Respiratory Flashcards
The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?
1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months.
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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) on airborne precautions during hospitalization; can send home with family because they are already exposed
(2) not required
(3) important, but not as important as taking medication
(4) correct—necessary to take medication for 6 to 9 months
The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following?
1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends."
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Strategy: Think about what the words mean.
(1) involves forced expiration; would not cause problems with asthma
(2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves
(3) school activities should be encouraged to help development
(4) walking is good exercise; running could be a problem if he has exercise-induced asthma
The nurse cares for clients in the pediatric clinic. A mother reports that her infant’s smile is “crooked”. The nurse should assess which of the following cranial nerves?
1. III. 2. V. 3. VII. 4. XI.
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Strategy: Think about each answer choice.
(1) oculomotor; provides innervation for extraocular movement
(2) trigeminal; provides sensation to facial muscles
(3) correct—facial; provides motor activity to the facial muscles
(4) spinal accessory; provides innervation to the trapezius and sternocleidomastoid muscles
An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse?
1. "Take the medication on a full stomach or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for 2 weeks."
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Strategy: Think about each answer choice.
(1) should be taken on an empty stomach
(2) correct—photosensitivity occurs with the use of this medication
(3) should be taken as directed
(4) unnecessary
A client at the health clinic asks the nurse if he should get a flu shot. Which of the following factors, if learned by the nurse in the history, would NOT be a reason for the client to receive the flu vaccine?
1. The client is 69 years old. 2. The client had bronchitis twice last year. 3. The client volunteers at a preschool. 4. The client lives with two large dogs.
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Strategy: Think about each answer choice.
(1) recommended for people over 65
(2) recommended for people with chronic respiratory or cardiovascular disease
(3) recommended for people who come in contact with young children
(4) correct—not at risk for getting the flu from a dog
The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective?
1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips.
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Strategy: “Teaching is effective” indicates a correct response.
(1) correct—describes esophageal speech
(2) describes electric larynx
(3) method of speech for patient with a tracheostomy
(4) describes tracheoesophageal fistula (TEF)
The nurse identifies which of the following clients as being at HIGHEST risk of developing pulmonary embolus?
1. A 19-year-old 4 days’ postpartum diagnosed with a placenta previa at 28 weeks’ gestation. 2. A 22-year-old client diagnosed with leukemia with a platelet count of 120,000/mm3, hemoglobin 9.0 g/dL. 3. A 40-year-old man who is obese and diagnosed with multiple pelvic fractures due to a motor vehicle accident 2 days ago. 4. A 65-year-old woman who had a fractured hip repaired 10 days ago and is currently receiving daily physical therapy.
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Strategy: Determine how each answer choice relates to pulmonary embolism.
(1) not at risk for pulmonary embolism
(2) at high risk for bleeding
(3) correct—obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli
(4) client does not have a high risk for pulmonary emboli
The nurse cares for a client diagnosed with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following is an appropriate nursing goal for the client?
1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus.
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Strategy: Think about each answer choice.
(1) correct—important to prevent the complication of pulmonary embolism in clients at high risk
(2) relates to arterial disease
(3) surgery is not anticipated for this client
(4) preventing embolism is the first priority
The nurse cares for a patient with a three-chamber water-seal drainage system (Pleur-evac). When the nurse checks the patient, the nurse notices that the fluid in the water-seal chamber does not fluctuate. Which of the following actions by the nurse is BEST?
1. Milk the tube gently toward the collection chamber. 2. Anticipate the need for a chest x-ray. 3. Add water to the water seal chamber to re-establish the system. 4. Clamp the chest tube and call the physician.
Show/hide explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) milking is done only with order of physician to clear obstruction due to clots, fluid is clear
(2) correct—fluctuations stop with re-expansion of lung, x-ray will confirm
(3) should be kept at level of 2 mL to maintain negative pressure
(4) only clamp tube when checking for air leaks or changing equipment
A client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) 4 weeks ago. The nurse observes the client in the outpatient clinic. The nurse is MOST concerned if which of the following is observed?
1. Fatigue and dark urine. 2. Malaise and glucosuria. 3. Proteinuria and lethargy. 4. Diluted urine and epigastric distress.
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Strategy: Determine how each answer choice relates to INH.
(1) correct—initial indications of hepatic dysfunction
(2) seen with pancreatic problems
(3) seen with renal problems
(4) is not seen with liver problems
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Which of the following actions should the nurse take FIRST?
1. Loosely cover the wound, preferably with a sterile dressing. 2. Place a sandbag over the wound. 3. Monitor chest wound drainage. 4. Place a firm, airtight, sterile dressing over the wound.
Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation.
(1) correct—implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not re-enter the pleural space
(2) implementation, would prevent air from escaping
(3) assessment, chest tube has not yet been inserted
(4) implementation, would prevent air from escaping
The nurse is caring for an elderly client diagnosed with type 1 diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The client usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse expects to take which of the following actions?
1. Hold the morning dose of NPH and regular insulin and monitor the blood glucose. 2. Give half the morning dose of NPH insulin together with the regular insulin and monitor the blood glucose when the client returns from surgery. 3. Give the full dose of NPH and regular insulin and monitor the blood glucose every 2-4 hours. 4. Give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—usually use sliding scale with regular insulin based on blood glucose readings
(2) may cause hypoglycemia because client will be NPO when NPH peaks, NPH intermediate-acting insulin, onset 1-2 hours, peaks 6-12 hours, duration 18-26 hours; regular insulin short-acting, onset 0.5-1 hour, peaks 2-4 hours, duration 6-8 hours
(3) client may become hypoglycemic because NPH will peak when client is NPO
(4) may cause hypoglycemia during surgery
