risk of developing MRSA? SELECT ALL THAT APPLY

A/ Prisioners
B/ People Who get Tattoos
C/ People living on Farms
D/ People who abuse IV drugs
E/ People who smoke
F/ People living in crowded places

Answer 19

A/ Prisioners
B/ People Who get Tattoos
D/ People who abuse IV drugs
F/ People living in crowded places

Streptococcus aureus is the agent, however it normally resides in the noses and on the skin of healthy people. This organism seeks opportunity to flourish and under these circumstances, they may be able to do so.

Other people at risk include:
Persons with a compromised immune system
Persons with poor hygiene practices
Persons who use contaminated items
Day-care attendees
Military recruits
Athletes

S. Aureus can enter the bloodstream through a cut or a wound and can cause sepsis, cellulitis, endocarditis, osteomyelitis, septic arthritis, toxic shock syndrome, pneumonia, organ failure and death

Question 20

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client?

1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury

Answer 20

2. Diminished breath sounds

This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

Question 21

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client?
SELECT ALL THAT APPLY

1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5. Pulmonary function tests that demonstrate increased vital capacity

Answer 21

2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise

Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

Question 22

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome?

1. Promote oxygen intake
2. Strengthen the diaphragm
3. Strengthen the intercostal muscles
4. Promote carbon dioxide elimination

Answer 22

4. Promote carbon dioxide elimination

Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

Question 23

The nurse is preparing a list of home care instructions for a client who has been hospitalized
and treated for tuberculosis. Which instructions should the nurse include on the list?
SELECT ALL THAT APPLY

1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary because family members already have been exposed.
5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
6. When one sputum culture is negative, the client is no longer considered infectious and
   usually can return to former employment.

Answer 23

1. Activities should be resumed gradually.
2. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
3. Respiratory isolation is not necessary because family members already have been exposed.
4. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand.

Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

Question 24

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

1. Dry cough
2. Hematuria
3. Bronchospasm
4. Blood-streaked sputum

Answer 24

3. Bronchospasm

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

Question 25

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

1. 1 minute
2. 5 seconds
3. 10 seconds
4. 30 seconds

Answer 25

3. 10 seconds

Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

Question 26

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate ?

1. Continue to suction.
2. Notify the health care provider immediately.
3. Stop the procedure and reoxygenate the client.
4. Ensure that the suction is limited to 15 seconds.

Answer 26

3. Stop the procedure and reoxygenate the client.

During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

Question 27

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

1. Cyanosis
2. Tracheal Shift
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation

Answer 27

3. Paradoxical chest movement

Flail chest results from multiple rib fractures. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

Question 28

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome

Answer 28

1. Right pneumothorax

Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion,
and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

Question 29

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate

Answer 29

4. Increased respiratory rate

The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

Question 30

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

1. Palpation and clubbing
2. Percussion and vibration
3. Hyperoxygenation and suctioning
4. Administer a bronchodilator and monitor peak flow

Answer 30

2. Percussion and vibration

Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus moving from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

Question 31

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for 1 1⁄2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

1. “I need to continue drug therapy for 2 months.”
2. “I can’t shop at the mall for the next 6 months.”
3. “I can return to work if a sputum culture comes back negative.”
4. “I should not be contagious after 2 to 3 weeks of medication therapy.”

Answer 31

4. “I should not be contagious after 2 to 3 weeks of medication therapy.”

The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.

Question 32

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care?

1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear

Answer 32

2. Particulate respirator, gown, and gloves

The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

Question 33

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken

Answer 33

3. Chest pain that occurs suddenly

The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly
reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

Because pulmonary embolism does not result from an infectious process or an allergic reaction, eliminate options 1 and 2 first. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore eliminate option 4.

Question 34

A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

1. Positive
2. Negative
3. Inconclusive
4. Need for repeat testing

Answer 34

1. Positive

The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.

Question 35

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

1. Fever
2. Fatigue
3. Weight loss
4. Shortness of breath

Answer 35

4. Shortness of breath

Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

Because sarcoidosis is a pulmonary problem, eliminate options 1 and 3 first. Select the correct option over option 2 because the shortness of breath (and impaired ventilation) appears first and would cause the fatigue as a secondary symptom.

Question 36

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?

1. Face tent
2. Venturi mask
3. Aerosol mask
4. Tracheostomy collar

Answer 36

2. Venturi mask

The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration.

Question 37

The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis?

1. Dyspnea
2. Chest pain
3. A bloody, productive cough
4. A cough with the expectoration of mucoid sputum

Answer 37

4. A cough with the expectoration of mucoid sputum

Options 1, 2, and 3 are late manifestations and signify cavitation and extensive lung involvement.

Question 38

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the
nurse should take what initial action? 
1. Administer oxygen
2. Check the client’s vital signs
3. Ventilate the client manually
4. Start cardiopulmonary resuscitation

Answer 38

3. Ventilate the client manually

If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the
ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.