Respiratory Disorders

Question 1

The home health-care nurse is talking on the telephone to a male client diagnosed with
hypertension and hears the client sneezing. The client tells the nurse that he has been
blowing his nose frequently. Which question should the nurse ask the client?
1. “Have you had the flu shot in the last two (2) weeks?”
2. “Are there any small children in the home?”
3. “Are you taking over-the counter-medicine for these symptoms?”
4. “Do you have any cold sores associated with your sneezing?”

Answer 1

3. A client diagnosed with hypertension
   should not take many of the over-thecounter
   medications because they work
   by causing vasoconstriction, which will increase
   the hypertension.

Question 2

The school nurse is presenting a class to students at a primary school on how to prevent
the transmission of the common cold virus. Which information should the nurse discuss?
1. Instruct the children to always keep a tissue or handkerchief with them.
2. Explain that children current with immunizations will not get a cold.
3. Tell the children that they should go to the doctor if they get a cold.
4. Include a demonstration of how to wash hands correctly

Answer 2

4. Hand washing is the single most useful

technique for prevention of disease.

Question 3

Which information should the nurse teach the client diagnosed with acute sinusitis?

1. Instruct the client to complete all the ordered antibiotics.
2. Teach the client how to irrigate the nasal passages.
3. Have the client demonstrate how to blow the nose.
4. Give the client samples of a narcotic analgesic for the headache.

Answer 3

1. The client should be taught to take all
   antibiotics as ordered. Discontinuing
   antibiotics prior to the full dose results in
   the development of antibiotic-resistant
   bacteria. Sinus infections are difficult to
   treat and may become chronic and will then
   require several weeks of therapy or possibly
   surgery to control.

Question 4

The client has been diagnosed with chronic sinusitis. Which signs and symptoms would
alert the nurse to a potentially life-threatening complication?
1. Muscle weakness.
2. Purulent sputum.
3. Nuchal rigidity.
4. Intermittent loss of muscle control.

Answer 4

3. Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential
   complication of sinusitis resulting from the
   close proximity of the sinus cavities to the
   meninges.

Question 5

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which
assessment data should the nurse notify the health-care provider about prior to surgery?
1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
2. The client has an oral temperature of 100.2°F and a dry cough.
3. There are one (1) to two (2) white blood cells in the urinalysis.
4. The client’s current International Normalized Ratio (INR) is 1.0.

Answer 5

2. A low-grade temperature and a cough could
   indicate the presence of an infection, in
   which case the health-care provider would
   not want to subject the client to anesthesia
   and the possibility of further complications.
   The surgery would be postponed.

Question 6

The influenza vaccine is in short supply. Which group of clients would the public health
nurse consider priority when administering the vaccine?
1. Elderly and chronically ill clients.
2. Child-care workers and children younger than age four (4) years.
3. Hospital chaplains and health-care workers.
4. Schoolteachers and students living in a dormitory.

Answer 6

1. The elderly and chronically ill are at greatest
   risk for developing serious complications
   if they contract the influenza virus.

Question 7

The client diagnosed with sinusitis who has undergone a Caldwell Luc procedure is
complaining of pain. Which intervention should the nurse implement first?
1. Administer the narcotic analgesic IVP.
2. Perform gentle oral hygiene.
3. Place the client in a semi-Fowler’s position.
4. Assess the client’s pain.

Answer 7

4. Prior to intervening the nurse must assess
   to determine the amount of pain and possible
   complications occurring that could be
   masked if narcotic medication is administered.

Question 8

The charge nurse on a surgical floor is making assignments. Which client should be
assigned to the most experienced registered nurse (RN)?
1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday
and has moderate pain.
2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this
morning who will not swallow medication.
3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has
purulent drainage on the drip pad.
4. The 45-year client diagnosed with a peritonsillar abscess who requires IVPB antibiotic
therapy four (4) times a day.

Answer 8

3. The postoperative client with purulent
   drainage could be developing an infection.
   The experienced nurse would be needed to
   assess and monitor the client’s condition.

Question 9

The client diagnosed with influenza A is being discharged from the emergency department
with a prescription for antibiotics. Which statement by the client indicates an
understanding of this prescription?
1. “These pills will make me feel better fast and I can return to work.”
2. “The antibiotics will help prevent me from developing a bacterial pneumonia.”
3. “If I had gotten this prescription sooner I could have prevented this illness.”
4. “I need to take these pills until I feel better; then I can stop taking the rest.”

Answer 9

2. Secondary bacterial infections often accompany influenza, and antibiotics are often
   prescribed to help prevent the development
   of a bacterial infection.

Question 10

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies
the client problem “altered communication.” Which intervention should the
nurse implement?
1. Instruct the client to drink a mixture of brandy and honey several times a day.
2. Encourage the client to whisper instead of trying to speak at a normal level.
3. Provide the client with a blank note pad for writing any communication.
4. Explain that the client’s aphonia may become a permanent condition.

Answer 10

3. Voice rest is encouraged for the client

experiencing laryngitis.

Question 11

Which nursing task could be delegated to an unlicensed nursing assistant?

1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids.
2. Encourage the client diagnosed with a cold to drink a glass of orange juice.
3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis.
4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.

Answer 11

2. Clients with colds are encouraged to drink
   2000 mL of liquids a day. The unlicensed
   nursing assistant could do this.

Question 12

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative
therapy?
1. Vitamin C, 2000 mg daily.
2. Strict bed rest.
3. Humidification of the air.
4. Decongestant therapy.

Answer 12

1. Alternative therapies are therapies that are
   not accepted medical practice. These may
   be encouraged as long as they do not interfere
   with the medical regimen. Vitamin C
   in large doses is thought to improve the
   immune system’s functions.

Question 13

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs
and symptoms would the nurse expect to find when assessing the client?
1. Confusion and lethargy.
2. High fever and chills.
3. Frothy sputum and edema.
4. Bradypnea and jugular vein distention.

Answer 13

1. The elderly client diagnosed with pneumonia
   may present with weakness, fatigue,
   lethargy, confusion, and poor appetite but
   not have any of the classic signs and symptoms
   of pneumonia.

Question 14

The nurse is planning the care of a client diagnosed with pneumonia and writes a
problem of “impaired gas exchange.” Which would be an expected outcome for this
problem?
1. Performs chest physiotherapy three (3) times a day.
2. Able to complete activities of daily living.
3. Ambulates in the hall and back several times during each shift.
4. Alert and oriented to person, place, time, and events.

Answer 14

4. Impaired gas exchange results in hypoxia,
   the earliest sign and symptom of which is a
   change in the level of consciousness.

Question 15

The nurse in a long-term care facility is planning the care for a client with a percutaneous
gastrostomy (PEG) feeding tube. Which interventions would the nurse include
in the plan of care?
1. Inspect the insertion line at the nare prior to instilling formula.
2. Elevate the head of the bed after feeding the client.
3. Place the client in the Sims position following each feeding.
4. Change the dressing on the feeding tube every three (3) days.

Answer 15

2. Elevating the head of the bed uses gravity
   to keep the formula in the gastric cavity
   and help prevent it from refluxing into the
   esophagus, which predisposes the client to
   aspiration.

Question 16

The client diagnosed with a community-acquired pneumonia is being admitted to the
medical unit. Which nursing intervention has the highest priority?
1. Administer the oral antibiotic stat.
2. Order the meal tray to be delivered as soon as possible.
3. Obtain a sputum specimen for culture and sensitivity.
4. Have the unlicensed nursing assistant weigh the client.

Answer 16

3. To determine the antibiotic that will effectively treat an infection, specimens for
   culture are taken prior to beginning the
   medication. Administering antibiotics prior
   to cultures may make it impossible to
   determine the actual agent causing the
   pneumonia.

Question 17

The 56-year-old client diagnosed with tuberculosis (TB) is being discharged.
Which statement made by the client indicates an understanding of the discharge
instructions?
1. “I will take my medication for the full three (3) weeks prescribed.”
2. “I must stay on the medication for months if I am to get well.”
3. “I can be around my friends because I have started taking antibiotics.”
4. “I should get a TB skin test every three (3) months to determine if I am well.”

Answer 17

2. Compliance with treatment plans for TB
   includes multi-drug therapy for six (6)
   months to one (1) year for the client to be
   free of the TB bacteria.

Question 18

The employee health nurse is administering tuberculin skin testing to employees who
have possibly been exposed to a client with active tuberculosis. Which statement indicates
the need for radiological evaluation instead of skin testing?
1. The client’s first skin test indicates a purple flat area at the site of injection.
2. The client’s second skin test indicates a red area measuring four (4) mm.
3. The client’s previous skin test was read as positive.
4. The client has never shown a reaction to the tuberculin medication.

Answer 18

3. If the client has ever reacted positively,
   then the client should have a chest x-ray to
   look for causation and inflammation.

Question 19

The nurse is caring for the client diagnosed with pneumonia. Which information
should the nurse include in the teaching plan? Select all that apply.
1. Place the client on oxygen by nasal cannula.
2. Plan for periods of rest during activities of daily living.
3. Place the client on a fluid restriction of 1000 mL per day.
4. Restrict the client’s smoking to two (2) to three (3) cigarettes per day.
5. Monitor the client’s pulse oximetry readings every four (4) hours.

Answer 19

1. The client diagnosed with pneumonia will
   have some degree of gas-exchange deficit.
   Administering oxygen would help the
   client.
2. Activities of daily living require energy and
   therefore oxygen consumption. Spacing the
   activities allows the client to rebuild oxygen
   reserves between activities.
3. Pulse oximetry readings provide the nurse
   with an estimate of oxygenation in the periphery.

Question 20

While feeding the client diagnosed with aspiration pneumonia, the client becomes
dyspneic, begins to cough, and is turning blue. Which nursing intervention would the
nurse implement first?
1. Suction the client’s nares.
2. Turn the client to the side.
3. Place the client in the Trendelenburg position.
4. Notify the health-care provider.

Answer 20

2. Turning the client to the side allows for
   the food to be coughed up and come out of
   the mouth, rather than be aspirated into
   the lungs.

Question 21

The day shift charge nurse on a medical unit is making rounds after report. Which
client should be seen first?
1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to
be sent to the lab.
2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged
feeding tube.
3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading
of 92%.
4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation
level of 89%.

Answer 21

3. A pulse oximetry reading of 92% means
   that the arterial blood oxygen saturation is
   somewhere around 60%–70%.

Question 22

The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation
procedures should the nurse implement?
1. Standard Precautions.
2. Contact Precautions.
3. Droplet Precautions.
4. Airborne Precautions.

Answer 22

4. Tuberculosis bacteria are capable of disseminating
   over distances on air currents.
   Clients with tuberculosis are placed in
   negative air pressure rooms where the air
   in the room is not allowed to crosscontaminate
   the air in the hallway.

Question 23

The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation
room and leaving the door open. Which action would be the nurse’s best
response?
1. Close the door and discuss the NA’s action when the NA comes out of the room.
2. Make the NA come back outside the room and then reenter closing the door.
3. Say nothing to the NA but report the incident to the nursing supervisor.
4. Enter the client’s room and discuss the matter with the NA immediately.

Answer 23

1. Closing the door reestablishes the negative
   air pressure, which prevents the air from
   entering the hall and contaminating the
   hospital environment. When correcting an
   individual, it is always best to do so in a
   private manner.

Question 24

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs
and symptoms would the nurse look for when assessing the client?
1. Pleuritic chest discomfort and anxiety.
2. Asymmetrical chest expansion and pallor.
3. Leukopenia and CRT 3 seconds.
4. Substernal chest pain and diaphoresis.

Answer 24

1. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever,
   chills, dyspnea, and cough.

Question 25

When assessing the client with COPD, which health promotion information would be most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Possibility for lifestyle changes.

Answer 25

4. The possibility of lifestyle changes is most important in health promotion. The most important is smoking cessation. The nurse needs to assess if the client has the willingness to consider cessation of smoking and carry out the plan. If the client refuses to stop, treatment will need to be altered.

Question 26

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Give oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client’s status.

Answer 26

1. The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client’s safety.

Question 27

When assessing the client with the diagnosis of COPD, which data would require the nurse to take immediate action? 1. Large amounts of thick white sputum. 2. Oxygen flow meter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

Answer 27

2. The nurse should decrease the oxygen rate. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. Careful monitoring is important to prevent complications.

Question 28

While the nurse is caring for the client diagnosed with COPD, which outcome would require a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

Answer 28

3. The expected outcome should be that the client is showing an improved activity tolerance; because the client is not meeting the expected outcome, the plan of care needs revision. The nurse needs to collaborate with the health-care team and with the client to establish interventions that will assist in improving the client’s outcome.

Question 29

The nurse is caring for the client diagnosed with end-stage COPD. Which data would warrant immediate intervention by the nurse? 1. The client’s pulse oximeter reading is 92%. 2. The client’s arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client’s sputum is rusty colored.

Answer 29

4. Rusty-colored sputum may indicate blood in the sputum and would require further assessment by the nurse.

Question 30

What statement made by the client diagnosed with chronic bronchitis indicates to the nurse that more teaching is needed? 1. “I should contact my health-care provider if my sputum changes color or amount.” 2. “I will take my bronchodilator regularly to prevent having bronchospasms.” 3. “This metered dose inhaler gives a precise amount of medication with each dose.” 4. “I need to return to the HCP to have my blood drawn with my annual physical.”

Answer 30

``` 4. Clients need to have blood levels drawn every six (6) months when taking bronchodilators. ```

Question 31

Which nursing diagnoses would be appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

Answer 31

1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and metabolic acidosis as seen on arterial blood gases. 2. Clients need to avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. When a client has difficulty breathing the client can become fatigued so that the client can stop breathing. Activities should be timed so rest periods are available to prevent fatigue. 4. Many clients have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because so much effort is expended to breathe.

Question 32

Which outcome would be appropriate for the client problem “ineffective gas exchange” for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to purse-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

Answer 32

1. Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange.

Question 33

The primary nurse observes the unlicensed nursing assistant removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the primary nurse take? 1. Praise the NA because this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the NA in front of the client that the oxygen must be left in place at all times. 4. Discuss the NA’s action with the charge nurse so that appropriate action can be taken.

Answer 33

2. The client needs the oxygen, and the nurse should not correct the NA in front of the client; it is embarrassing for the NA, and the client loses confidence in the staff.

Question 34

When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse expect? 1. Clubbing of the client’s fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.

Answer 34

3. Sputum production, along with cough and dyspnea on exertion, are the early signs/ symptoms of COPD.

Question 35

What statement made by the client would indicate that the nurse’s discharge teaching was effective for the client diagnosed with COPD? 1. “I need to get an influenza vaccine each year, even when there is a shortage.” 2. “I need to get a vaccine for pneumonia each year with my flu shot.” 3. “If I reduce my cigarette smoking to six (6) a day, I won’t have difficulty breathing.” 4. “I need to restrict my drinking liquids to keep from having so much phlegm.”

Answer 35

1. Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority.

Question 36

Which referral would be appropriate for a client diagnosed with COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

Answer 36

3. The American Lung Association has information that is helpful for a client with COPD.

Question 37

The nurse is completing the admission assessment on a 13-year-old client diagnosed with asthma. Which signs and symptoms would the nurse expect to find? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea.

Answer 37

3. During an asthma attack the muscles surrounding bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces, and dyspnea.

Question 38

The nurse is planning the care of a client diagnosed with asthma and has written a problem of “anxiety.” Which nursing intervention should be implemented? 1. Stay with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

Answer 38

1. Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and that the client is not alone.

Question 39

The case manager is arranging a care planning meeting regarding the care of a 65- year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply. 1. Nursing. 2. Pharmacy. 3. Social Work. 4. Occupational Therapy. 5. Speech Therapy.

Answer 39

1. Nursing is the one discipline that is with the client around the clock. Therefore nurses have knowledge of the client that the other disciplines might not know. 2. The pharmacist will be able to discuss the medication regimen that the client is receiving and make suggestions regarding other medications or medication interactions. 3. The social worker may be able to assist with financial information or home care arrangements

Question 40

``` The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a “rescue inhaler.” 3. Use of systemic steroids. 4. Leukotriene agonists. ```

Answer 40

2. Clients with intermittent asthma will have exacerbations that are treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers.

Question 41

The nurse knows the client understands teaching regarding mast cell stabilizer medications when the client makes which statement? 1. “I should take two (2) puffs when I begin to have an asthma attack.” 2. “I must taper off the medications and not stop taking them abruptly.” 3. “These drugs will be most effective if taken at bedtime.” 4. “These drugs are not good at the time of an attack.”

Answer 41

4. Mast cell drugs are routine maintenance | medications and do not treat an attack.

Question 42

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

Answer 42

2. Pulmonary functions tests are completed to determine the forced vital capacity (FVC), the forced expiratory vital capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicate respiratory compromise.

Question 43

The registered nurse and a licensed practical nurse are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the licensed practical nurse? Select all that apply. 1. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1000 mL. 2. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. 3. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed. 4. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications. 5. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.

Answer 43

1. A forced vital capacity of 1000 mL is considered normal for most females. 2. The client should be encouraged to pace the activities of daily living; this is expected for a client diagnosed with asthma. 5. A pulse oximetry level of 95% is normal.

Question 44

The charge nurse is making rounds. Which client should the nurse assess first? 1. The 29-year-old client diagnosed with reactive airway disease who is complaining that the nurse caring for him was rude. 2. The 76-year-old client diagnosed with heart failure who has 2 edema of the lower extremities. 3. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL. 4. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.

Answer 44

1. The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening.

Question 45

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warmup exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

Answer 45

3. Using a bronchodilator immediately prior | to exercising will reduce bronchospasms.

Question 46

The client diagnosed with restrictive airway disease, asthma, has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for fifteen (15) seconds before swallowing. 4. Take the medication immediately when an attack starts.

Answer 46

2. The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth, oral candidiasis.

Question 47

The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral would be important to include? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse

Answer 47

2. Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack.

Question 48

The nurse is discharging a client newly diagnosed with restrictive airway disease, asthma. Which statement indicates the client understands the discharge instructions? 1. “I will call 911 if my medications don’t control an attack.” 2. “I should wash my bedding in warm water.” 3. “I can still eat at the Chinese restaurant when I want.” 4. “If I get a headache I should take a nonsteroidal anti-inflammatory drug.”

Answer 48

1. The client must be able to recognize a lifethreatening situation and initiate the correct procedure.

Question 49

The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease? 1. The client worked with asbestos for a short time many years ago. 2. The client has no family history for this type of lung cancer. 3. The client has numerous tattoos covering both upper and lower arms. 4. The client has smoked two (2) packs of cigarettes a day for 20 years.

Answer 49

4. Smoking is the number-one risk factor for developing cancer of the lung. More than 85% of lung cancers are attributable to inhalation of chemicals. There are more than 400 chemicals in each puff of cigarette smoke, 17 of which are known to cause cancer.

Question 50

The nurse writes a problem of “impaired gas exchange” for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply. 1. Apply O2 via nasal cannula. 2. Have the dietitian plan for six (6) small meals per day. 3. Place the client in respiratory isolation. 4. Assess vital signs for fever. 5. Listen to lung sounds every shift.

Answer 50

1. Respiratory distress is a common finding in clients diagnosed with lung cancer. As the tumor grows and takes up more space or blocks air movement, the client may need to be taught positioning for lung expansion. The administration of oxygen will help the client to use the lung capacity that is available to get oxygen to the tissues. 2. Clients with lung cancer frequently become fatigued trying to eat. Providing six (6) small meals spaces the amount of food the client eats throughout the day. 4. Clients with cancer of the lung are at risk for developing an infection from lowered resistance as a result of treatments or from the tumor blocking secretions in the lung. Therefore, monitoring for the presence of fever, a possible indication of infection, is important. 5. Assessment of the lungs should be completed on a routine and PRN basis.

Question 51

The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate? 1. Lung cancer is the number-two cause of cancer deaths in both men and women. 2. Lung cancer is the number-one cause of cancer deaths in both men and women. 3. Lung cancer deaths are not significant in relation to other cancers. 4. Lung cancer deaths have continued to increase in the male population.

Answer 51

2. Lung cancers are responsible for almost twice as many deaths among males as any other cancer and more deaths than breast cancer in females.

Question 52

The nurse and an unlicensed nursing assistant are caring for a group of clients on a medical unit. Which information provided by the assistant warrants immediate intervention by the nurse? 1. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup. 2. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table. 3. The client receiving Procrit, a biologic response modifier, has a T 99.2°, P 68, R 24, and BP of 198/102. 4. The client receiving prednisone, a steroid, is complaining of an upset stomach after eating breakfast.

Answer 52

3. Biologic response modifiers that stimulate the bone marrow can increase the client’s blood pressure to dangerous levels. This BP is very high and warrants immediate attention.

Question 53

The client diagnosed with lung cancer has been told that the cancer has metastasized to the brain. Which intervention should the nurse implement? 1. Discuss implementing an advance directive. 2. Explain the use of chemotherapy for brain involvement. 3. Teach the client to discontinue driving. 4. Have the significant other make decisions for the client.

Answer 53

1. This situation indicates a terminal process, and the client should make decisions for the end of life.

Question 54

The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach? 1. Investigational regimens provide a better chance of survival for the client. 2. Investigational treatments have not been proved helpful to clients. 3. Clients will be paid to participate in an investigational program. 4. Only clients that are dying qualify for investigational treatments.

Answer 54

2. Investigational treatments are just that— treatments being investigated to see if they are effective in the care of clients diagnosed with cancer. There is no guarantee the treatments will help the client.

Question 55

The staff on an oncology unit is interviewing applicants for a position as the unit manager. Which type of organizational structure does this represent? 1. Centralized decision-making. 2. Decentralized decision-making. 3. Shared governance. 4. Pyramid with filtered-down decisions.

Answer 55

3. Shared governance is a system where the staff is empowered to make decisions such as scheduling and hiring of certain staff. Staff members are encouraged to participate in developing policies and procedures to reach set goals.

Question 56

The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates that more teaching is needed? 1. “It doesn’t matter if I smoke now. I already have cancer.” 2. “I should see the oncologist at my scheduled appointment.” 3. “If I begin to run a fever I should notify the HCP.” 4. “I should plan for periods of rest throughout the day.”

Answer 56

1. Research indicates that smoking will still | interfere with the client’s response to treatment.

Question 57

The nurse working in an outpatient clinic is interviewing clients. Which information provided by the client warrants further investigation? 1. The client uses Vicks VapoRub every night before bed. 2. The client has had an appendectomy. 3. The client takes a multiple vitamin pill every day. 4. The client has been coughing up blood in the mornings.

Answer 57

4. Coughing up blood could indicate a lung | cancer and should be investigated.

Question 58

The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse? 1. The client has an intake of 1500 mL IV and an output of 1000 mL. 2. The client has 450 mL of bright-red drainage in the chest tube. 3. The client is complaining of pain at a “10” on a 1–10 scale. 4. The client has absent lung sound on the side of the surgery.

Answer 58

2. This is about a pint of blood loss and could | indicate the client is hemorrhaging.

Question 59

The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach? 1. The test will confirm the MRI results. 2. The client can eat and drink immediately after the test. 3. The HCP can do a biopsy of the tumor through the scope. 4. There is no discomfort associated with this procedure.

Answer 59

3. The HCP can take biopsies and wash of the lung tissue for pathological diagnosis during the procedure.

Question 60

The client diagnosed with oat cell carcinoma of the lung tells the nurse, “I am so tired of all this. I might as well just end it all.” Which should be the nurse’s first response? 1. Respond by saying, “This must be hard for you. Would you like to talk?” 2. Tell the HCP of the client’s statement. 3. Refer the client to a social worker or spiritual advisor. 4. Find out if the client has a plan to carry out suicide.

Answer 60

4. The priority action any time a client makes a statement regarding taking his or her own life is to determine if the client has thought it through enough to have a plan. A plan indicates an emergency situation.

Question 61

The nurse is admitting a client with a diagnosis of rule out cancer of the larynx. Which information should the nurse teach? 1. Demonstrate the proper method of gargling with normal saline. 2. Perform voice exercises for 30 minutes three (3) times a day. 3. Explain that a lighted instrument will be placed in the throat to biopsy the area. 4. Teach the client to self-examine the larynx monthly.

Answer 61

3. A laryngoscopy will be done to allow for visualization of the vocal cords and to obtain a biopsy for pathological diagnosis.

Question 62

The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. For which prophylactic procedure will the nurse prepare the client? 1. Removal of the teeth. 2. Taking anti-emetic medications every four (4) hours. 3. Wearing sunscreen on the area at all times. 4. Placement of a PEG tube.

Answer 62

1. The teeth will be in the area of radiation and the roots of teeth are highly sensitive to radiation, which results in root abscesses. The teeth are removed and the client is fitted for dentures prior to radiation.

Question 63

``` The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client? 1. Total parenteral nutrition. 2. Soft, regular diet. 3. Partial parenteral nutrition. 4. Clear liquid diet. ```

Answer 63

2. The client should be eating normal foods by this time. The consistency should be soft to allow for less chewing of the food and easier swallowing because a portion of the throat musculature has been removed. The client should be taught to turn the head toward the affected side when swallowing to help prevent aspiration.

Question 64

The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention would have priority? 1. Take the client to the intensive care unit for a visit. 2. Explain that the client will need to ask for pain medication. 3. Demonstrate the use of an anti-embolism hose. 4. Find out if the client can read and write.

Answer 64

4. The client is having the vocal cords removed and will be unable to speak. Communication is a high priority for this client. If the client is able to read and write, a Magic Slate or pad of paper should be provided. If the client is illiterate, the nurse and the client should develop a method of communication using pictures.

Question 65

The client has had a total laryngectomy. Which referral is specific for this surgery? 1. CanSurmount. 2. Dialogue. 3. Lost Chord Club. 4. SmokEnders.

Answer 65

3. The Lost Chord Club is an American Cancer Society–sponsored group of survivors of larynx cancer. These clients are able to discuss the feelings and needs of clients that have had laryngectomies because they have all had this particular surgery.

Question 66

The nurse and unlicensed nursing assistant are caring for a group of clients on a surgical floor. Which information provided by the nursing assistant requires immediate intervention by the nurse? 1. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection. 2. The client who has had a right upper lobectomy is complaining that the patient controlled analgesia (PCA) pump is not giving any relief. 3. The client diagnosed with cancer of the lung is complaining of being tired and short of breath. 4. The client admitted with chronic obstructive pulmonary disease is making a whistling sound with every breath.

Answer 66

1. The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. A continuous bright-red drainage indicates bleeding, and this client should be assessed immediately.

Question 67

The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with cancer of the lung who has chest tubes. 2. The client diagnosed with laryngeal spasms who has stridor. 3. The client diagnosed with laryngeal cancer who has multiple fistulas. 4. The client who is two (2) hours post-partial laryngectomy.

Answer 67

1. Chest tubes are part of the nursing education curriculum. The new graduate should be capable of caring for this client or at least knowing when to get assistance.

Question 68

The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem would have the highest priority? 1. Wound infection. 2. Hemorrhage. 3. Respiratory distress. 4. Knowledge deficit.

Answer 68

3. Respiratory distress is the highest priority. There is a chance to stop the bleeding or treat an infection, but a client who is not breathing dies very quickly.

Question 69

The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image? 1. The client requests a consultation by the speech therapist. 2. The client has a towel placed over the mirror. 3. The client is attempting to shave himself. 4. The client practices neck and shoulder exercises.

Answer 69

2. Placing a towel over the mirror indicates the client is having difficulty looking at his reflection, a body-image problem.

Question 70

The HCP has recommended a total laryngectomy for a male client diagnosed with cancer of the larynx but the client refuses. Which intervention by the nurse illustrates the ethical principle of nonmalfeasance? 1. The nurse listens to the client explain why he is refusing surgery. 2. The nurse and significant other insist that the client have the surgery. 3. The nurse refers the client to a counselor for help with the decision. 4. The nurse asks a cancer survivor to come and discuss the surgery with the client.

Answer 70

1. This is an example of nonmalfeasance where the nurse “does no harm.” In attempting to discuss the client’s refusal, the nurse is not trying to influence the client; the nurse is merely attempting to listen therapeutically.

Question 71

The client diagnosed with cancer of the larynx has had four (4) weeks of radiation therapy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain? 1. The cancer has grown to obstruct the esophagus. 2. The treatments are working on the cancer and the throat is edematous. 3. Cancers are painful and this is expected. 4. The treatments are also affecting the esophagus, causing ulcerations.

Answer 71

``` 4. The esophagus is extremely radiosensitive, and esophageal ulcerations are common. The pain can become so severe that the client cannot swallow saliva. This is a situation in which the client will be admitted to the hospital for IV narcotic pain medication and possibly total parenteral nutrition. ```

Question 72

The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply. 1. The client will be able to speak again after the surgery area has healed. 2. The client should wear a protective covering over the stoma when showering. 3. The client should clean the stoma and then apply a petroleum-based ointment. 4. The client should use a humidifier in the room. 5. The client can get a special telephone for communication.

Answer 72

2. The client breathes through a stoma in the neck. Care should be taken not to allow water to enter the stoma. 4. The client has lost the use of the nasal passages to humidify the inhaled air, and artificial humidification is useful until the client’s body adapts to the change. 5. There is special equipment available for clients who cannot hear or speak.

Question 73

The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?______

Answer 73

880 units. If there are 20,000 units of heparin in 500 mL of D5W, then there are 40 units in each mL. 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour. 40 × 22 = 880

Question 74

``` The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging (MRI). ```

Answer 74

1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis.

Question 75

Which assessment data would support that the client has experienced a pulmonary embolus? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

Answer 75

2. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath.

Question 76

The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? 1. The client’s ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client’s telemetry exhibits occasional premature ventricular contractions. 3. The client’s pulse oximeter reading is 90%. 4. The client’s urinary output for the 12-hour shift is 800 mL.

Answer 76

3. The normal pulse oximeter reading is 93%–100%. A reading of 90% indicates the client has an arterial oxygen level of around 60.

Question 77

The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client’s bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.

Answer 77

4. Bed rest reduces metabolic demands and | tissue needs for oxygen.

Question 78

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

Answer 78

3. A therapeutic INR is 2–3; therefore, the | nurse should administer the medication.

Question 79

The nurse identified the client problem “decreased cardiac output” for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client’s arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

Answer 79

2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output.

Question 80

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

Answer 80

1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. 3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. 4. Invasive procedures increase the risk of tissue trauma and bleeding. 5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids.

Question 81

Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? 1. “I am going to use a regular-bristle toothbrush.” 2. “I will take antibiotics prior to having my teeth cleaned.” 3. “I can take enteric-coated aspirin for my headache.” 4. “I will wear a medic alert band at all times.”

Answer 81

4. The client should wear a medic alert band at all times so that if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy.

Question 82

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) liters a day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

Answer 82

1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE.

Question 83

The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

Answer 83

3. A normal PTT is 39 seconds; therefore, 58–78 is 1.5 to 2 times the normal value and is within the therapeutic range. A PTT of 98 means the client is not clotting and the medication should be held.

Question 84

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen ten (10) L via nasal cannula. 2. Place the client in a high Fowler’s position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client’s lung sounds.

Answer 84

2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system.

Question 85

The client is admitted to the emergency department with chest trauma. When assessing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy bloody sputum and consolidation. 4. Barrel chest and polycythemia.

Answer 85

2. Unequal lung expansion and dyspnea would | indicate a pneumothorax.

Question 86

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client’s pulse oximeter reading.

Answer 86

3. The key to the answer is “2 hours.” The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop.

Question 87

Which intervention should the nurse implement for a male client who has had a leftsided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn’t take deep breaths, he could die.

Answer 87

1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis.

Question 88

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client’s chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed. 4. The nursing assistant uses a bedside commode for the client.

Answer 88

2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the nursing assistant.

Question 89

The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client’s respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

Answer 89

4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.

Question 90

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

Answer 90

3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.

Question 91

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

Answer 91

1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.

Question 92

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

Answer 92

2. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.

Question 93

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in a low-Fowler’s position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

Answer 93

2. The system must be patent and intact to function properly. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.

Question 94

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

Answer 94

4. A client that is two (2) hours postbronchoscopy procedure could safely be assigned to an LPN.

Question 95

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

Answer 95

2. The insertion of a chest tube is an invasive procedure and so requires informed consent. Without a consent form, this procedure cannot be done on an alert and oriented client.

Question 96

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client’s bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client’s chart.

Answer 96

1. Assessment of the lung sounds could indicate that the client’s lung has reexpanded because it has been three (3) days since the chest tube has been inserted.

Question 97

The unlicensed nursing assistant (NA) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the NA to put the bed in the lowest position. 3. Instruct the NA to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the NA.

Answer 97

1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, so the nurse should demonstrate the proper way to bathe a client in the bed.

Question 98

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client’s arterial blood gas results.

Answer 98

3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.

Question 99

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

Answer 99

1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

Question 100

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near drowning. The client asks the nurse, “What is happening to me? Why did I get this?” Which statement by the nurse is most appropriate? 1. “Most people who drown end up developing ARDS.” 2. “Platelets and fluid enter the alveoli due to permeability instability.” 3. “Your lungs are filling up with fluid, causing breathing problems.” 4. “Smoking has caused your lungs to become weakened, so you got ARDS.”

Answer 100

3. This is a very basic explanation of ARDS and explains why the client is having trouble breathing.

Question 101

Which assessment data would indicate the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client’s urine output is 100 mL in two (2) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

Answer 101

3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.

Question 102

The health-care provider ordered stat arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) amp of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

Answer 102

1. These arterial blood gases are within normal limits and therefore the nurse should not take any action except to continue to monitor the client.

Question 103

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

Answer 103

4. The ET tube should be secure to ensure that it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.

Question 104

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

Answer 104

2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.

Question 105

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client’s lung sounds.

Answer 105

2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation bag (ambu) until the problem is resolved.

Question 106

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client’s level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler’s position.

Answer 106

1. Altered level of consciousness is the earliest sign of hypoxemia. 3. The client is at risk for complications of immobility; therefore the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload. Therefore the nurse should monitor and maintain the fluid intake. 5. Fowler’s position facilitates lung expansion and reduces the workload of breathing.

Question 107

Which instruction is most important for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate

Answer 107

1. Not smoking is vital to prevent further | lung damage.

Question 108

The client diagnosed with ARDS is on a ventilator and the high alarm indicates that there is an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

Answer 108

1. When peak airway pressure is increased, the nurse should implement the intervention that is less invasive for the client. This alarm goes off with a plugged airway, “bucking” in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.

Question 109

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? A. Have trouble falling asleep? B. Need to urinate during the night? C. Awaken abruptly during the night? D. Sleep more than 8 hours per night? E. Need to sleep with the head elevated?

Answer 109

A. C. E. The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

Question 110

``` What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? A. Chest excursion B. Spinal curvatures C. Respiratory pattern D. Fingernails and their base ```

Answer 110

D. Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger

Question 111

``` The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes ```

Answer 111

B. After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

Question 112

``` A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A. Thoracentesis B. Pulmonary angiogram C. CT scan of the patient's chest D. Positron emission tomography (PET) ```

Answer 112

D. PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

Question 113

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? A. Monitor the patient for laryngeal edema. B. Assess the patient's level of consciousness. C. Monitor and manage the patient's level of pain. D. Assess the patient's heart rate and blood pressure.

Answer 113

A. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

Question 114

``` After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? A. Bronchospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis ```

Answer 114

B. Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

Question 115

``` The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? A. Pain B. Atelectasis C. Pneumonia D. Pleural effusion ```

Answer 115

B. Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

Question 116

The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? A. Restlessness, tachypnea, tachycardia, and diaphoresis B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis C. Combativeness, retractions with breathing, cyanosis, and decreased output D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

Answer 116

A. With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.

Question 117

``` When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? A. Vomiting B. Increased urination C. Decreased heart rate D. Rapid respiratory rate ```

Answer 117

D. When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

Question 118

After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? A. Decreased response to hypercapnia B. Decreased number of functional alveoli C. Increased calcification of costal cartilage D. Decreased respiratory defense mechanisms

Answer 118

D. These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.

Question 119

``` The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases D. Pulmonary function tests ```

Answer 119

C. Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators

Question 120

``` The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? A. Stridor B. Rhonchi C. Coarse crackles D. Bronchovesicular ```

Answer 120

C. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

Question 121

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? A. Cough sound, sputum production, pattern B. Frequency, a family history, hematemesis C. Smoking, medications, residence location D. Weight loss, activity tolerance, orthopnea

Answer 121

A. The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.

Question 122

``` During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? A. Trachea moved to the left B. Increased tactile fremitus C. Decreased tactile fremitus D. Diminished chest movement ```

Answer 122

A. Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

Question 123

``` The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? A. Motion B. Anemia C. Dark skin color D. Thick acrylic nails ```

Answer 123

A. Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

Question 124

``` In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? A. Cyanosis B. Tripod position C. Kussmaul respirations D. Accessory muscle use E. Increased AP diameter ```

Answer 124

B. D. Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age.

Question 125

The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? A. Test the drainage for the presence of glucose. B. Suction the nose to maintain airway clearance. C. Document the findings and continue monitoring. D. Apply a drip pad and reassure the patient this is normal.

Answer 125

A. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

Question 126

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply)? A. Tilt patient's head backwards. B. Apply ice compresses to the nose. C. Tilt head forward while lying down. D. Pinch the entire soft lower portion of the nose. E. Partially insert a small gauze pad into the bleeding nostril.

Answer 126

B. D. First aid measures to control epistaxis include placing the patient in a sitting position, leaning forward. Pinching the soft lower portion of the nose or inserting a small gauze pad into the bleeding nostril should stop the bleeding within 15 minutes. Tilting the head back or forward does not stop the bleeding, but rather allows the blood to enter the nasopharynx, which could result in aspiration or nausea/vomiting from swallowing blood. Lying down also will not decrease the bleeding.

Question 127

``` When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? A. Patient comfort B. Airway patency C. Incisional drainage D. Blood pressure and heart rate ```

Answer 127

B. Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

Question 128

``` When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin? A. Cola B. Applesauce C. French fries D. White grape juice ```

Answer 128

A. When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice with which to start.

Question 129

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? A. Hypersensitivity to eggs B. Age greater than 80 years C. History of upper respiratory infections D. Chronic obstructive pulmonary disease (COPD)

Answer 129

A. Although current vaccines are highly purified, and reactions are extremely uncommon, a hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

Question 130

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure

Answer 130

B. Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

Question 131

What is the priority nursing assessment in the care of a patient who has a tracheostomy? A. Electrolyte levels and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

Answer 131

C. The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

Question 132

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? A. Suction the tracheostomy opening. B. Maintain the airway with a sterile hemostat. C. Use an Ambu bag and mask to ventilate the patient. D. Insert the tracheostomy tube obturator into the stoma.

Answer 132

B. As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

Question 133

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? A. Apply an external splint to the nose. B. Insert plastic nasal implant surgically. C. Humidify the air for mouth breathing. D. Maintain surgical packing in the nose.

Answer 133

D. A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

Question 134

``` The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply)? A. Cover the nose when coughing. B. Obtain an influenza vaccination. C. Stay at home when symptomatic. D. Drink non-caffeinated fluids daily. E. Obtain antibiotic therapy promptly. ```

Answer 134

A. B. C. Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

Question 135

``` The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? A. Coughing B. Fever, chills C. Dust allergy D. Maxillary pain ```

Answer 135

D. The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.

Question 136

``` The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect? A. Nasal packing B. Epistaxis balloon C. Gastrostomy tube D. Peripheral skin care ```

Answer 136

C. Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.

Question 137

A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? A. Bilateral erythema of especially large tonsils B. Temperature 102.2° F, diaphoresis, and chills C. Contraction of neck muscles during inspiration D. β-hemolytic streptococcus in the throat culture

Answer 137

C. Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

Question 138

``` The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? A. Electromyograph B. Intraoral electrolarynx C. Neck type electrolarynx D. Transesophageal puncture ```

Answer 138

D. The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs, vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

Question 139

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? A. Maintain adequate fluid intake. B. Splint the chest when coughing. C. Maintain a 30-degree elevation. D. Maintain a semi-Fowler's position. E. Instruct patient to cough at end of exhalation.*

Answer 139

A. B. E. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

Question 140

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions

Answer 140

A. Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

Question 141

``` Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Respiratory rate of 28 C. Oxygen saturation of 85% D. Presence of greenish sputum ```

Answer 141

A. The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.

Question 142

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

Answer 142

C. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

Question 143

What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer cough suppressant q4hr. C. Teach patient to splint the affected area. D. Increase fluid intake to 3 L/day if tolerated.

Answer 143

D. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

Question 144

``` During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guérin (BCG) ```

Answer 144

A. The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent.

Question 145

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

Answer 145

D. The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

Question 146

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM

Answer 146

B. The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

Question 147

``` During admission of a patient diagnosed with non–small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? A. Asbestos exposure B. Exposure to uranium C. Chronic interstitial fibrosis D. History of cigarette smoking E. Geographic area in which he was born ```

Answer 147

A. B. D. Non–small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk, but not necessarily where the patient was born.

Question 148

What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on right side B. Maintaining adequate fluid intake C. Positioning patient with "good lung" down D. Performing postural drainage every 4 hours

Answer 148

C. Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

Question 149

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? A. Perform a comprehensive health history with the patient to review prior respiratory problems. B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Answer 149

D. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.

Question 150

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of A. cough reflex. B. mucociliary clearance. C. reflex bronchoconstriction. D. ability to filter particles from the air.

Answer 150

B. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

Question 151

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? A. Continue with ambulation since this is a normal response to activity. B. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

Answer 151

C. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

Question 152

``` When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? A. Obesity B. Pneumonia C. Malignancy D. Cigarette smoking E. Prolonged air travel ```

Answer 152

A. C. D. E. An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

Question 153

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? A. Notify the physician. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

Answer 153

D. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

Question 154

``` When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant ```

Answer 154

A. Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

Question 155

The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says, A. "I will be given amphotericin B to treat the fungus." B. "I got this fungus because I am immunocompromised." C. "I need to be isolated from my family and friends so they won't get it." D. "The effectiveness of my therapy can be monitored with fungal serology titers."

Answer 155

C. The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

Question 156

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? A. The patient has lung cancer. B. The incision will be medial sternal or lateral. C. Chest tubes will not be needed postoperatively. D. Less discomfort and faster return to normal activity

Answer 156

D. The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

Question 157

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? A. Lobectomy surgery is usually needed to drain the abscess. B. IV antibiotic therapy will be used for a prolonged period of time. C. Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. D. No further culture and sensitivity tests are needed if the patient takes the medication as ordered.

Answer 157

C. IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

Question 158

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

Answer 158

C. If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

Question 159

``` The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? A. Pulmonary infarction B. Pulmonary hypertension C. Cytomegalovirus (CMV) D. Bronchiolitis obliterans (BOS) ```

Answer 159

D. Bronchiolitis obliterans (BOS) is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.

Question 160

``` During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? A. Laryngospasm B. Pulmonary edema C. Narrowing of the airway D. Overdistention of the alveoli ```

Answer 160

C. Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing.

Question 161

``` A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? A. Anxiety B. Cyanosis C. Bradycardia D. Hypercapnia ```

Answer 161

A. An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

Question 162

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Allow time to calm the patient. B. Observe for signs of diaphoresis. C. Evaluate the use of intercostal muscles. D. Monitor the patient for bilateral chest expansion.

Answer 162

C. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.

Question 163

``` Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? A. Supine B. Lithotomy C. High Fowler's D. Reverse Trendelenburg ```

Answer 163

C. The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation

Question 164

The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? A. Wheezing becomes louder. B. Cough remains nonproductive. C. Vesicular breath sounds decrease. D. Aerosol bronchodilators stimulate coughing.

Answer 164

A. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.

Question 165

``` The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? A. Work of breathing B. Fear of suffocation C. Effects of medications D. Anxiety and restlessness ```

Answer 165

A. When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.

Question 166

``` The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? A. IV fluids B. Biofeedback therapy C. Systemic corticosteroids D. Pulmonary function testing ```

Answer 166

C. Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used, but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma

Question 167

``` A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? A. Oxygen tent B. Venturi mask C. Nasal cannula D. Oxygen-conserving cannula ```

Answer 167

B. The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered

Question 168

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? A. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. B. Use the flow meter each morning after taking medications to evaluate their effectiveness. C. Increase the doses of the long-term control medication if the peak flow numbers decrease. D. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

Answer 168

A. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.

Question 169

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." B. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." C. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." D. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

Answer 169

A. The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

Question 170

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after what occurs? A. Hypertension and pulmonary edema B. Oropharyngeal candidiasis and hoarseness C. Elevation of blood glucose and calcium levels D. Adrenocortical dysfunction and hyperglycemia

Answer 170

B. Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

Question 171

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? A. "I will pay less for medication because it will last longer." B. "More of the medication will get down into my lungs to help my breathing." C. "Now I will not need to breathe in as deeply when taking the inhaler medications." D. "This device will make it so much easier and faster to take my inhaled medications."

Answer 171

B. A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler

Question 172

Which test result identifies that a patient with asthma is responding to treatment? A. An increase in CO2 levels B. A decreased exhaled nitric oxide C. A decrease in white blood cell count D. An increase in serum bicarbonate levels

Answer 172

B. Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in the asthma patient.

Question 173

``` The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? A. Pulse rate of 72/minute B. Temperature of 98.4° F C. Oxygen saturation 96% D. Respiratory rate of 18/minute ```

Answer 173

A. Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 indicates that the patient did not experience tachycardia as an adverse effect.

Question 174

``` The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? A. Albuterol (Proventil) B. Salmeterol (Serevent) C. Beclomethasone (Qvar) D. Ipratropium bromide (Atrovent) ```

Answer 174

A. Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).

Question 175

``` The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? A. Apical pulse B. Daily weight C. Bowel sounds D. Deep tendon reflexes ```

Answer 175

B. Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.

Question 176

``` When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply)? A. Exercise B. Allergies C. Emotional stress D. Decreased humidity E. Upper respiratory infections ```

Answer 176

A.B.C.E. Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD).

Question 177

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? A. Chew a hard candy before the first puff of medication. B. Rinse the mouth with water before each puff of medication. C. Ask for a breath mint following the second puff of medication. D. Rinse the mouth with water following the second puff of medication.

Answer 177

D. Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

Question 178

The nurse is evaluating if a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? A. Place it in water to see if it floats. B. Keep track of the number of inhalations used. C. Shake the canister while holding it next to the ear D. Check the indicator line on the side of the canister.

Answer 178

B. It is no longer appropriate to see if a canister floats in water or not since this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used. (100 puffs/2 puffs each day = 50 days)

Question 179

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? A. An overproduction of the antiprotease α1 -antitrypsin B. Hyperinflation of alveoli and destruction of alveolar walls C. Hypertrophy and hyperplasia of goblet cells in the bronchi D. Collapse and hypoventilation of the terminal respiratory unit

Answer 179

B. In COPD there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

Question 180

``` A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? A. Arterial pH 7.26 B. PaCO2 50 mm Hg C. Patient in tripod position D. Increased sputum expectoration ```

Answer 180

A. The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.

Question 181

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which finding? A. Absence of dyspnea B. Improved mental status C. Effective and productive coughing D. PaO2 within normal range for the patient

Answer 181

C. Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.

Question 182

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? A. Order fruits and fruit juices to be offered between meals. B. Order a high-calorie, high-protein diet with six small meals a day. C. Teach the patient to use frozen meals at home that can be microwaved. D. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

Answer 182

B. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with non-protein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

Question 183

The nurse teaches pursed lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? A. Loosening secretions so that they may be coughed up more easily B. Promoting maximal inhalation for better oxygenation of the lungs C. Preventing bronchial collapse and air trapping in the lungs during exhalation D. Increasing the respiratory rate and giving the patient control of respiratory patterns

Answer 183

C. The purpose of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.

Question 184

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? A. Acute respiratory failure B. Secondary respiratory infection C. Fluid volume excess resulting from cor pulmonale D. Pulmonary edema caused by left-sided heart failure

Answer 184

C. Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

Question 185

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? A. "Long-term home oxygen therapy should be used to prevent respiratory failure." B. "Oxygen will not be needed until or unless you are in the terminal stages of this disease." C. "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." D. "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

Answer 185

D. Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.

Question 186

Before discharge, the nurse discusses activity levels with a 61-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? A. Slightly increase activity over the current level. B. Swim for 10 min/day, gradually increasing to 30 min/day. C. Limit exercise to activities of daily living to conserve energy. D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

Answer 186

D. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 – patient's age).

Question 187

``` The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which assessment finding? A. Decreased respiratory rate B. Increased respiratory rate C. Increased peak flow readings D. Decreased sputum production ```

Answer 187

C. Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates (PEFRs).

Question 188

The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? A. "Avoid shaking the inhaler before use." B. "Breathe out slowly before positioning the inhaler." C. "Using a spacer should be avoided for this type of medication." D. "After taking a puff, hold the breath for 30 seconds before exhaling."

Answer 188

B. It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.

Question 189

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? A. "I can rinse my mouth following the two puffs to get rid of the bad taste." B. "I should wait at least 1 to 2 minutes between each puff of the inhaler." C. "Because this medication is not fast-acting, I cannot use it in an emergency if my breathing gets worse." D. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

Answer 189

D. The patient should not just keep taking extra puffs of the inhaler to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status. Rinsing the mouth after the puffs will eliminate a bad taste. Waiting 1 to 2 minutes between each puff will facilitate the effectiveness of the administration. Ipratropium is not used in an emergency for COPD.

Question 190

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? A. Smoking causes a hoarse voice. B. Cough will become nonproductive. C. Decreased alveolar macrophage function D. Sense of smell is decreased with smoking.

Answer 190

C. The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.

Question 191

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? A. Fat soluble vitamins and dietary salt should be avoided. B. Insulin may be needed with a diabetic diet if diabetes mellitus develops. C. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. D. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

Answer 191

C. The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.

Question 192

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? A. Increasing dyspnea B. Temperature below 98.6° F C. Decreased sputum production D. Unable to drink 3 L low-sodium fluids

Answer 192

A. The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.