TEST 4: The Client with Respiratory Health Problems Flashcards

Question 1

Q

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

A

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

Q

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.
Operating machinery and driving may be dangerous while taking antihistamines.
Continue taking antihistamines even if nasal infection develops.
The effect of antihistamines is not felt until a day later.
Do not use alcohol with antihistamines.
Increase fluid intake to 2,000 mL/day.

Answer

A

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

Q

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?
“I should limit the use of the inhaler to early morning and bedtime use.”
“It is important to not shake the canister because that can damage the spray device.”
“I should hold one nostril closed while I insert the spray into the other nostril.”
“The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.”

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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?
“Use your nasal decongestant spray regularly to help clear your nasal passages.”
“Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
“It is important to increase your activity. A daily brisk walk will help promote drainage.”
“Keep a diary of when your symptoms occur. This can help you identify what precipitates your
attacks.”

Answer

A

1. 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

Q

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

A

7.5 mL

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

CN: Pharmacological and parenteral therapies; CL: Apply

Question 9

Q

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

Answer

A

1. 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

Q

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

A

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

Q

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?
Nausea.
Repeated swallowing.
Increased respiratory rate.
Increased pain.

Answer

A

1. 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

Q

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?
Avoid activities that elicit the Valsalva maneuver.
Take aspirin to control nasal discomfort.
Avoid brushing the teeth until the nasal packing is removed.
Apply heat to the nasal area to control swelling.

Answer

A

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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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?
Take analgesics every 4 hours around the clock.2. Use corticosteroid nasal spray as needed to control symptoms.
Use a bedside humidifier while sleeping.
Apply cold compresses to the area.

Answer

A

1. 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

Q

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

A

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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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?
Vertigo.
Bell’s palsy.
Hypoventilation.
Loss of gag reflex.

Answer

A

1. 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

Q

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

A

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

Q

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?
Discussing the behavior with the spouse to determine the cause.
Exploring future plans.
Respecting the need for privacy.
Encouraging expression of feelings nonverbally and in writing.

Answer

A

1. 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

Q

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

Answer

A

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

Q

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

Answer

A

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

Q

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:
Initiate teaching about the care of a stoma.
Explain that the stoma will not always look as it does now.
Inform the client of the benefits of family support at this time.
Explore why the client believes the stoma is “disgusting.”

Answer

A

1. 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

Q

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.
Ask the nursing assistant to tie the tracheostomy tube ties in the back of the client’s neck.
Reposition the gauze pad around the stoma with the open end downward.
Ask a registered nurse to change the ties and position another gauze pad around the stoma.

Answer

A

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

Q

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.
Stopping smoking.
Using a HEPA filter in the home.
Limiting alcohol intake.
Brushing teeth after every meal.
Avoiding raising the voice to be heard over the noise in the factory.

Answer

A

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

Q

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

Answer

A

1. 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

Q

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?
Maintain the head of the bed at 30 to 40 degrees.
Teach the client how to use esophageal speech.
Initiate small feedings of soft foods.
Irrigate drainage tubes as needed.

Answer

A

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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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.
An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness
of breath.
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.
A 35-year-old client with suspected tuberculosis who has a cough.
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

A

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

Q

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

A

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

Q

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?
Age.
Osteoarthritis.
Vegetarian diet.
Daily bathing.

Answer

A

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

Q

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

A

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

Q

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?
Urinalysis.
Sputum culture.
Chest radiograph.
Red blood cell count.

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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:
“Do you have a history of seizures?”
“Do you have any cardiac history?”
“Have you had any recent infections?”
“Have you had a previous allergy to penicillin?”

Answer

A

. 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

Q

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?
Position changes every 4 hours.
Nasotracheal suctioning to clear secretions.
Frequent linen changes.
Frequent offering of a bedpan.

Answer

A

1. 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

Q

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:
Decreased cellular demand for oxygen.
Reduced episodes of coughing.
Diminished pain when breathing deeply.
Ability to expectorate secretions more easily.

Answer

A

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

Q

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

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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.
Decreased pain when breathing.
Prolonged clotting time.
Decreased temperature.
Decreased respiratory rate.
Increased ability to expectorate secretions.

Answer

A

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

Q

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

A

1. 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

Q

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

Answer

A

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

Q

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%

Assure the client is maintaining complete bed rest.
Check the urine output.
Ask the client to drink more fluids.
Notify the physician.
Administer acetaminophen (Tylenol) as prescribed.

Answer

A

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

Q

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

Answer

A

1. 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

Q

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

A

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

Q

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

Answer

A

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

Q

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:

Initiate airborne precautions.
Apply oxygen at 2 L per nasal cannula.
Collect a sputum sample.
Reassess vital signs.

Answer

A

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

Q

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

A

1. 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

Q

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:
Vertigo.2. Facial paralysis.
Impaired vision.
Difficulty swallowing.

Answer

A

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

Q

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
Request that the health care provider review the prescriptions for a duplication between
isoniazid and ethambutol.
Inform the client that all drugs will be discontinued until the client can eat solid foods.
Ask the pharmacist to check for drug interactions between the rifampin and isoniazid.
Tell the client that it is important to continue to take the medications because the combination
of drugs prevents bacterial resistance

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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?
Offering the client emotional support.
Teaching the client about the disease and its treatment.
Coordinating various agency services.
Assessing the client’s environment for sanitation.

Answer

A

1. 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

Q

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

Answer

A

1. 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

Q

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

Answer

A

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

Q

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

Answer

A

1. 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

Q

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

A

1. 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

Q

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.
“I will need to dispose of my old clothing when I return home.”
“I should always cover my mouth and nose when sneezing.”
“It is important that I isolate myself from family when possible.”
“I should use paper tissues to cough in and dispose of them promptly.”
“I can use regular plates and utensils whenever I eat.”

Answer

A

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

Q

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

Answer

A

1. 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

Q

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

Answer

A

1. 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

Answer 65

A

1. 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

Answer 66

A

1. 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

Answer 67

A

1. 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

Answer 68

A

1. 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

Answer 69

A

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

Answer 70

A

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

Answer 71

A

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

Answer 72

A

1. 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

Answer 73

A

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

Answer 74

A

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

Answer 75

A

1. 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

Answer 76

A

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

Answer 77

A

1. 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

Answer 78

A

1. 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

Answer 79

A

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

Answer 80

A

1. 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

Answer 81

A

1. 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

Answer 82

A

1. 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

Answer 83

A

1. 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

Answer 84

A

1. 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

Answer 85

A

1. 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

Answer 86

A

1. 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

Answer 87

A

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

Answer 88

A

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

Answer 89

A

1. 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

Answer 90

A

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

Answer 91

A

1. 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

Answer 92

A

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

Answer 93

A

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

Answer 94

A

1. 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

Answer 95

A

1. 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

Answer 96

A

1. 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

Answer 97

A

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

Answer 98

A

1. 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

Answer 99

A

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

Answer 100

A

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

Answer 101

A

1. 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

Answer 102

A

The Client with Lung Cancer

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

Answer 103

A

1. 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

Answer 104

A

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

Answer 105

A

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

Answer 106

A

1. 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

Answer 107

A

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

Answer 108

A

1. 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

Answer 109

A

1. 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

Answer 110

A

1. 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

Answer 111

A

1. 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

Answer 112

A

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

Answer 113

A

1. 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

Answer 114

A

1. 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

Answer 115

A

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

Answer 116

A

1. 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

Answer 117

A

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

Answer 118

A

1. 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

Answer 119

A

1. 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

Answer 120

A

1. 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

Answer 121

A

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

Answer 122

A

0.7 mL

CN: Pharmacological and parenteral therapies; CL: Apply

Answer 123

A

1. 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

Answer 124

A

1. 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

Answer 125

A

1. 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

Answer 126

A

1. 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

Answer 127

A

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

Answer 128

A

1. 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

Answer 129

A

1. 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

Answer 130

A

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

Answer 131

A

1. 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

Answer 132

A

Correct answer:
The fluid typically localizes at the base of the thorax.

CN: Management of care; CL: Synthesize

Answer 133

A

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

Answer 134

A

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

Answer 135

A

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

Answer 136

A

1. 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

Answer 137

A

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

Answer 138

A

1. 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

Answer 139

A

1. 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

Answer 140

A

1. 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

Answer 141

A

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

Answer 142

A

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

Answer 143

A

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

Answer 144

A

1. 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

Answer 145

A

1. 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

Answer 146

A

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

Answer 147

A

1. 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

Answer 148

A

1. 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

Answer 149

A

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

Answer 150

A

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

Answer 151

A

1. 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

Answer 152

A

1. 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

Answer 153

A

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

Answer 154

A

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

Answer 155

A

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

Answer 156

A

1. 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

Answer 157

A

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

Answer 158

A

1. 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

Answer 159

A

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

Answer 160

A

1. 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

Answer 161

A

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