TEST 4: The Client with Respiratory Health Problems

Question 1

The Client with an Upper Respiratory Tract
Infection
1. A nurse is completing the health history for a client who has been taking echinacea for a head
cold. The client asks, “Why isn’t this helping me feel better?” Which of the following responses by
the nurse would be the most accurate?
1. “There is limited information as to the effectiveness of herbal products.”
2. “Antibiotics are the agents needed to treat a head cold.”
3. “The head cold should be gone within the month.”
4. “Combining herbal products with prescription antiviral medications is sure to help you.”

Answer 1

1. 1. At this time, there is no strong research evidence to warrant recommendations of herbal
      products for management of colds; further study is needed to show evidence of therapeutic effects and
      indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An
      uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-
      drug interaction with herbal products and prescriptions.
      CN: Basic care and comfort; CL: Synthesize

Question 2

2. A nurse is teaching a client about taking antihistamines. Which of the following instructions
   should the nurse include in the teaching plan? Select all that apply.
3. Operating machinery and driving may be dangerous while taking antihistamines.
4. Continue taking antihistamines even if nasal infection develops.
5. The effect of antihistamines is not felt until a day later.
6. Do not use alcohol with antihistamines.
7. Increase fluid intake to 2,000 mL/day.

Answer 2

2. 1, 4, 5. Antihistamines have an anticholinergic action and a drying effect and reduce nasal,
   salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect
   is drowsiness, so operating machinery and driving are not recommended. There is also an additive
   depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during
   antihistamine use. The client should ensure adequate fluid intake of at least eight glasses per day due
   to the drying effect of the drug. Antihistamines have no antibacterial action. The effect of
   antihistamines is prompt, not delayed.
   CN: Pharmacological and parenteral therapies; CL: Create

Question 3

3. A client with allergic rhinitis is instructed on the correct technique for using an intranasal
   inhaler. Which of the following statements would demonstrate to the nurse that the client understands
   the instructions?
4. “I should limit the use of the inhaler to early morning and bedtime use.”
5. “It is important to not shake the canister because that can damage the spray device.”
6. “I should hold one nostril closed while I insert the spray into the other nostril.”
7. “The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.”

Answer 3

3. 3. When using an intranasal inhaler, it is important to close off one nostril while inhaling the
      spray into the other nostril to ensure the best inhalation of the spray. Use of the inhaler is not limited
      to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip
      should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation
      of the medication.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 4

4. Which of the following would be an expected outcome for a client recovering from an upper
   respiratory tract infection? The client will:
5. Maintain a fluid intake of 800 mL every 24 hours.
6. Experience chills only once a day.
7. Cough productively without chest discomfort.
8. Experience less nasal obstruction and discharge.

Answer 4

4. 4. A client recovering from an upper respiratory tract infection should report decreasing or no
      nasal discharge and obstruction. Daily fluid intake should be increased to more than 1 L every 24
      hours to liquefy secretions. The temperature should be below 100°F (37.8°C) with no chills or
      diaphoresis. A productive cough with chest pain indicates a pulmonary infection, not an upper
      respiratory tract infection.
      CN: Physiological adaptation; CL: Evaluate

Question 5

5. The nurse teaches the client how to instill nose drops. Which of the following techniques is
   correct?
6. The client uses sterile technique when handling the dropper.
7. The client blows the nose gently before instilling drops.
8. The client uses a new dropper for each instillation.
9. The client sits in a semi-Fowler’s position with the head tilted forward after administration of
   the drops.

Answer 5

5. 2. The client should blow the nose before instilling nose drops. Instilling nose drops is a clean
      technique. The dropper should be cleaned after each administration, but it does not need to be
      changed. The client should assume a position that will allow the medication to reach the desired area;
      this is usually a supine position.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 6

6. The nurse should include which of the following instructions in the teaching plan for a client
   with chronic sinusitis?
7. Avoid the use of caffeinated beverages.
8. Perform postural drainage every day.3. Take hot showers twice daily.
9. Report a temperature of 102°F (38.9°C) or higher.

Answer 6

6. 3. The client with chronic sinusitis should be instructed to take hot showers in the morning and
      evening to promote drainage of secretions. There is no need to limit caffeine intake. Performing
      postural drainage will inhibit removal of secretions, not promote it. Clients should elevate the head of
      the bed to promote drainage. Clients should report all temperatures higher than 100.4°F (38°C),
      because a temperature that high can indicate infection.
      CN: Reduction of risk potential; CL: Synthesize

Question 7

7. A client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea. Which of
   the following instructions would be appropriate for the nurse to give the client?
8. “Use your nasal decongestant spray regularly to help clear your nasal passages.”
9. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
10. “It is important to increase your activity. A daily brisk walk will help promote drainage.”
11. “Keep a diary of when your symptoms occur. This can help you identify what precipitates your
    attacks.”

Answer 7

7. 4. It is important for clients with allergic rhinitis to determine the precipitating factors so that
      they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays
      should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate
      for allergic rhinitis because an infection is not present. Increasing activity will not control the client’s
      symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen.
      CN: Health promotion and maintenance; CL: Synthesize

Question 8

9. Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of
   the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
   _______________________ mL.

Answer 8

8. 7.5 mL

300 mg / x = 200 mg / 5 mml
x = 7.5 ml

CN: Pharmacological and parenteral therapies; CL: Apply

Question 9

9. Pseudoephedrine (Sudafed) has been prescribed as a nasal decongestant. Which of the
   following is a possible adverse effect of this drug?
10. Constipation.
11. Bradycardia.
12. Diplopia.
13. Restlessness.

Answer 9

9. 4. Adverse effects of pseudoephedrine (Sudafed) are experienced primarily in the
      cardiovascular system and through sympathetic effects on the central nervous system (CNS). The most
      common CNS adverse effects include restlessness, dizziness, tension, anxiety, insomnia, and
      weakness. Common cardiovascular adverse effects include tachycardia, hypertension, palpitations,
      and arrhythmias. Constipation and diplopia are not adverse effects of pseudoephedrine. Tachycardia,
      not bradycardia, is an adverse effect of pseudoephedrine.
      CN: Pharmacological and parenteral therapies; CL: Analyze

Question 10

The Client Undergoing Nasal Surgery
10. A health care provider has just inserted nasal packing for a client with epistaxis. The client is
taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
1. Use 81 mg of aspirin daily for relief of discomfort.
2. Omit the next dose of ramipril (Altace).
3. Remove the packing if there is difficulty swallowing.
4. Avoid rigorous aerobic exercise.

Answer 10

The Client Undergoing Nasal Surgery
10. 4. Epistaxis, or nosebleed, is a common, sudden emergency. Commonly, no apparent
explanation for the bleeding is known. With significant blood loss, systemic symptoms, such as
vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur.
Because aerobic exercise may increase blood pressure and increased blood pressure can cause
epistaxis, the client with hypertension should avoid it. Aspirin inhibits platelet aggregation, reducing
the ability of the blood to clot. The client should continue to take his antihypertension medication,
ramipril (Altace). Posterior nasal packing should be left in place for 1 to 3 days.
CN: Health promotion and maintenance; CL: Synthesize

Question 11

11. A client has had surgery for a deviated nasal septum. Which of the following would indicate
    that bleeding was occurring even if the nasal drip pad remained dry and intact?
12. Nausea.
13. Repeated swallowing.
14. Increased respiratory rate.
15. Increased pain.

Answer 11

11. 2. Because of the dense nasal packing, bleeding may not be apparent through the nasal drip
       pad. Instead, the blood may run down the throat, causing the client to swallow frequently. The back of
       the throat, where the blood will be apparent, can be assessed with a flashlight. An accumulation of
       blood in the stomach can cause nausea and vomiting, but nausea would not be the initial indicator of
       bleeding. An increased respiratory rate occurs in shock but is not an early sign of bleeding in a client
       who has undergone nasal surgery. Increased pain warrants further assessment but is not an indicator
       of bleeding.
       CN: Reduction of risk potential; CL: Analyze

Question 12

12. A client who has undergone outpatient nasal surgery is ready for discharge and has nasal
    packing in place. Which of the following discharge instructions would be appropriate for the client?
13. Avoid activities that elicit the Valsalva maneuver.
14. Take aspirin to control nasal discomfort.
15. Avoid brushing the teeth until the nasal packing is removed.
16. Apply heat to the nasal area to control swelling.

Answer 12

12. 1. The client should be instructed to avoid any activities that cause Valsalva’s maneuver (eg,constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture lines. The
       client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral
       hygiene is important to rid the mouth of old dried blood and to enhance the client’s appetite. Cool
       compresses, not heat, should be applied to decrease swelling and control discoloration of the area.
       CN: Physiological adaptation; CL: Create

Question 13

13. Which of the following statements should indicate to the nurse that a client has understood the
    discharge instructions provided after nasal surgery?
14. “I should not shower until my packing is removed.”
15. “I will take stool softeners and modify my diet to prevent constipation.”
16. “Coughing every 2 hours is important to prevent respiratory complications.”
17. “It is important to blow my nose each day to remove the dried secretions.”

Answer 13

13. 2. Constipation can cause straining during defecation, which can induce bleeding. Showering
       is not contraindicated. The client should take measures to prevent coughing, which can cause
       bleeding. The client should avoid blowing the nose for 48 hours after the packing is removed.
       Thereafter, the client should blow the nose gently, using the open-mouth technique to minimize
       bleeding in the surgical area.
       CN: Physiological adaptation; CL: Evaluate

Question 14

14. The nurse is planning to give preoperative instructions to a client who will be undergoing
    rhinoplasty. Which of the following instructions should be included?
15. After surgery, nasal packing will be in place for 7 to 10 days.
16. Normal saline nose drops will need to be administered preoperatively.
17. The results of the surgery will be immediately obvious postoperatively.
18. Aspirin-containing medications should not be taken for 2 weeks before surgery.

Answer 14

14. 4. Aspirin-containing medications should be discontinued for 2 weeks before surgery to
       decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline
       nose drops are not routinely administered preoperatively. The results of the surgery will not be
       obvious immediately after surgery because of edema and ecchymosis.
       CN: Reduction of risk potential; CL: Create

Question 15

15. Which of the following assessments is a priority immediately after nasal surgery?
16. Assessing the client’s pain.
17. Inspecting for periorbital ecchymosis.
18. Assessing respiratory status.
19. Measuring intake and output.

Answer 15

15. 3. Immediately after nasal surgery, ineffective breathing patterns may develop as a result of
       the nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing for
       airway obstruction is a priority. Assessing for pain is important, but it is not as high a priority as
       assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not
       typically a priority nursing assessment after nasal surgery.
       CN: Physiological adaptation; CL: Analyze

Question 16

16. After nasal surgery, the client expresses concern about how to decrease facial pain and
    swelling while recovering at home. Which of the following discharge instructions would be most
    effective for decreasing pain and edema?
17. Take analgesics every 4 hours around the clock.2. Use corticosteroid nasal spray as needed to control symptoms.
18. Use a bedside humidifier while sleeping.
19. Apply cold compresses to the area.

Answer 16

16. 4. Applying cold compresses helps to decrease facial swelling and pain from edema.
       Analgesics may decrease pain, but they do not decrease edema. A corticosteroid nasal spray would
       not be administered postoperatively because it can impair healing. Use of a bedside humidifier
       promotes comfort by providing moisture for nasal mucosa, but it does not decrease edema.
       CN: Basic care and comfort; CL: Synthesize

Question 17

17. A client is being discharged with nasal packing in place. The nurse should instruct the client
to:
1. Perform frequent mouth care.
2. Use normal saline nose drops daily.
3. Sneeze and cough with mouth closed.
4. Gargle every 4 hours with salt water.

Answer 17

17. 1. Frequent mouth care is important to provide comfort and encourage eating. Mouth care
       promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When
       sneezing and coughing, the client should do so with the mouth open to decrease the chance of
       dislodging the packing. Gargling should not be attempted with packing in place.
       CN: Basic care and comfort; CL: Create

Question 18

18. Which of the following activities should the nurse teach the client to implement after the
    removal of nasal packing on the 2nd postoperative day?
19. Avoid cleaning the nares until swelling has subsided.
20. Apply water-soluble jelly to lubricate the nares.
21. Keep a nasal drip pad in place to absorb secretions.
22. Use a bulb syringe to gently irrigate nares.

Answer 18

18. 2. After removal of nasal packing, the client should be instructed to apply water-soluble jelly
       to the nares to lubricate the nares and promote comfort. Swelling gradually subsides over several
       weeks; the client can gently clean the nares as soon as packing is removed. A nasal drip pad is not
       needed after removal of packing. Irrigation with a bulb syringe may interfere with healing and
       introduce infection.
       CN: Basic care and comfort; CL: Synthesize

Question 19

19. The nurse is teaching a client how to manage a nosebleed. Which of the following
    instructions would be appropriate to give the client?
20. “Tilt your head backward and pinch your nose.”
21. “Lie down flat and place an ice compress over the bridge of the nose.”
22. “Blow your nose gently with your neck flexed.”
23. “Sit down, lean forward, and pinch the soft portion of your nose.”

Answer 19

19. 4. The client should assume a sitting position and lean forward. Firm pressure should be
       applied to the soft portion of the nose for approximately 10 minutes. Tilting the head backward cancause the client to swallow blood, which can obscure the amount of bleeding and also can lead to
       nausea. Ice compresses may be applied, but the client should not lie flat. Blowing the nose is to be
       avoided because it can increase bleeding.
       CN: Reduction of risk potential; CL: Synthesize

Question 20

20. An elderly client had posterior packing inserted to control a severe nosebleed. After
    insertion of the packing, the client should be closely monitored for which of the following
    complications?
21. Vertigo.
22. Bell’s palsy.
23. Hypoventilation.
24. Loss of gag reflex.

Answer 20

20. 3. Posterior packing may alter the respiratory status of the client, especially in elderly clients,
       causing hypoventilation. Clients should be observed carefully for changes in level of consciousness,
       respiratory rate, and heart rate and rhythm after the insertion of the packing. Vertigo does not occur as
       a result of the insertion of posterior packing. Bell’s palsy, a disorder of the seventh cranial nerve, is
       not associated with epistaxis or nasal packing. Loss of gag reflex does not occur as a result of the
       insertion of posterior packing.
       CN: Reduction of risk potential; CL: Analyze

Question 21

The Client with Cancer of the Larynx
21. Postoperative nursing management of the client following a radical neck dissection for
laryngeal cancer requires:
1. Complete bed rest minimizing head movement.
2. Vital signs once a shift.
3. Clear liquid diet started at 48 hours.
4. Frequent suctioning of the laryngectomy tube.

Answer 21

The Client with Cancer of the Larynx
21. 4. The nurse must maintain patency of the airway with frequent suctioning of the laryngectomy
tube that can become occluded from secretions, blood, and mucus plugs. Once the client is
hemodynamically stable, getting out of bed should be encouraged to prevent postoperative
complications. Vital signs should be monitored more frequently in a postoperative client. A swallow
study is done at approximately 5 to 7 days after surgery, prior to starting oral intake.
CN: Physiological adaptation; CL: Synthesize

Question 22

22. A client who has had a total laryngectomy appears withdrawn and depressed. The client
    keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing
    intervention would most likely be therapeutic for the client?
23. Discussing the behavior with the spouse to determine the cause.
24. Exploring future plans.
25. Respecting the need for privacy.
26. Encouraging expression of feelings nonverbally and in writing.

Answer 22

22. 4. The client has undergone body changes and permanent loss of verbal communication. He
       may feel isolated and insecure. The nurse can encourage him to express his feelings and use this
       information to develop an appropriate plan of care. Discussing the client’s behavior with his wife
       may not reveal his feelings. Exploring future plans is not appropriate at this time because more
       information about the client’s behavior is needed before proceeding to this level. The nurse can
       respect the client’s need for privacy while also encouraging him to express his feelings.
       CN: Psychosocial adaptation; CL: Synthesize

Question 23

23. The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of
    time the nurse should suction the client?
24. 10 seconds.
25. 15 seconds.
26. 25 seconds.
27. 30 seconds.

Answer 23

23. 1. A client should be suctioned for no longer than 10 seconds at a time. Suctioning for longer
       than 10 seconds may reduce the client’s oxygen level so much that he becomes hypoxic.
       CN: Reduction of risk potential; CL: Apply

Question 24

24. When suctioning a tracheostomy tube 3 days following insertion, the nurse should follow
    which of the following procedures?
25. Use a sterile catheter each time the client is suctioned.
26. Clean the catheter in sterile water after each use and reuse for no longer than 8 hours.
27. Protect the catheter in sterile packaging between suctioning episodes.
28. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.

Answer 24

24. 1. The recommended technique is to use a sterile catheter each time the client is suctioned.
       There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is
       not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a
       clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.
       CN: Reduction of risk potential; CL: Apply

Question 25

25. The client with a laryngectomy does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. The nurse should: 1. Initiate teaching about the care of a stoma. 2. Explain that the stoma will not always look as it does now. 3. Inform the client of the benefits of family support at this time. 4. Explore why the client believes the stoma is “disgusting.”

Answer 25

25. 4. Changes in body image are expected after a laryngectomy, and the nurse should first explore what is upsetting the client the most at this time. Many clients are concerned about how their family members will respond to the physical changes that have occurred as a result of a laryngectomy, but discussing the importance of family support is not helpful; instead, the nurse should allow the client to communicate any negative feelings or concerns that exist because of the surgery. The client's feelings are not related to a knowledge deficit, and therefore, it is too early to begin teaching about stoma care. It is also not helpful to offer reassurances about the change in appearance; the client will requiretime to adjust to the changed body image. CN: Psychosocial adaptation; CL: Synthesize

Question 26

26. The nurse is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure below). The nursing policy manual recommends use of the gauze pad. The nurse should:1. Make sure the gauze pad is dry and the client is in a comfortable position. 2. Ask the nursing assistant to tie the tracheostomy tube ties in the back of the client's neck. 3. Reposition the gauze pad around the stoma with the open end downward. 4. Ask a registered nurse to change the ties and position another gauze pad around the stoma.

Answer 26

26. 1. The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad. CN: Basic care and comfort; CL: Evaluate

Question 27

27. What areas of education should the nurse provide employees in a factory making products that cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply. 1. Stopping smoking. 2. Using a HEPA filter in the home. 3. Limiting alcohol intake. 4. Brushing teeth after every meal. 5. Avoiding raising the voice to be heard over the noise in the factory.

Answer 27

27. 1, 3. The primary risk factors for laryngeal cancer are smoking and alcohol abuse. Smoking cessation is most successful with a support group or counseling. Heavy drinking should be avoided since the risk increases with amount of alcohol consumption. HEPA filters help trap small particles and allergens to reduce allergy symptoms and asthma. Poor oral hygiene is not a risk factor, nor is overusing the voice. CN: Health promotion and maintenance; CL: Create

Question 28

28. A client has had hoarseness for more than 2 weeks. The nurse should: 1. Refer the client to a health care provider for a prescription for an antibiotic. 2. Instruct the client to gargle with salt water at home. 3. Assess the client for dysphagia. 4. Instruct the client to take a throat analgesic.

Answer 28

28. 3. Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat. CN: Physiological adaptation; CL: Synthesize

Question 29

29. A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care? 1. Maintain the head of the bed at 30 to 40 degrees. 2. Teach the client how to use esophageal speech. 3. Initiate small feedings of soft foods. 4. Irrigate drainage tubes as needed.

Answer 29

29. 1. Immediately after surgery, the client should be maintained in a position with the head of the bed elevated 30 to 40 degrees (semi-Fowler's position) to decrease tissue edema, facilitate breathing, and decrease pain related to edema formation. Immediately postoperatively, the client should be provided alternative means of communicating, such as a communication board. As healing progresses and edema subsides, a speech therapist should work with the client to explore various voice restoration options, such as the use of a voice prosthesis, electrolarynx, artificial larynx, or esophageal speech. Food is not initiated in the immediate postoperative phase; enteral feedings are usually used to meet nutritional needs until edema subsides. Irrigation of the drainage tubes is an inappropriate action. CN: Basic care and comfort; CL: Synthesize

Question 30

30. Which of the following is an expected outcome for a client recovering from a total laryngectomy? The client will: 1. Regain the ability to taste and smell food. 2. Demonstrate appropriate care of the gastrostomy tube. 3. Communicate feelings about body image changes. 4. Demonstrate sterile suctioning technique for stoma care.

Answer 30

30. 3. It is important that the client be able to communicate his or her feelings about the body image changes that have occurred as a result of surgery. Open communication helps promote adjustment. The client may not regain the ability to taste and smell food because of no longer breathing through the nose or because of radiation therapy treatments, or both. A gastrostomy tube would not typically be placed after a total laryngectomy, nor would it be necessary for the client to demonstrate sterile suctioning technique for stoma care. The client would use clean technique. CN: Physiological adaptation; CL: Evaluate

Question 31

31. Which of the following home care instructions would be appropriate for a client with a laryngectomy?1. Perform mouth care every morning and evening. 2. Provide adequate humidity in the home. 3. Maintain a soft, bland diet. 4. Limit physical activity to shoulder and neck exercises.

Answer 31

31. 2. Adequate humidity should be provided in the home to help keep secretions moist. A bedside humidifier is recommended. A high fluid intake is also important to liquefy secretions. Mouth care is important to prevent drying of mucous membranes and should be performed frequentlythroughout the day, especially before and after meals, to help stimulate appetite. The client may eat any food that can be chewed and swallowed comfortably. The client may resume physical activity as tolerated. CN: Reduction of risk potential; CL: Synthesize

Question 32

32. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority in what order the nurse would assess these clients after receiving report. 1. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath. 2. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain. 3. A 35-year-old client with suspected tuberculosis who has a cough. 4. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.

Answer 32

32. 1. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath. 2. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain. 4. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress. 3. A 35-year-old client with suspected tuberculosis who has a cough. The elderly client with pneumonia, an elevated temperature, and shortness of breath is the most acutely ill client described and should be the client with the highest priority. The elevated temperature and the shortness of breath can lead to a decrease in the client's oxygen levels, and can predispose the client to dehydration and confusion. Then the nurse should assess the client with the thoracotomy who is requesting pain medication and administer any needed medication. The client with emphysema should be the next priority so that the bronchodilator can be administered on schedule as close as possible. The nurse would then assess the client with suspected tuberculosis and a cough. CN: Management of care; CL: Synthesize

Question 33

The Client with Pneumonia 33. An elderly client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. The nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? 1. Perform circulation checks to bilateral upper extremities each shift. 2. Attach the ties of the restraints to the bedframe. 3. Reevaluate the need for restraints and document weekly. 4. Ensure the restraint order has been signed by the physician within 72 hours.

Answer 33

The Client with Pneumonia 33. 2. Restraints should be secured to the bedframe, not the siderails, to ensure that the siderails can be raised and lowered safely. Circulation checks, re-evaluating need for restraints, and documentation should be done every 1 to 2 hours. Medical restraint prescriptions must be renewed and signed by a physician every 24 hours. CN: Safety and infection control; CL: Synthesize

Question 34

34. A 79-year-old client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia? 1. Age. 2. Osteoarthritis. 3. Vegetarian diet. 4. Daily bathing.

Answer 34

34. 1. The client's age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia. CN: Reduction of risk potential; CL: Analyze

Question 35

``` 35. Which of the following are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Quality of breath sounds. 2. Presence of bowel sounds. 3. Occurrence of chest pain. 4. Amount of peripheral edema. 5. Color of nail beds. ```

Answer 35

35. 1, 3, 5. A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chestpain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia. CN: Physiological adaptation; CL: Analyze

Question 36

36. A client with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? 1. Urinalysis. 2. Sputum culture. 3. Chest radiograph. 4. Red blood cell count.

Answer 36

36. 2. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Urinalysis, a chest radiograph, and a red blood cell count do not need to be obtained before initiation of antibiotic therapy for pneumonia. CN: Reduction of risk potential; CL: Apply

Question 37

37. When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values? 1. Serum sodium. 2. Serum potassium. 3. Serum creatinine. 4. Serum calcium.

Answer 37

37. 3. It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 38

38. Penicillin has been prescribed for a client admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the client: 1. “Do you have a history of seizures?” 2. “Do you have any cardiac history?” 3. “Have you had any recent infections?” 4. “Have you had a previous allergy to penicillin?”

Answer 38

38. . 4. The nurse should determine if the client is allergic to penicillin prior to administering the drug. History of seizures, recent infections, and a cardiac history are not contraindications to for this client for receiving penicillin. While important to know, recent infections will not preclude this client receiving penicillin at this time. CN: Pharmacological and Parenteral Therapies; CL: Apply

Question 39

39. A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? 1. Position changes every 4 hours. 2. Nasotracheal suctioning to clear secretions. 3. Frequent linen changes. 4. Frequent offering of a bedpan.

Answer 39

39. 3. Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario. CN: Basic care and comfort; CL: Synthesize

Question 40

40. Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's: 1. Decreased cellular demand for oxygen. 2. Reduced episodes of coughing. 3. Diminished pain when breathing deeply. 4. Ability to expectorate secretions more easily.

Answer 40

40. 1. Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body's need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths. CN: Physiological adaptation; CL: Evaluate

Question 41

``` 41. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? 1. Decreased cardiac output. 2. Pleural effusion. 3. Inadequate peripheral circulation. 4. Decreased oxygenation of the blood. ```

Answer 41

41. 4. A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia. CN: Physiological adaptation; CL: Analyze

Question 42

42. A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: 1. A mild but constant aching in the chest. 2. Severe midsternal pain. 3. Moderate pain that worsens on inspiration. 4. Muscle spasm pain that accompanies coughing.

Answer 42

42. 3. Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest painis usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm. CN: Physiological adaptation; CL: Analyze

Question 43

43. Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? 1. Encourage the client to breathe shallowly. 2. Have the client practice abdominal breathing. 3. Offer the client incentive spirometry. 4. Teach the client to splint the rib cage when coughing.

Answer 43

43. 4. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain. CN: Physiological adaptation; CL: Synthesize

Question 44

44. The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which of the following? Select all that apply. 1. Decreased pain when breathing. 2. Prolonged clotting time. 3. Decreased temperature. 4. Decreased respiratory rate. 5. Increased ability to expectorate secretions.

Answer 44

44. 1, 3. Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate and does not facilitate expectoration of secretions. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 45

``` 45. Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? 1. Coma. 2. Apathy.3. Irritability. 4. Depression. ```

Answer 45

45. 3. Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia. CN: Physiological adaptation; CL: Analyze

Question 46

46. The client with pneumonia develops mild constipation, and the nurse administers docusate sodium (Colace) as prescribed. This drug works by: 1. Softening the stool. 2. Lubricating the stool. 3. Increasing stool bulk. 4. Stimulating peristalsis.

Answer 46

46. 1. Docusate sodium (Colace) is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis. CN: Pharmacological and parenteral therapies; CL: Apply

Question 47

47. The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should do which of the following? Select all that apply. VITAL SIGNS ``` 8 AM 38.3 C 90 BPM 16 CPM 112/74 MMHG 93% ``` ``` 10 AM - 104 BPM 18 CPM 110/68 MMHG 92% ``` ``` 12 PM 38.8 C 118 BPM 24 CPM 116/78 MMHG 92% ``` 1. Assure the client is maintaining complete bed rest. 2. Check the urine output. 3. Ask the client to drink more fluids. 4. Notify the physician. 5. Administer acetaminophen (Tylenol) as prescribed.

Answer 47

47. 2, 3, 5. A client with pneumonia experiencing diaphoresis is at risk for dehydration and increased temperature and heart rate. The fluid status, intake, and urine output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume deficit may also increase the heart rate. The underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and increased intake of fluids. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety. It is not necessary to notify the physician. CN: Physiological adaptation; CL: Synthesize

Question 48

48. Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? 1. A respiratory rate of 25 to 30 breaths/min. 2. The ability to perform activities of daily living without dyspnea. 3. A maximum loss of 5 to 10 lb (2.27 to 4.53 kg) of body weight. 4. Chest pain that is minimized by splinting the rib cage.

Answer 48

48. 2. An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2.27 to 4.53 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain. CN: Management of care; CL: Evaluate

Question 49

The Client with Tuberculosis 49. A client newly diagnosed with tuberculosis (TB) is being admitted with the prescription for “isolation precautions for tuberculosis.” The nurse should assign the client to which type of room? 1. A room at the end of the hall for privacy. 2. A private room to implement airborne precautions. 3. A room near the nurses' station to ensure confidentiality. 4. A room with windows to allow sunlight

Answer 49

The Client with Tuberculosis49. 1. Implementing airborne precautions for possible TB requires a private room assignment. In addition to isolating the client by using a private room, engineering controls can help prevent the spread of TB; a room at the end of the hall will aid in controlling airflow direction and can prevent contamination of air in adjacent areas. Confidentiality is provided for every client, regardless of the client's room location. Sunlight is not a component of isolation precautions. CN: Physiological adaptation; CL: Apply

Question 50

50. Which of the following symptoms is common in clients with active tuberculosis? 1. Weight loss. 2. Increased appetite. 3. Dyspnea on exertion. 4. Mental status changes.

Answer 50

50. 1. Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis. CN: Physiological adaptation; CL: Analyze

Question 51

``` The nurse is reviewing the history and physical and physician prescriptions on the chart of a newly admitted client. HISTORY AND PHYSICAL TAB SUBJECTIVE: 19-year old reports a constant cough for the past "few weeks" with "dark" sputum for the past few days. Has night sweats, 10-lb weight loss in the past monght, and "always" being tired. He took one Tylenol about an hour prior to arrival. OBJECTIVE: BP 120/64 HR 84/reg RESPI 26/unlabored/slight wheezing in right lower lobe posteriorly O2 SAT 92% TEMP 99.9 F (37.7) SKIN Warm, slightly diaphoretic NONPRODUCTIVE COUGH AT THIS TIME ``` ASSESSMENT: Possible respiratory infection PHYSICIAN PRESCRIPTION TAB ---- CHEST XRAY SPUTUM SPECIMEN OXYGEN AT 2L PER NASAL CANNULA The nurse should first: 1. Initiate airborne precautions. 2. Apply oxygen at 2 L per nasal cannula. 3. Collect a sputum sample. 4. Reassess vital signs.

Answer 51

51. 1. There is a high risk and potential for tuberculosis, and airborne precautions should be implemented immediately to prevent the spread of infection. After initiating precautions the nurse can start the oxygen, check the vital signs, and collect the sputum specimen. CN: Safety and infection control; CL: Synthesize

Question 52

``` 52. A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for: 1. Decreased serum creatinine. 2. Difficulty swallowing. 3. Hearing loss. 4. IV infiltration. ```

Answer 52

52. 3. Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin is given via intramuscular injection. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 53

53. A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: 1. Vertigo.2. Facial paralysis. 3. Impaired vision. 4. Difficulty swallowing.

Answer 53

53. 1. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 54

54. The nurse is reconciling the prescriptions for a client diagnosed recently with pulmonary tuberculosis who is being admitted to the hospital for a total hip replacement (see medication prescription sheet). The client asks if it is necessary to take all of these medications while in the hospital. The nurse should: MEDICATION PRESCRIPTION ISONIAZID (INH) 300 MG PO DAILY RIFAMPIN (RIFADIN) 600 MG PO DAILY PYRIDOXINE (VITAMIN B6)10 MG PO DAILY ETHAMBUTOL 400 MG PO DAILY PYRAZINAMIDE 1.5 G PO DAILY DR. SMITH 6-29-11 1. Request that the health care provider review the prescriptions for a duplication between isoniazid and ethambutol. 2. Inform the client that all drugs will be discontinued until the client can eat solid foods. 3. Ask the pharmacist to check for drug interactions between the rifampin and isoniazid. 4. Tell the client that it is important to continue to take the medications because the combination of drugs prevents bacterial resistance

Answer 54

54. 4. The nurse should tell the client that it is necessary to take all of these medications because combination drug therapy prevents bacterial resistance; they will be administered throughout the hospitalization to maintain blood levels. The health care provider will review the prescriptions per hospital policy because the client is being admitted to the hospital; there is no duplication between any of the drugs being prescribed for this client. It is not necessary to ask the pharmacist to check for drug interactions as these drugs are commonly used together. CN: Pharmacologic and parenteral therapy; CL: Synthesize

Question 55

55. The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: 1. Dust particles. 2. Droplet nuclei. 3. Water. 4. Eating utensils.

Answer 55

55. 2. Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli. Tuberculosis is not spread by eating utensils, dishes, or other fomites. CN: Safety and infection control; CL: Apply

Question 56

56. What is the rationale that supports multidrug treatment for clients with tuberculosis? 1. Multiple drugs potentiate the drugs' actions. 2. Multiple drugs reduce undesirable drug adverse effects. 3. Multiple drugs allow reduced drug dosages to be given. 4. Multiple drugs reduce development of resistant strains of the bacteria.

Answer 56

56. 4. Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy.Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (eg, antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs. CN: Pharmacological and parenteral therapies; CL: Apply

Question 57

57. The client with tuberculosis is to be discharged home with community health nursing follow- up. Of the following nursing interventions, which should have the highest priority? 1. Offering the client emotional support. 2. Teaching the client about the disease and its treatment. 3. Coordinating various agency services. 4. Assessing the client's environment for sanitation.

Answer 57

57. 2. Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment. CN: Basic care and comfort; CL: Synthesize

Question 58

58. The nurse is reading the results of a tuberculin skin test (see figure). The nurse shouldinterpret the results as: 1. Negative. 2. Needing to be repeated. 3. Positive. 4. False.

Answer 58

58. 3. The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purified protein derivative (PPD) by measuring the size of the firm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a firm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false. CN: Physiological adaptation; CL: Analyze

Question 59

59. Which of the following techniques for administering the Mantoux test is correct? 1. Hold the needle and syringe almost parallel to the client's skin. 2. Pinch the skin when inserting the needle. 3. Aspirate before injecting the medication. 4. Massage the site after injecting the medication.

Answer 59

59. 1. The Mantoux test is administered via intradermal injection. The appropriate technique for an intradermal injection includes holding the needle and syringe almost parallel to the client's skin, keeping the skin slightly taut when the needle is inserted, and inserting the needle with the bevel side up. There is no need to aspirate, a technique that assesses for incorrect placement in a blood vessel, when giving an intradermal injection. The injection site is not massaged. CN: Pharmacological and parenteral therapies; CL: Apply

Question 60

60. A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client: 1. Lives in a long-term care facility. 2. Has no known risk factors. 3. Is immunocompromised. 4. Works as a health care provider in a hospital.

Answer 60

60. 3. An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (eg, prisons, long-term care facilities, hospitals, homeless shelters, etc.), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (eg, diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories. CN: Physiological adaptation; CL: Analyze

Question 61

``` 61. Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease? 1. 45-year-old mother. 2. 17-year-old daughter. 3. 8-year-old son. 4. 76-year-old grandmother. ```

Answer 61

61. 4. Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States and Canada include the urban poor, clients with acquired immunodeficiency syndrome, and minority groups.CN: Safety and infection control; CL: Analyze

Question 62

62. The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) indicate(s) that the client has understood the nurse's instructions? Select all that apply. 1. “I will need to dispose of my old clothing when I return home.” 2. “I should always cover my mouth and nose when sneezing.” 3. “It is important that I isolate myself from family when possible.” 4. “I should use paper tissues to cough in and dispose of them promptly.” 5. “I can use regular plates and utensils whenever I eat.”

Answer 62

62. 2, 4, 5. When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, and using regular plates and utensils indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to be isolated from family members. CN: Health promotion and maintenance; CL: Evaluate

Question 63

63. A client has a positive reaction to the Mantoux test. The nurse interprets this reaction to mean that the client has: 1. Active tuberculosis. 2. Had contact with Mycobacterium tuberculosis. 3. Developed a resistance to tubercle bacilli. 4. Developed passive immunity to tuberculosis.

Answer 63

63. 2. A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible. CN: Reduction of risk potential; CL: Analyze

Question 64

64. A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to: 1. Adhere to a low-cholesterol diet. 2. Supplement the diet with pyridoxine (vitamin B 6 ). 3. Get extra rest. 4. Avoid excessive sun exposure.

Answer 64

64. 2. INH competes for the available vitamin B 6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B 6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 65

65. The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects? 1. Increases the risk of vaginal infection. 2. Has mutagenic effects on ova. 3. Decreases the effectiveness of hormonal contraceptives. 4. Inhibits ovulation.

Answer 65

65. 3. INH interferes with the effectiveness of hormonal contraceptives, and female clients of childbearing age should be counseled to use an alternative form of birth control while taking the drug. INH does not increase the risk of vaginal infection, nor does it affect the ova or ovulation. CN: Pharmacological and parenteral therapies; CL: Apply

Question 66

``` 66. Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk? 1. Cool and damp weather. 2. Active exercise and exertion. 3. Physical and emotional stress. 4. Rest and inactivity. ```

Answer 66

66. 3. Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis. CN: Physiological adaptation; CL: Analyze

Question 67

67. In which areas of the United States and Canada is the incidence of tuberculosis highest? 1. Rural farming areas. 2. Inner-city areas. 3. Areas where clean water standards are low. 4. Suburban areas with significant industrial pollution.

Answer 67

67. 2. Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence. CN: Safety and infection control; CL: Analyze

Question 68

68. The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis? 1. Take the medication with antacids. 2. Double the dosage if a drug dose is missed. 3. Increase intake of dairy products. 4. Limit alcohol intake.

Answer 68

68. 4. Isoniazid and rifampin (Rifamate) is a hepatotoxic drug. The client should be warned to limit intake of alcohol during drug therapy. The drug should be taken on an empty stomach. If antacids are needed for gastrointestinal distress, they should be taken 1 hour before or 2 hours after the drug is administered. The client should not double the dose of the drug because of potential toxicity. The client taking the drug should avoid foods that are rich in tyramine, such as cheese and dairy products, or he may develop hypertension.CN: Pharmacological and parenteral therapies; CL: Create

Question 69

9. A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply. 1. Having eye examinations every 6 months. 2. Maintaining follow-up monitoring of liver enzymes. 3. Decreasing protein intake in the diet.4. Avoiding alcohol intake. 5. The urine may have an orange color.

Answer 69

69. 2, 4, 5. A potential adverse effect of rifampin (Rifadin) is hepatotoxicity. Clients should be instructed to avoid alcohol intake while taking rifampin and keep follow-up appointments for periodic monitoring of liver enzyme levels to detect liver toxicity. Rifampin causes the urine to turn an orange color and the client should understand that this is normal. It is not necessary to restrict protein intake in the diet or have the eyes examined due to rifampin therapy. CN: Pharmacological and parenteral therapies; CL: Create

Question 70

70. The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client? 1. Ask the client's spouse to supervise the daily administration of the medications. 2. Visit the client weekly to verify compliance with taking the medication. 3. Notify the physician of the client's noncompliance and request a different prescription. 4. Remind the client that tuberculosis can be fatal if it is not treated promptly.

Answer 70

70. 1. Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment. CN: Safety and infection control; CL: Synthesize

Question 71

The Client with Chronic Obstructive Pulmonary Disease 71. The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order should the nurse explain the steps to the client? 1. “Breathe in normally through your nose for two counts (while counting to yourself, one, two).” 2. “Relax your neck and shoulder muscles.” 3. “Pucker your lips as if you were going to whistle.” 4. “Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four).”

Answer 71

The Client with Chronic Obstructive Pulmonary Disease 71. 2. “Relax your neck and shoulder muscles.” 1. “Breathe in normally through your nose for two counts (while counting to yourself, one, two).” 3. “Pucker your lips as if you were going to whistle.” 4. “Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four).” The nurse should first instruct the client to relax the neck and the shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through pursed lips. CN: Health promotion and maintenance; CL: Apply

Question 72

72. The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.35; PCO 2 62 (8.25 kPa); PO 2 70 (9.31 kPa) (34 mmol/L); HCO 3 34. The nurse should first: 1. Apply a 100% nonrebreather mask. 2. Assess the vital signs. 3. Reposition the client. 4. Prepare for intubation.

Answer 72

72. 2. Clients with chronic COPD have CO 2 retention and the respiratory drive is stimulated when the PO 2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation. CN: Physiological adaptation; CL: Synthesize

Question 73

73. When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to: 1. Develop respiratory infections easily. 2. Maintain current status. 3. Require less supplemental oxygen. 4. Show permanent improvement.

Answer 73

73. 1. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of thedisease, but permanent improvement is highly unlikely. CN: Management of care; CL: Synthesize

Question 74

74. The client with chronic obstructive pulmonary disease (COPD) is taking theophylline. The nurse should instruct the client to report which of the following signs of theophylline toxicity? Select all that apply. 1. Nausea. 2. Vomiting.3. Seizures. 4. Insomnia. 5. Vision changes.

Answer 74

74. 1, 2, 3, 4. The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 μmol/L). At higher levels, the client will experience signs of toxicity such as nausea, vomiting, seizure, and insomnia. The nurse should instruct the client to report these signs and to keep appointments to have theophylline blood levels monitored. If the theophylline level is below the therapeutic range, the client may be at risk for more frequent exacerbations of the disease. CN: Physiological Integrity; CL: Apply

Question 75

75. Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? 1. The client promises to do pursed-lip breathing at home. 2. The client states actions to reduce pain. 3. The client will use oxygen via a nasal cannula at 5 L/min. 4. The client agrees to call the physician if dyspnea on exertion increases.

Answer 75

75. 4. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia. CN: Basic care and comfort; CL: Evaluate

Question 76

76. Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? 1. Increased anteroposterior chest diameter. 2. Underdeveloped neck muscles. 3. Collapsed neck veins. 4. Increased chest excursions with respiration.

Answer 76

76. 1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD. CN: Physiological adaptation; CL: Analyze

Question 77

77. When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? 1. Participate regularly in aerobic exercises. 2. Maintain a high-protein diet. 3. Avoid exposure to people with known respiratory infections. 4. Abstain from cigarette smoking.

Answer 77

77. 4. Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneficial, will not decrease the risk of COPD. Insufficient protein intake and exposure to people with respiratory infections do not increase the risk of COPD. CN: Health promotion and maintenance; CL: Synthesize

Question 78

78. Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? 1. To promote oxygen intake. 2. To strengthen the diaphragm. 3. To strengthen the intercostal muscles. 4. To promote carbon dioxide elimination.

Answer 78

78. 4. Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed- lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles. CN: Physiological adaptation; CL: Evaluate

Question 79

79. Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1. Maintaining functional ability. 2. Minimizing chest pain. 3. Increasing carbon dioxide levels in the blood. 4. Treating infectious agents.

Answer 79

79. 1. A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD. CN: Basic care and comfort; CL: Synthesize

Question 80

80. A client's arterial blood gas values are as follows: pH, 7.31; PaO 2 , 80 mm Hg; PaCO 2 , 65 mm Hg; HCO 3– , 36 mEq/L. The nurse should assess the client for: 1. Cyanosis. 2. Flushed skin. 3. Irritability. 4. Anxiety.

Answer 80

80. 2. The high PaCO 2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosisis a sign of hypoxia. Irritability and anxiety are not common with a PaCO 2 level of 65 mm Hg but are associated with hypoxia. CN: Reduction of risk potential; CL: Analyze

Question 81

81. When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects:1. While inhaling through an open mouth. 2. While exhaling through pursed lips. 3. After exhaling but before inhaling. 4. While taking a deep breath and holding it.

Answer 81

81. 2. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias. CN: Basic care and comfort; CL: Synthesize

Question 82

82. The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan? 1. Clubbing of nail beds. 2. Hypertension. 3. Peripheral edema. 4. Increased appetite.

Answer 82

82. 3. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites. CN: Physiological adaptation; CL: Synthesize

Question 83

83. The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? 1. Normal breath sounds. 2. Prolonged inspiration. 3. Normal chest movement. 4. Coarse crackles and rhonchi.

Answer 83

83. 4. Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended. CN: Physiological adaptation; CL: Analyze

Question 84

84. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO 2 level. The nurse plans to administer oxygen as prescribed. Which of the following statements is true concerning oxygen administration to a client with COPD? 1. High oxygen concentrations will cause coughing and dyspnea. 2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. 3. Increased oxygen use will cause the client to become dependent on the oxygen. 4. Administration of oxygen is contraindicated in clients who are using bronchodilators.

Answer 84

84. 2. Clients who have a long history of COPD may retain carbon dioxide (CO 2 ). Gradually the body adjusts to the higher CO 2 concentration, and the high levels of CO 2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators. CN: Physiological adaptation; CL: Apply

Question 85

``` 85. Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? 1. Low-fat, low-cholesterol diet. 2. Bland, soft diet. 3. Low-sodium diet. 4. High-calorie, high-protein diet. ```

Answer 85

85. 4. The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium- restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods. CN: Basic care and comfort; CL: Synthesize

Question 86

86. The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for which of the following? 1. Suppression of the client's respiratory infection. 2. Decrease in bronchial secretions. 3. Less difficulty breathing. 4. Thinning of tenacious, purulent sputum.

Answer 86

86. 3. Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 87

87. The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included? 1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. 2. Lie flat on the back, splint the thorax, take two deep breaths, and cough. 3. Take several rapid, shallow breaths and then cough forcefully.4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

Answer 87

87. 1. The goal of effective coughing is to conserve energy, facilitate removal of secretions, andminimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation (“huff” cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing. CN: Basic care and comfort; CL: Create

Question 88

The Client with Asthma 88. A client uses a metered-dose inhaler (MDI) to aid in management of asthma. Which action indicates to the nurse that the client needs further instruction regarding its use? Select all that apply. 1. Activation of the MDI is not coordinated with inspiration. 2. The client inspires rapidly when using the MDI. 3. The client holds his breath for 3 seconds after inhaling with the MDI. 4. The client shakes the MDI after use. 5. The client performs puffs in rapid succession.

Answer 88

The Client with Asthma 88. 1, 2, 3, 4, 5. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a sufficient amount of time between puffs to provide an adequate amount of inhalation medication. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 89

89. A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client? 1. Initiate oxygen therapy as prescribed and reassess the client in 10 minutes. 2. Draw blood for an arterial blood gas. 3. Encourage the client to relax and breathe slowly through the mouth. 4. Administer bronchodilators as prescribed.

Answer 89

89. 4. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention. CN: Management of care; CL: Synthesize

Question 90

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; P CO2 48 (6.4 kPa); P O2 58 (7.7 kPa); HCO 3 26 (26 mmol/L). Which of the following prescriptions should the nurse perform first? 1. Albuterol nebulizer. 2. Chest x-ray. 3. Ipratropium inhaler. 4. Sputum culture.

Answer 90

90. 1. The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable. CN: Physiological adaptation; CL: Synthesize

Question 91

91. A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? 1. Promote bronchodilation. 2. Act as an expectorant. 3. Have an anti-inflammatory effect. 4. Prevent development of respiratory infections.

Answer 91

91. 3. Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 92

92. The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following indicates that the client is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 2. The head is tilted down while inhaling the medicine. 3. The client waits 5 minutes between puffs. 4. The client rinses the mouth with water following administration. 5. The client lies supine for 15 minutes following administration.

Answer 92

92. 1, 4. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 93

93. A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverseeffects of metaproterenol? 1. Irregular heartbeat. 2. Constipation. 3. Pedal edema. 4. Decreased pulse rate.

Answer 93

93. 1. Irregular heartbeats should be reported promptly to the care provider. Metaproterenol maycause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta- adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 94

94. A client who has been taking flunisolide nasal spray, two inhalations a day, for treatment of asthma has painful, white patches in the mouth. Which response by the nurse would be most appropriate? 1. “This is an anticipated adverse effect of your medication. It should go away in a couple of weeks.” 2. “You are using your inhaler too much and it has irritated your mouth.” 3. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent.” 4. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”

Answer 94

94. 3. Use of oral inhalant corticosteroids such as flunisolide can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 95

95. A nurse is teaching a client to use a metereddose inhaler (MDI) to administer bronchodilator medication. Indicate the correct order of the steps the client should take to use the MDI appropriately. 1. Shake the inhaler immediately before use. 2. Hold breath for 5 to 10 seconds and then exhale. 3. Activate the MDI on inhalation. 4. Breathe out through the mouth.

Answer 95

94. 3. Use of oral inhalant corticosteroids such as flunisolide can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 96

96. Which of the following is an expected outcome for an adult client with well-controlled asthma? 1. Chest x-ray demonstrates minimal hyperinflation. 2. Temperature remains lower than 100°F (37.8°C). 3. Arterial blood gas analysis demonstrates a decrease in PaO 2 . 4. Breath sounds are clear.

Answer 96

96. 4. Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest x-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal. CN: Physiological adaptation; CL: Evaluate

Question 97

97. Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? 1. Incorporate physical exercise as tolerated into the daily routine.2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors in the work and home environment. 4. Use sedatives to ensure uninterrupted sleep at night.

Answer 97

97. 1. Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep. CN: Reduction of risk potential; CL: Create

Question 98

98. The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? 1. Occupational exposure to toxins. 2. Viral respiratory infections. 3. Exposure to cigarette smoke. 4. Exercising in cold temperatures.

Answer 98

98. 2. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacksare triggered by exercising in cold weather. CN: Reduction of risk potential; CL: Synthesize

Question 99

``` 99. Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma? 1. Cough productive of yellow sputum. 2. Bilateral expiratory wheezing. 3. Chest tightness. 4. Respiratory rate of 30 breaths/min. ```

Answer 99

99. 1. A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present. CN: Physiological adaptation; CL: Analyze

Question 100

100. A client diagnosed with asthma has been prescribed fluticasone (Flovent) one puff every 12 hours per inhaler. Place in correct order the statements the nurse would use when teaching the client how to properly use the inhaler with a spacer. 1. “Hold your breath for at least 10 seconds, then breathe in and out slowly.” 2. “Take off the cap and shake the inhaler.” 3. “Rinse your mouth.” 4. “Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it.” 5. “Press down on the inhaler once and breathe in slowly.” 6. “Attach the spacer.”

Answer 100

100. 2. “Take off the cap and shake the inhaler.” 6. “Attach the spacer.” 4. “Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it.” 5. “Press down on the inhaler once and breathe in slowly.” 1. “Hold your breath for at least 10 seconds, then breathe in and out slowly.” 3. “Rinse your mouth.” Using a spacer, especially with an inhaled corticosteroid, can make it easier for the medication to reach the lungs; it can also prevent excess medication remaining in the mouth and throat where it can lead to minor irritation. It is important for the client to empty the lungs, breathe in slowly, and hold breath in order to draw as much medication into the lungs as possible. Rinsing after using a corticosteroid inhaler may help prevent irritation and infection; rinsing will also reduce the amount of drug swallowed and absorbed systemically. CN: Health promotion and maintenance; CL: Apply

Question 101

101. The nurse is caring for a client who has asthma. The nurse should conduct a focused assessment to detect which of the following? 1. Increased forced expiratory volume. 2. Normal breath sounds. 3. Inspiratory and expiratory wheezing. 4. Morning headaches.

Answer 101

101. 3. The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [Forced Expiratory Flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found in more advanced cases of COPD signal nocturnal hypercapnia or hypoxemia. CN: Physiological adaptation; CL: Analyze

Question 102

``` The Client with Lung Cancer 102. The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should: 1. Assess breath sounds. 2. Remove the catheter. 3. Insert a peripheral IV. 4. Reposition the client. ```

Answer 102

The Client with Lung Cancer 102. 1. The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client. Repositioning may be considered after assessments are done. CN: Physiological adaptation; CL: Synthesize

Question 103

103. A recently extubated client has shortness of breath. The nurse reports the client's discomfort to the health care provider and the results of the recently prescribed arterial blood gas analysis. After reviewing the report of the complete blood count (see below), the nurse should also report which of the following to the health care provider? 1. PT. 2. Hemoglobin and hematocrit. 3. WBC. 4. Platelets. ***WITH LAB VALUES***

Answer 103

103. 2. The nurse should review the CBC with differential to evaluate the client's hemoglobin and hematocrit, which are abnormal and should be reported to the health care provider. Anemia leads to decreased oxygen-carrying capacity of the blood. A client unable to compensate for the anemia may experience a profound sense of dyspnea. There has been a significant drop in the Hgb and Hct since the previous report, and these should be reported to the physician. A 1 C is a laboratory test evaluating glycosylated hemoglobin and is in the normal range. This test is used to diagnose diabetes and/or monitor diabetic glucose control over time. Blood culture is obtained to assess infection in the blood. PT is a coagulation study reflecting liver function and clotting time and is in the normal range. CN: Physiological adaptation; CL: Synthesize

Question 104

104. A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increases the client's risk of developing postoperative pulmonary complications? 1. Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). 2. The client tends to keep her real feelings to herself. 3. She ambulates and can climb one flight of stairs without dyspnea. 4. The client is 58 years of age.

Answer 104

104. 1. Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this client's height and weight. It is thought that emotional responses can affect overall health; however, not verbalizing one's feelings is not a contributing factor in postoperative pulmonary complications. The client's current activity level and age do not place her at increased risk for complications. CN: Physiological adaptation; CL: Analyze

Question 105

105. The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, “I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago.” What would be the nurse's best response to the client? 1. “It's okay to be scared. What is it about cancer that you're afraid of?” 2. “It's normal to be scared. I would be, too. We'll help you through it.” 3. “Don't be so hard on yourself. You don't know if your smoking caused the cancer.” 4. “Do you feel guilty because you smoked?”

Answer 105

105. 1. Acknowledging the basic feeling the client expresses—fear—and asking an open-ended question allows the client to explain any fears. The other options dismiss the client's feelings and may give false reassurance or label the client's feelings. The client should be encouraged to explore feelings about a cancer diagnosis. CN: Psychosocial adaptation; CL: Synthesize

Question 106

106. A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. The nurse should: 1. Let the client rest, so that the client is not stimulated to cough.2. Encourage the client to take deep breaths to help control the pain. 3. Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve the pain. 4. Obtain a more detailed assessment of the client's pain using a pain scale.

Answer 106

106. 4. Systematic pain assessment is necessary for adequate pain management in the postoperative client. Guidelines from a variety of health care agencies and nursing groups recommend that institutions adopt a pain assessment scale to assist in facilitating pain management. Even though the client is receiving morphine sulfate by PCA, assessment is needed if she is experiencing pain. The concern is not to eliminate coughing but to control pain adequately. Coughing is necessary to prevent postoperative atelectasis and pneumonia. Breathing exercises may help control pain in some circumstances; however, most clients with thoracic surgery require parenteral opioid analgesics in the early postoperative period. Although it is necessary that the PCA device be checked periodically to ensure that it is functioning properly, if the machine is functional and the client's pain is not relieved, further intervention, beginning with a pain assessment, is indicated. CN: Basic care and comfort; CL: Synthesize

Question 107

107. Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer? 1. The support available to assist the client at home. 2. The distance the client lives from the hospital. 3. The client's ability to do home blood pressure monitoring. 4. The client's knowledge of the causes of lung cancer.

Answer 107

107. 1. Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support they have to assist them with self-care at home. The distance the client lives from the hospital is not a critical factor in discharge planning. There are no data indicating that home bloodpressure monitoring is needed. Knowledge of the causes of lung cancer, although important, is not the most essential area to evaluate given the client's postoperative status. CN: Psychosocial adaptation; CL: Synthesize

Question 108

108. Which of the following would be a significant intervention to help prevent lung cancer? 1. Encourage cigarette smokers to have yearly chest radiographs. 2. Instruct people about techniques for smoking cessation. 3. Recommend that people have their houses and apartments checked for asbestos leakage. 4. Encourage people to install central air filters in their homes.

Answer 108

108. 2. Epidermoid cancer involving the larger bronchi is almost entirely associated with heavy cigarette smoking. The American and Canadian Cancer Societies report that smoking is responsible for more than 80% of lung cancers in men and women. The prevalence of lung cancer is related to the duration and intensity of the smoking, so nurses can best prevent lung cancer by persuading clients to stop smoking. Chest radiographs aid in detection of lung cancer; they do not prevent it. Exposure to asbestos has been implicated as a risk factor for lung cancer, but cigarette smoking is the major risk factor. There are no data to support the use of home air filters in the prevention of lung cancer. CN: Health promotion and maintenance; CL: Synthesize

Question 109

109. After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises? 1. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange. 2. Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery. 3. Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated. 4. Deep breathing expands the alveoli and increases the lung surface available for ventilation.

Answer 109

109. 4. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon. CN: Physiological adaptation; CL: Evaluate

Question 110

110. Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client? 1. Repositioning the client immediately after administering pain medication. 2. Reassessing the client 30 minutes after administering pain medication. 3. Verbally reassuring the client after administering pain medication. 4. Readjusting the pain medication dosage as needed according to the client's condition.

Answer 110

110. 2. It is essential that the nurse evaluate the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of the pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client's pain, repositioning the client immediately after administering pain medication is not necessary. Verbally reassuring the client after administering pain medication may be useful to help instill confidence in the treatment plan; however, it is not as important as evaluating the effectiveness of the medication. Readjusting the pain medication dosage as needed according to the client's condition is essential, but the effectiveness of the medication must be evaluated first. CN: Physiological adaptation; CL: Synthesize

Question 111

111. While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action? 1. Lower the head of the bed and call the physician. 2. Prepare an aspiration tray. 3. Mark the area with a skin pencil at the outer periphery of the crackling. 4. Turn off the suction of the chest drainage system.

Answer 111

111. 3. This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual finding and is not dangerous if confined, and the nurse should mark the area to detect if the area is expanding. Progression can be serious, especially if the neck is involved; a tracheotomy may be needed at that point. If emphysema progresses noticeably in 1 hour, the physician should be notified. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and fluid; therefore, the system should not be turned off. CN: Physiological adaptation; CL: Synthesize

Question 112

112. When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following? 1. Contract the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale. 2. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as iftrying to blow out a candle. 3. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds. 4. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.

Answer 112

112. 1. The recommended procedure for teaching clients postoperatively to deep breathe includes contracting (pulling in) the abdominal muscles and taking a slow, deep breath through the nose. This breath is held 3 to 5 seconds, which facilitates alveolar ventilation by improving the inspiratory phase of ventilation. Exhaling slowly as if trying to blow out a candle is a technique used in pursed- lip breathing to facilitate exhalation in clients with chronic obstructive pulmonary disease. It isrecommended that the abdominal muscles be contracted, not relaxed, to promote deep breathing. The client should breathe through the nose. CN: Physiological adaptation; CL: Synthesize

Question 113

113. Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis? 1. Turn from side to side. 2. Raise and lower the head. 3. Raise the arm on the affected side over the head. 4. Flex and extend the elbow on the affected side.

Answer 113

113. 3. A client who has undergone chest surgery should be taught to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power. Turning from side to side, raising and lowering the head, and flexing and extending the elbow on the affected side do not exercise the shoulder joint. CN: Basic care and comfort; CL: Synthesize

Question 114

114. When caring for a client with a chest tube and water-seal drainage system, the nurse should: 1. Verify that the air vent on the water-seal drainage system is capped when the suction is off. 2. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. 3. Ensure that the chest tube is clamped when moving the client out of the bed. 4. Make sure that the drainage apparatus is always below the client's chest level.

Answer 114

114. 4. The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended. CN: Physiological adaptation; CL: Synthesize

Question 115

115. A client has a chest tube attached to a water-seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine that: 1. The lung has fully expanded. 2. The lung has collapsed. 3. The chest tube is in the pleural space. 4. The mediastinal space has decreased.

Answer 115

115. 1. Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been re-established; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluctuation occurs because, during inspiration, intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space. CN: Physiological adaptation; CL: Analyze

Question 116

116. The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. The nurse should: 1. Continue monitoring as usual; this is expected. 2. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. 3. Decrease the suction to −15 cm H 2 O and continue observing the system for changes in bubbling during the next several hours. 4. Drain half of the water from the water-seal chamber.

Answer 116

116. 2. There should never be constant bubbling in the water-seal bottle; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction or draining part of the water in the water-seal chamber will not reduce the leak. CN: Physiological adaptation; CL: Synthesize

Question 117

117. A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should: 1. Check the tubing to ensure that the client is not lying on it or kinking it. 2. Increase the suction. 3. Lower the drainage bottles 2 to 3 feet (61 to 91.4 cm) below the level of the client's chest. 4. Ensure that the chest tube has two clamps on it to prevent air leaks.

Answer 117

117. 1. In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from re-expanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a physician's prescription. The normal position of the drainage bottles is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done. CN: Physiological adaptation; CL: Synthesize

Question 118

118. The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, which should the nurse do? 1. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. 2. Notify the physician of the amount of chest tube drainage.3. Add water to maintain the water seal. 4. Lower the drainage system to maintain gravity flow.

Answer 118

118. 4. To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal. CN: Physiological adaptation; CL: Synthesize

Question 119

``` 119. Which of the following should be readily available at the bedside of a client with a chest tube in place? 1. A tracheostomy tray. 2. Another sterile chest tube. 3. A bottle of sterile water. 4. A spirometer. ```

Answer 119

119. 3. A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use. CN: Physiological adaptation; CL: Apply

Question 120

120. The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed? 1. Adhesive strip (Steri-strips). 2. Petroleum gauze. 3. 4 × 4 gauze with antibiotic ointment. 4. No dressing is necessary.

Answer 120

120. 2. Gauze saturated with petroleum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dressings with antibiotic ointment or adhesives are not used. CN: Management of care; CL: Apply

Question 121

``` The Client with Chest Trauma 121. A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. Diminished bilateral breath sounds. 2. Muffled heart sounds. 3. Respiratory distress. 4. Tracheal deviation. ```

Answer 121

The Client with Chest Trauma 121. 3. Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade. CN: Physiological adaptation; CL: Analyze

Question 122

A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Round to one decimal point. _________________ mL.

Answer 122

122. 0.7 mL | CN: Pharmacological and parenteral therapies; CL: Apply

Question 123

123. A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. Which is the primary client goal at this time? 1. Reduce the client's anxiety. 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume.

Answer 123

123. 2. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation. CN: Physiological adaptation; CL: Synthesize

Question 124

124. A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system.

Answer 124

124. 3. Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column. CN: Physiological adaptation; CL: Analyze

Question 125

125. A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Respiratory rate greater than 16 breaths/min. 2. Continuous bubbling in the water-seal chamber. 3. Fluid in the chest tube. 4. Fluctuation of fluid in the water-seal chamber.

Answer 125

125. 2. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/min may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber. CN: Physiological adaptation; CL: Synthesizevv

Question 126

126. Which of the following findings would suggest pneumothorax in a trauma victim? 1. Pronounced crackles. 2. Inspiratory wheezing. 3. Dullness on percussion. 4. Absent breath sounds.

Answer 126

126. 4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse willhear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid. CN: Physiological adaptation; CL: Evaluate

Question 127

127. For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicatesuccessful achievement of this goal? 1. Pain rating of 0 on a scale of 0 to 10 by the client. 2. Decreased client anxiety. 3. Respiratory rate of 26 breaths/min. 4. PaO 2 of 70 mm Hg (9.31 kPa).

Answer 127

127. 1. If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/min is not within normal limits, nor is the PaO 2 of 70 mm Hg (9.31 kPa), but these values are not measures of pain relief. CN: Physiological adaptation; CL: Evaluate

Question 128

128. A client undergoes surgery to repair lung injuries. Postoperative prescriptions include the transfusion of one unit of packed red blood cells at a rate of 60 mL/h. How long will this transfusion take to infuse? 1. 2 hours. 2. 4 hours. 3. 6 hours. 4. 8 hours.

Answer 128

128. 2. One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia. CN: Pharmacological and parenteral therapies; CL: Apply

Question 129

``` 129. The primary reason for infusing blood at a rate of 60 mL/h is to help prevent which of the following complications? 1. Emboli formation. 2. Fluid volume overload. 3. Red blood cell hemolysis. 4. Allergic reaction. ```

Answer 129

129. 2. Too-rapid infusion of blood, or any intravenous fluid, can cause fluid volume overload and related problems such as pulmonary edema. Emboli formation, red blood cell hemolysis, and allergic reaction are not related to rapid infusion. CN: Pharmacological and parenteral therapies; CL: Apply

Question 130

130. A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1. Sudden, sharp chest pain. 2. Wheezing breath sounds over affected side. 3. Hemoptysis. 4. Cyanosis.

Answer 130

130. 1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax. CN: Physiological adaptation; CL: Analyze

Question 131

131. The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. For administration of oxygen. 2. To promote formation of lung scar tissue. 3. To insert antibiotics into the pleural space. 4. To remove air and fluid.

Answer 131

131. 4. A chest tube is inserted to re-expand the lung and remove air and fluid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax. CN: Basic care and comfort; CL: Evaluate

Question 132

132. The nurse is preparing the client diagnosed with pleural effusion for a left-sided thoracentesis. The x-ray shows fluid in the pleural cavity. During the preparation for the procedure, the client asks where the physician will “put the needle.” Select the appropriate site from the diagram below.

Answer 132

132. Correct answer: The fluid typically localizes at the base of the thorax. CN: Management of care; CL: Synthesize

Question 133

133. A client is undergoing a thoracentesis. The nurse should monitor the client during and immediately after the procedure for which of the following? Select all that apply. 1. Pneumothorax. 2. Subcutaneous emphysema. 3. Tension pneumothorax. 4. Pulmonary edema. 5. Infection.

Answer 133

133. 1, 2, 3, 4. Following a thoracentesis, the nurse should assess the client for possible complications of the procedure such as pneumothorax, tension pneumothorax, and subcutaneous emphysema, which can occur because of the needle entering the chest cavity. Pulmonary edema could occur if a large volume was aspirated causing a significant mediastinal shift. Although infection is a possible complication, signs of infection will not be evident immediately after the procedure. CN: Management of care; CL: Synthesize

Question 134

134. When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should chart the breathing pattern as: 1. Cheyne-Stokes respiration. 2. Hyperventilation. 3. Obstructive sleep apnea. 4. Bior's respiration.

Answer 134

134. 1. Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is the increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Bior's respiration, also known as “cluster breathing,” is periods of normal respirations followed by varying periods of apnea. CN: Health promotion and maintenance; CL: Analyze

Question 135

The Client with Acute Respiratory Distress Syndrome 135. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit. 2. The client has increased secretions requiring frequent suctioning. 3. The SpO 2 and PO 2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema.

Answer 135

The Client with Acute Respiratory Distress Syndrome 135. 3, 4, 5. The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern. CN: Physiological adaptation; CL: Synthesize

Question 136

136. The nurse has calculated a low PaO 2 /FIO 2 (P/F) ratio less than 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? 1. Supine. 2. Semi-Fowler's. 3. Lateral side. 4. Prone.

Answer 136

136. 4. Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units,improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees. CN: Physiological adaptation; CL: Synthesize

Question 137

137. A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.

Answer 137

137. 1, 4, 5. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis. CN: Management of care; CL: Create

Question 138

138. Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. Teaching cigarette smoking cessation. 2. Maintaining adequate serum potassium levels. 3. Monitoring clients for signs of hypercapnia. 4. Replacing fluids adequately during hypovolemic states.

Answer 138

138. 4. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS. CN: Physiological adaptation; CL: Synthesize

Question 139

139. The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? 1. Elevated carbon dioxide level. 2. Hypoxia not responsive to oxygen therapy. 3. Metabolic acidosis. 4. Severe, unexplained electrolyte imbalance.

Answer 139

139. 2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO 2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS. CN: Physiological adaptation; CL: Analyze

Question 140

A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea.The nurse reviews a report of blood gas values that recently arrived, shown below. ``` LABORATORY RESULTS BLOOD CHEMISTRY PH 7.35 PaCO2 24 mmHg HCO3 22 mEq/L PaO2 95 mmHg ``` Which finding should the nurse report to the physician? 1. pH. 2. PaCO 2 . 3. HCO 3– . 4. PaO 2

Answer 140

140. 2. The normal range for PaCO 2 is 35 to 45 mm Hg (4.7 to 6 kPa). Thus, this client's PaCO 2 level is low. The client is experiencing respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the physician because it requires intervention. The increase in ventilation decreases the PaCO 2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO 2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45. CN: Reduction of risk potential; CL: Analyze

Question 141

141. A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO 2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for: 1. Initiating IV sedation. 2. Starting a high-protein diet. 3. Providing pain medication. 4. Increasing the ventilator rate.

Answer 141

141. 1. The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate. CN: Physiological adaptation; CL: Synthesize

Question 142

142. A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. The nurse should report which of the following to the health care provider? 1. Arterial oxygen level of 46 mm Hg. 2. Respirations of 12. 3. Lack of adventitious lung sounds. 4. Oxygen saturation of 96% on room air.

Answer 142

142. 1. Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen levelbelow 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg to the health care provider. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation. CN: Physiologic adaptation; CL: Synthesize

Question 143

143. A client has the following arterial blood gas values: pH, 7.52; PaO 2 , 50 mm Hg (6.7 kPa); PaCO 2 , 28 mm Hg (3.72 kPa); HCO 3– , 24 mEq/L (24 mmol/L). Based upon the client's PaO 2 , which of the following conclusions would be accurate? 1. The client is severely hypoxic. 2. The oxygen level is low but poses no risk for the client. 3. The client's PaO 2 level is within normal range. 4. The client requires oxygen therapy with very low oxygen concentrations.

Answer 143

143. 1. Normal PaO 2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When PaO 2 falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO 2 at 55 to 60 mm Hg (7.3 to 8 kPa) or more. CN: Physiological adaptation; CL: Analyze

Question 144

144. A client has the following arterial blood gas values: pH, 7.52; PaO 2 , 50 mm Hg (6.7 kPa); PaCO 2 , 28 mm Hg (3.7 kPa); HCO 3– , 24 mEq/L (24 mmol/L). The nurse determines that which of thefollowing is a possible cause for these findings? 1. Chronic obstructive pulmonary disease (COPD). 2. Diabetic ketoacidosis with Kussmaul's respirations. 3. Myocardial infarction. 4. Pulmonary embolus.

Answer 144

144. 4. A PaCO 2 of 28 mm Hg (3.7 kPa) and PaO 2 of 50 mm Hg (6.7 kPa) are both abnormal; the PaO 2 of 50 mm Hg (6.7 kPa) signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO 2 . The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin. CN: Physiological adaptation; CL: Analyze

Question 145

145. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? 1. Tracheostomy. 2. Use of a nasal cannula. 3. Mechanical ventilation. 4. Insertion of a chest tube.

Answer 145

145. 3. Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces. CN: Physiological adaptation; CL: Apply

Question 146

146. Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? 1. Septic shock. 2. Chronic obstructive pulmonary disease. 3. Asthma. 4. Heart failure.

Answer 146

146. 1. The two risk factors most commonly associated with the development of ARDS are gram- negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS. CN: Reduction of risk potential; CL: Apply

Question 147

147. Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. Assessing the client's skin color. 2. Monitoring the respiratory rate. 3. Verifying the amount of cuff inflation. 4. Auscultating breath sounds bilaterally.

Answer 147

147. 4. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the endotracheal tube. CN: Basic care and comfort; CL: Evaluate

Question 148

148. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1. Administering oxygen every 2 hours. 2. Turning the client every 4 hours. 3. Administering sedatives to promote rest. 4. Suctioning if cough is ineffective.

Answer 148

148. 4. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress because sedatives can depress respirations. CN: Physiological adaptation; CL: Synthesize

Question 149

149. Which of the following complications is associated with mechanical ventilation? 1. Gastrointestinal hemorrhage. 2. Immunosuppression. 3. Increased cardiac output. 4. Pulmonary emboli.

Answer 149

149. 1. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. CN: Physiological adaptation; CL: Analyze

Question 150

The Client with Carbon Monoxide Poisoning 150. A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? 1. Initiate gastric lavage. 2. Maintain body temperature. 3. Administer 100% oxygen by mask. 4. Obtain a psychiatric referral.

Answer 150

The Client with Carbon Monoxide Poisoning 150. 3. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature; thus, steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate. CN: Physiological adaptation; CL: Synthesize

Question 151

151. A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: 1. Put all four side rails up on the bed. 2. Ask the unlicensed personnel to place restraints on the client's upper extremities. 3. Request that the client's roommate put the call light on when the client is attempting to get out of bed. 4. Check on the client at regular intervals to ascertain the need to use the bathroom.

Answer 151

151. 4. Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written prescription from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety. CN: Safety and infection control; CL: Synthesize

Question 152

152. Which of the following is an expected outcome for a client with carbon dioxide poisoning? 1. A relatively matched ventilation-to-perfusion ratio. 2. A low ventilation-to-perfusion ratio. 3. A high ventilation-to-perfusion ratio. 4. An equal PaO 2 and PaCO 2 ratio.

Answer 152

151. 4. Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written prescription from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety. CN: Safety and infection control; CL: Synthesize

Question 153

``` Managing Care Quality and Safety 153. The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation? 1. Standard precautions. 2. Contact precautions. 3. Droplet precautions. 4. Airborne precautions. ```

Answer 153

Managing Care Quality and Safety 153. 4. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (eg, mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if recirculation is unavoidable. Standard precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that the blood, body fluids, secretions, and excretions of all clients may contain transmissible infectious agents. Standard precautions include hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Contact precautions are for clients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory ormucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission. CN: Safety and infection control; CL: Synthesize

Question 154

154. A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. 1. Administer the cefazolin. 2. Verify the medication prescription as written by the physician. 3. Contact the pharmacy and speak to a pharmacist. 4. Request that cephalexin be sent promptly. 5. Return the cefazolin to the pharmacy.

Answer 154

154. 2, 3, 4, 5. One of the “five rights” of drug administration is “right medication.” Cefazolin was not the medication prescribed. The pharmacist is the professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse. CN: Safety and infection control; CL: Synthesize

Question 155

155. A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients? 1. A client with an endotracheal tube transferred out of the intensive care unit that day. 2. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago. 3. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C). 4. A client receiving D5W IV at 125 mL/h with 75 mL remaining.

Answer 155

155. 1. A client with an endotracheal tube transferred out of the intensive care unit that day. 3. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C). 4. A client receiving D5W IV at 125 mL/h with 75 mL remaining. 2. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago. Because two major complications of endotracheal tube intubation, inadvertent extubation and aspiration, can be catastrophic events, assessment of this client is the first priority. Cellulitis is a serious infection as there is inflammation of subcutaneous tissues; third spacing of fluid may promote the formation of a fluid volume deficit, which can be exacerbated by the fever due to insensible fluid loss. The nurse should assess this client next to determine current vital signs and fluid status. The nurse should assess the client with the IV fluids next because the new bag of fluids will need to be hung in 30 to 40 minutes. IV therapy necessitates that the client be assessed for signs and symptoms of adequate hydration (moist mucous membranes, elastic skin turgor, vital signs within normal limits, adequate urine output, and level of consciousness within normal limits), and the IV access site needs to be assessed. From the information provided, there is no indication that the client who had the cerebrovascular accident is unstable. Thus, this client is the last priority for assessment. CN: Management of care; CL: Synthesize

Question 156

156. Which of the following individuals has the highest priority for receiving seasonal influenza vaccination? 1. A 60-year-old man with a hiatal hernia. 2. A 36-year-old woman with three children. 3. A 50-year-old woman caring for a spouse with cancer. 4. A 60-year-old woman with osteoarthritis.

Answer 156

156. 3. Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described because her husband is likely to be immunocompromised and particularly susceptible to the flu. A healthy 60-year-old man or a healthy 36-year-old woman is not in a high-priority category for influenza vaccination. A 60-year-old woman with osteoarthritis does not have a higher priority for influenza vaccination than a home care provider. CN: Reduction of risk potential; CL: Analyze

Question 157

``` 157. The nurse is a member of a team that is planning a client-centered approach to care ofclients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply. 1. The community. 2. Clinical information systems. 3. Delivery system design. 4. Administrative leadership. 5. Emphasis on the acute care setting. ```

Answer 157

157. 1, 2, 3. The process of changing a health care system from an acute care model to a CCM uses continuous quality improvement (CQI) methods. The goal of the CCM is to improve the health of chronically ill clients. The CCM identifies six basic areas upon which health care organizations need to focus to improve quality of care and delivery: health systems, delivery system design, decision support, clinical information systems, self-management support, and the community. This system requires health care services that are client-centered and coordinated among members of the health care staff and the client and the family. CCM does not focus on the administrative leadership or the care in the acute care setting alone. CN: Management of care; CL: Synthesize

Question 158

158. The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level? ITEM / SCALE History of falling; immedicate or within 3 months No - 0 Yes - 25 Secondary diagnosis No - 0 Yes 15 Ambulatory Aid Bed Rest/Nurse assist - 0 Crutches/Cane/walker - 15 Furniture - 30 IV/Heparin Lock No - 0 Yes - 20 Gait Transferring Normal/Bedrest - 0 Immobile Weak - 10 Impaired - 20 Mental Status Oriented to own ability - 0 Forgets limitations - 15 1. 20, low risk. 2. 30, medium risk. 3. 40, medium risk. 4. 60, high risk.

Answer 158

158. 4. Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety. CN: Safety and infection control; CL: Analyze

Question 159

159. The nurse is caring for a client who has been placed on droplet precautions. Which of the following protective gear is required to take care of this client? Select all that apply. 1. Gloves. 2. Gown. 3. Surgical mask. 4. Glasses. 5. Respirator.

Answer 159

159. 1, 2, 3, 4. Gloves, gown, surgical mask, and eye protection/glasses are worn to protect health care workers and to help prevent the spread of infection when clients are placed in droplet isolation. Because droplets are too heavy to be airborne, a respirator is not required when caring for a client in droplet precautions. CN: Safety and infection control; CL: Apply

Question 160

160. While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first action should be to: 1. Push the “code blue” (emergency response) button. 2. Call the rapid response team. 3. Open the client's airway. 4. Call for a defibrillator.

Answer 160

160. 3. The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the “code blue” button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be necessary nor the appropriate action once the client's airway has been opened. CN: Safety and infection control; CL: Synthesize

Question 161

161. The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement the following interventions to ensure the client's safety? 1. Review the client's medications for interactions that may cause or increase confusion. 2. Assess the client's respiratory status including oxygen saturation. 3. Ensure the client does not need toileting or pain medications. 4. Contact the physician and request a prescription for soft wrist restraints

Answer 161

161. 2. Assess the client's respiratory status including oxygen saturation. 3. Ensure the client does not need toileting or pain medications. 1. Review the client's medications for interactions that may cause or increase confusion. 4. Contact the physician and request a prescription for soft wrist restraints The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination.Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort. CN: Safety and infection control; CL: Synthesize