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The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? Wheezing becomes louder. Cough remains nonproductive. Vesicular breath sounds decrease. Aerosol bronchodilators stimulate coughing.
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Wheezing becomes louder. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.
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During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? Laryngospasm Pulmonary edema Narrowing of the airway Overdistention of the alveoli
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Narrowing of the airway Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing
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A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? Anxiety Cyanosis Bradycardia Hypercapnia
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Anxiety An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.
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The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? Allow time to calm the patient. Observe for signs of diaphoresis. Evaluate the use of intercostal muscles. Monitor the patient for bilateral chest expansion.
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Evaluate the use of intercostal muscles. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.
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Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? Supine Lithotomy High Fowler's Reverse Trendelenburg
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High Fowler's The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.
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The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? Work of breathing Fear of suffocation Effects of medications Anxiety and restlessness
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Work of breathing When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.
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The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing
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Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used, but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.
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A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? Oxygen tent Venturi mask Nasal cannula Oxygen-conserving cannula
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Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.
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While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Use the flow meter each morning after taking medications to evaluate their effectiveness. Increase the doses of the long-term control medication if the peak flow numbers decrease. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.
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Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.
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The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? "Close lips tightly around the mouthpiece and breathe in deeply and quickly." "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."
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"Close lips tightly around the mouthpiece and breathe in deeply and quickly." The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.
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The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after what occurs? Hypertension and pulmonary edema Oropharyngeal candidiasis and hoarseness Elevation of blood glucose and calcium levels Adrenocortical dysfunction and hyperglycemia
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Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.
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The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? "I will pay less for medication because it will last longer." "More of the medication will get down into my lungs to help my breathing." "Now I will not need to breathe in as deeply when taking the inhaler medications." "This device will make it so much easier and faster to take my inhaled medications."
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"More of the medication will get down into my lungs to help my breathing." A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.
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Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels
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A decreased exhaled nitric oxide Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in the asthma patient.
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The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Pulse rate of 72/minute Temperature of 98.4° F Oxygen saturation 96% Respiratory rate of 18/minute
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Pulse rate of 72/minute Correct Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 indicates that the patient did not experience tachycardia as an adverse effect.
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The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? Albuterol (Proventil) Salmeterol (Serevent) Beclomethasone (Qvar) Ipratropium bromide (Atrovent)
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Albuterol (Proventil) Correct Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).
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The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? Apical pulse Daily weight Bowel sounds Deep tendon reflexes
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Daily weight Correct Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.
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When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply)? Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections
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Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD).
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The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? Chew a hard candy before the first puff of medication. Rinse the mouth with water before each puff of medication. Ask for a breath mint following the second puff of medication. Rinse the mouth with water following the second puff of medication.
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Rinse the mouth with water following the second puff of medication. Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.
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The nurse is evaluating if a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? Place it in water to see if it floats. Keep track of the number of inhalations used. Shake the canister while holding it next to the ear Check the indicator line on the side of the canister.
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Keep track of the number of inhalations used. It is no longer appropriate to see if a canister floats in water or not since this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used. (100 puffs/2 puffs each day = 50 days)
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When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? An overproduction of the antiprotease α1-antitrypsin Hyperinflation of alveoli and destruction of alveolar walls Hypertrophy and hyperplasia of goblet cells in the bronchi Collapse and hypoventilation of the terminal respiratory unit
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Hyperinflation of alveoli and destruction of alveolar walls In COPD there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.
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A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? Arterial pH 7.26 PaCO2 50 mm Hg Patient in tripod position Increased sputum expectoration
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Arterial pH 7.26 The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.
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The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which finding? Absence of dyspnea Improved mental status Effective and productive coughing PaO2 within normal range for the patient
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Effective and productive coughing Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.
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When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? Order fruits and fruit juices to be offered between meals. Order a high-calorie, high-protein diet with six small meals a day. Teach the patient to use frozen meals at home that can be microwaved. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.
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Order a high-calorie, high-protein diet with six small meals a day. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with non-protein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.
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The nurse teaches pursed lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? Loosening secretions so that they may be coughed up more easily Promoting maximal inhalation for better oxygenation of the lungs Preventing bronchial collapse and air trapping in the lungs during exhalation Increasing the respiratory rate and giving the patient control of respiratory patterns
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Preventing bronchial collapse and air trapping in the lungs during exhalation The purpose of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.
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Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? Acute respiratory failure Secondary respiratory infection Fluid volume excess resulting from cor pulmonale Pulmonary edema caused by left-sided heart failure
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Fluid volume excess resulting from cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.
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A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? "Long-term home oxygen therapy should be used to prevent respiratory failure." "Oxygen will not be needed until or unless you are in the terminal stages of this disease." "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."
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"You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.
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Before discharge, the nurse discusses activity levels with a 61-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? Slightly increase activity over the current level. Swim for 10 min/day, gradually increasing to 30 min/day. Limit exercise to activities of daily living to conserve energy. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.
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Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient's age).
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The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which assessment finding? Decreased respiratory rate Increased respiratory rate Increased peak flow readings Decreased sputum production
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Increased peak flow readings Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates (PEFRs).
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The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? "Avoid shaking the inhaler before use." "Breathe out slowly before positioning the inhaler." "Using a spacer should be avoided for this type of medication." "After taking a puff, hold the breath for 30 seconds before exhaling."
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"Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.
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When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? Smoking causes a hoarse voice. Cough will become nonproductive. Decreased alveolar macrophage function Sense of smell is decreased with smoking.
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Decreased alveolar macrophage function The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.
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When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? Fat soluble vitamins and dietary salt should be avoided. Insulin may be needed with a diabetic diet if diabetes mellitus develops. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.
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Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.
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When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? Increasing dyspnea Temperature below 98.6° F Decreased sputum production Unable to drink 3 L low-sodium fluids
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Increasing dyspnea The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.
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1. A clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurse's best answer? A) "The most important risk factor for COPD is exposure to occupational toxins." B) "The most important risk factor for COPD is inadequate exercise." C) "The most important risk factor for COPD is exposure to dust and pollen." D) "The most important risk factor for COPD is cigarette smoking."
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D Feedback: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.
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2. A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? A) Lung cancer B) Cystic fibrosis C) Respiratory failure D) Hemothorax
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C Feedback: Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.
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3. A nurse is caring for a young adult patient whose medical history includes an alpha1-antitrypsin deficiency. This deficiency predisposes the patient to what health problem? A) Pulmonary edema B) Lobular emphysema C) Cystic fibrosis (CF) D) Empyema
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B Feedback: A host risk factor for COPD is a deficiency of alpha1-antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young patients to rapid development of lobular emphysema even in the absence of smoking. This deficiency does not influence the patient's risk of pulmonary edema, CF, or empyema.
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4. The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient? A) Signs of oxygen toxicity B) Chronic chest pain C) A barrel chest D) Long, thin fingers
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C Feedback: In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The patient would not show signs of oxygen toxicity unless he or she received excess supplementary oxygen.
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5. A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position? A) Sitting upright, leaning forward slightly B) Low Fowler's, with the neck slightly hyperextended C) Prone D) Trendelenburg
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A Feedback: The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowler's positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.
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6. A nurse is evaluating the diagnostic study data of a patient with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis? A) Elevated sweat chloride concentration B) Presence of protein in the urine C) Positive phenylketonuria D) Malignancy on lung biopsy
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A Feedback: Gene mutations affect transport of chloride ions, leading to CF, which is characterized by thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. Proteinuria, positive phenylketonuria, and malignancy are not diagnostic for CF.
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7. A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A) Administer corticosteroids by metered dose inhaler B) Administer inhaled anticholinergics C) Administer an inhaled beta-adrenergic agonist D) Utilize a peak flow monitoring device
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C Feedback: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.
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8. A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? A) Gradually increase levels of physical exertion. B) Change filters on heaters and air conditioners frequently. C) Take prescribed medications as scheduled. D) Avoid goose-down pillows.
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C Feedback: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.
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9. A student nurse is preparing to care for a patient with bronchiectasis. The student nurse should recognize that this patient is likely to experience respiratory difficulties related to what pathophysiologic process? A) Intermittent episodes of acute bronchospasm B) Alveolar distention and impaired diffusion C) Dilation of bronchi and bronchioles D) Excessive gas exchange in the bronchioles
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C Feedback: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue. It is not characterized by acute bronchospasm, alveolar distention, or excessive gas exchange.
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10. A nurse is caring for a 6-year-old patient with cystic fibrosis. In order to enhance the child's nutritional status, what intervention should most likely be included in the plan of care? A) Pancreatic enzyme supplementation with meals B) Provision of five to six small meals per day rather than three larger meals C) Total parenteral nutrition (TPN) D) Magnesium, thiamine, and iron supplementation
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A Feedback: Nearly 90% of patients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical.
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11. A patient arrives in the emergency department with an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patient's care? A) Oral administration of diuretics B) Intravenous fluids to reduce the viscosity of secretions C) Postural chest drainage D) Pulmonary function testing
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C Feedback: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the patient's symptoms.
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12. A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A) Shallow respirations B) Increased anterior-posterior (A-P) diameter C) Bilateral wheezes D) Bradypnea
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C Feedback: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's A-P diameter does not normally change.
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13. A nurse is developing the teaching portion of a care plan for a patient with COPD. What would be the most important component for the nurse to emphasize? A) Smoking up to one-half of a pack of cigarettes weekly is allowable. B) Chronic inhalation of indoor toxins can cause lung damage. C) Minor respiratory infections are considered to be self-limited and are not treated. D) Activities of daily living (ADLs) should be clustered in the early morning hours.
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B Feedback: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all patients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit patients to perform these without excessive distress.
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14. A nursing is planning the care of a patient with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? A) Taking prophylactic antibiotics as ordered B) Adhering to the treatment regimen in order to cure the disease C) Avoiding airplanes, buses, and other crowded public places D) Setting realistic short-term and long-range goals
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D Feedback: A major area of teaching involves setting and accepting realistic short-term and long-range goals. Emphysema is not considered curable and antibiotics are not used on a preventative basis. The patient does not normally need to avoid public places.
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15. A nurse is documenting the results of assessment of a patient with bronchiectasis. What would the nurse most likely include in documentation? A) Sudden onset of pleuritic chest pain B) Wheezes on auscultation C) Increased anterior-posterior (A-P) diameter D) Clubbing of the fingers
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D Feedback: Characteristic symptoms of bronchiectasis include chronic cough and production of purulent sputum in copious amounts. Clubbing of the fingers also is common because of respiratory insufficiency. Sudden pleuritic chest pain is a common manifestation of a pulmonary embolism. Wheezes on auscultation are common in patients with asthma. An increased A-P diameter is noted in patients with COPD.
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16. A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing an FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding? A) Strong exercise tolerance B) Exhalation volume is normal C) Respiratory infection D) Obstructive lung disease
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D Feedback: Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of forced expiration volume in 1 second to forced vital capacity. Obstructive lung disease is apparent when an FEV1/FVC ratio is less than 70%.
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17. A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? A) Increases the amount of mucus production B) Destabilizes hemoglobin C) Shrinks the alveoli in the lungs D) Collapses the alveoli in the lungs
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A Feedback: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.
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18. A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? A) Pets B) Lack of sleep C) Psychosocial stress D) Bacteria
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A Feedback: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Lack of sleep, stress, and bacteria are not common triggers for asthma attacks.
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19. A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching? A) Lie supine to facilitate air entry B) Avoid pursed lip breathing C) Use diaphragmatic breathing D) Use chest breathing
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C Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in patients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.
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20. A nurse is caring for a patient who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the patient for which of the following clinical manifestations? A) Copious sputum production B) Pain on inspiration C) Pigeon chest D) Dry cough
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A Feedback: Clinical manifestations of bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers. Because of the copious production of sputum, the cough is rarely dry. A pigeon chest is not associated with the disease and patients do not normally experience pain on inspiration.
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21. A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF? A) Alveolar mucus plugging, infection, and eventual bronchiectasis B) Bronchial mucus plugging, inflammation, and eventual bronchiectasis C) Atelectasis, infection, and eventual COPD D) Bronchial mucus plugging, infection, and eventual COPD
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B Feedback: The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes. Infection, atelectasis, and COPD are not hallmark pathologies of CF.
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22. An older adult patient has been diagnosed with COPD. What characteristic of the patient's current health status would preclude the safe and effective use of a metered-dose inhaler (MDI)? A) The patient has not yet quit smoking. B) The patient has severe arthritis in her hands. C) The patient requires both corticosteroids and beta2-agonists. D) The patient has cataracts.
answer
B Feedback: Safe and effective MDI use requires the patient to be able to manipulate the device independently, which may be difficult if the patient has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a patient can safely use more than one MDI.
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23. A nurse is preparing to perform an admission assessment on a patient with COPD. It is most important for the nurse to review which of the following? A) Social work assessment B) Insurance coverage C) Chloride levels D) Available diagnostic tests
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D Feedback: In addition to the patient's history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of patients. Chloride levels are relevant to CF, not COPD. Insurance coverage is not normally the domain of the nurse.
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24. An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A) Kyphosis and clubbing of the fingers B) Dyspnea and hypoxemia C) Sepsis and pneumothorax D) Bradypnea and pursed lip breathing
answer
B Feedback: These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
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25. A nurse is caring for a patient with COPD. The patient's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? Select all that apply. A) Negative sputum culture B) Increased viscosity of lung secretions C) Increased respiratory rate D) Increased expiratory flow rate E) Relief of dyspnea
answer
D, E Feedback: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the patient's respiratory status. Bronchodilators would not have a direct result on the patient's infectious process.
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26. A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? A) Fine or coarse crackles on auscultation B) Wheezes or diminished breath sounds on auscultation C) Reduced respiratory rate or lethargy D) Slow, deliberate respirations
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B Feedback: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.
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27. The case manager for a group of patients with COPD is providing health education. What is most important for the nurse to assess when providing instructions on self-management to these patients? A) Knowledge of alternative treatment modalities B) Family awareness of functional ability and activities of daily living (ADLs) C) Knowledge of the pathophysiology of the disease process D) Knowledge about self-care and their therapeutic regimen
answer
D Feedback: When providing instructions about self-management, it is important for the nurse to assess the knowledge of patients and family members about self-care and the therapeutic regimen. This supersedes knowledge of alternative treatments or the pathophysiology of the disease, neither of which is absolutely necessary for patients to know. The patient's own knowledge is more important than that of the family.
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28. A nurse is developing a teaching plan for a patient with COPD. What should the nurse include as the most important area of teaching? A) Avoiding extremes of heat and cold B) Setting and accepting realistic short- and long-range goals C) Adopting a lifestyle of moderate activity D) Avoiding emotional disturbances and stressful situations
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B Feedback: A major area of teaching involves setting and accepting realistic short-term and long-range goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals.
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29. A nurse is assessing a patient who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply. A) Pulmonary hypertension B) Airway obstruction C) Pulmonary infections D) Genetic disorders E) Atelectasis
answer
B, C, D Feedback: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis.
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30. A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize? A) The patient will successfully mobilize pulmonary secretions. B) The patient will maintain an oxygen saturation level of 98%. C) The patient's pulmonary blood pressure will decrease to within reference ranges. D) The patient will resume prediagnosis level of function within 72 hours.
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A Feedback: Nursing management focuses on alleviating symptoms and helping patients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the patient with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals.
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31. An interdisciplinary team is planning the care of a patient with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply. A) Occupational therapy B) Antimicrobial therapy C) Positive pressure isolation D) Chest physiotherapy E) Smoking cessation
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B, D, E Feedback: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of patients with bronchiectasis. Occupational therapy and isolation are not normally indicated.
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32. A patient's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patient's statements suggests a need for further education? A) "I know that these drugs can sometimes make my heart beat faster." B) "I've heard that this drug is particularly good at preventing asthma attacks during exercise." C) "I'll make sure to use this each time I feel an asthma attack coming on." D) "I've heard that this drug sometimes gets less effective over time."
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C Feedback: LABAs are not used for management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.
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33. A nurse is providing health education to the family of a patient with bronchiectasis. What should the nurse teach the patient's family members? A) The correct technique for chest palpation and auscultation B) Techniques for assessing the patient's fluid balance C) The technique for providing deep nasotracheal suctioning D) The correct technique for providing postural drainage
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D Feedback: A focus of the care of bronchiectasis is helping patients clear pulmonary secretions; consequently, patients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary.
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34. A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. A) Chest tightness B) Crackles C) Bradypnea D) Wheezing E) Cough
answer
A, D, E Feedback: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.
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35. A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A) Rescue inhalers B) Anti-inflammatory drugs C) Antibiotics D) Antitussives
answer
B Feedback: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.
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36. A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? A) Dyspnea and increased respiratory secretions B) Nausea and vomiting C) Cough and oral thrush D) Fatigue and decreased level of consciousness
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C Feedback: Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.
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37. A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? A) To ensure long-term prevention of asthma exacerbations B) To cure any systemic infection underlying asthma attacks C) To prevent recurrent pulmonary infections D) To gain prompt control of inadequately controlled, persistent asthma
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D Feedback: Prednisone is used for a short-term (3-10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.
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38. An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? A) Encouraging patients to carry a corticosteroid rescue inhaler at all times B) Educating patients about recognizing and avoiding asthma triggers C) Teaching patients to utilize alternative therapies in asthma management D) Ensuring that patients keep their immunizations up to date
answer
B Feedback: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
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39. An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? A) Highest airflow during a forced inspiration B) Highest airflow during a forced expiration C) Airflow during a normal inspiration D) Airflow during a normal expiration
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B Feedback: Peak flow meters measure the highest airflow during a forced expiration.
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40. A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A) Teach the patient strategies for promoting diaphragmatic breathing. B) Administer supplementary oxygen by simple face mask. C) Teach the patient to perform airway suctioning. D) Assist the patient in developing an appropriate exercise program.
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A Feedback: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in patients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate.
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A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
answer
22 resp/min
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Nursing students are gathered for a study session about the pulmonary system. One student asks the others to name the primary causes for an acute exacerbation of COPD. Which of the following responses should be in the reply? Choose all that apply.
answer
Air pollution • Tracheobronchial infection
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A client experiencing an asthmatic attack is prescribed methylprednisolone (Solu-Medrol) intravenously. The nurse:
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Assesses fasting blood glucose levels
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A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply.
answer
Inflamed airways that obstruct airflow • Mucus secretions that block airways • Overinflated alveoli that impair gas exchange
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A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
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Weigh yourself daily and report a gain of 2 lb in 1 day."
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Emphysema is described by which of the following statements?
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A disease of the airways characterized by destruction of the walls of overdistended alveoli
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Upon assessment, the nurse suspects that a patient with COPD may have bronchospasm. What manifestations validate the nurse's concern? (Select all that apply.)
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Compromised gas exchange • Decreased airflow • Wheezes
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A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
answer
anxiety
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As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
answer
Respiratory acidosis
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Which of the following medications are classified as leukotriene modifiers (inhibitors)
answer
Montelukast (Singulair) • Zafirlukast (Accolate) • Zileuton (Zyflo)
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A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure?
answer
Respiratory acidosis
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55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse
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Asks the client, "What are your allergies?"
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A patient with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this patient includes which of the following?
answer
Implementing measures to clear pulmonary secretions
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In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?
answer
respiratory acidosis
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The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment?
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provide sufficient O2
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Which of the following is true about both lung transplant and bullectomy?
answer
Both are aimed at improving the overall quality of life of a patient with COPD.
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A nurse has just completed teaching with a patient who has been prescribed a meter-dosed inhaler for the first time. Which of the following statements would the nurse use to initiate further teaching and follow-up care?
answer
"I do not need to rinse my mouth with this type of inhaler."
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n which stage of COPD is the forced expiratory volume (FEV) less than 30%?
answer
3
question
Emphysema is described by which of the following statements? a) A disease that results in a common clinical outcome of reversible airflow obstruction b) Chronic dilatation of a bronchus or bronchi c) A disease of the airways characterized by destruction of the walls of overdistended alveoli d) Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of 2 consecutive years
answer
c) A disease of the airways characterized by destruction of the walls of overdistended alveoli Explanation: Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of over-distended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli. Also, a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of 2 consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.
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Which of the following is the most important risk factor for development of COPD? a) Air pollution b) Cigarette smoking c) Occupational exposure d) Genetic abnormalities
answer
b) Cigarette smoking Explanation: Risk factors for COPD include environmental exposures and host factors. The most important environmental risk factor for COPD worldwide is cigarette smoking. A dose-response relationship exists between the intensity of smoking (pack-year history) and the decline in pulmonary function. Other environmental risk factors include smoking pipes, cigars, and other types of tobacco. Passive smoking (i.e., second-hand smoke) also contributes to respiratory symptoms and COPD. Air pollution is a risk factor for development of COPD, but it is not the most important risk factor.
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Which type of chest configuration is typical of the patient with COPD? a) Pigeon chest b) Flail chest c) Barrel chest d) Funnel chest
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c) Barrel chest Explanation: In patients with COPD who have a primary emphysematous component, chronic hyperinflation leads to the "barrel chest" thorax configuration. This configuration results from a more fixed position of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest results from a displaced sternum. Flail chest results when the ribs are fractured. Funnel chest occurs when there is a depression in the lower portion of the sternum; it is associated with Marfan's syndrome or rickets.
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In which grade of COPD is the forced expiratory volume (FEV) less than 30%? a) III b) I c) II d) IV
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d) IV Explanation: COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment with COPD, and the potential for exacerbations. Grade I: (mild), FEV1/FVC < 70% and FEV1 ≥ 80% predicted. Grade II (moderate): FEV1/FVC1 < 70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC < 70% and FEV1 < 30% to 50% predicted. Grade IV (very severe): FEV1/FVC < 70% and FEV1 < 30% predicted.
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The nurse is caring for a patient with COPD. In COPD, the body attempts to improve oxygen-carrying capacity by increasing the amounts of red blood cells. Which of the following is the term for this process? a) Emphysema b) Bronchitis c) Asthma d) Polycythemia
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d) Polycythemia Explanation: Polycythemia is an increase in the red blood cell concentration in the blood. In COPD, the body attempts to improve oxygen-carrying capacity by producing increasing amounts of red blood cells.
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Which of the following is the strongest predisposing factor for asthma? a) Air pollution b) Congenital malformations c) Male gender d) Allergy
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d) Allergy Explanation: Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens also increases the risk of asthma. Common allergens can be seasonal (grass, tree, and weed pollens) or perennial (mold, dust, roaches, animal dander).
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A patient is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which of the following medications is contraindicated in the treatment of asthma exacerbations? a) Atrovent (Ipratropium) b) Intal (Cromolyn Sodium) c) Xopenex (Levalbuterol HFA) d) Proventil (Albuterol)
answer
b) Intal (Cromolyn Sodium) Explanation: Intal is contraindicated in patients with acute asthma exacerbation. Indications for Intal are long-term prevention of symptoms in mild, persistent asthma; it may modify inflammation. Intal is also a preventive treatment prior to exposure to exercise or known allergen. Proventil (albuterol), Xopenex (levalbuterol HFA), and Atrovent (ipratropium) can be used to relieve acute symptoms.
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As status asthmaticus worsens, the nurse would expect the patient to develop which of the following acid-base imbalances? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratory alkalosis d) Respiratory acidosis
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d) Respiratory acidosis Explanation: There is reduced PaO2 and initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, PaCO2 increases and the pH decreases, reflecting respiratory acidosis.
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Which of the following diagnostic test is the most accurate in assessing acute airway obstruction? a) Spirometry b) Pulmonary function studies c) Pulse oximetry d) Arterial blood gases (ABGs)
answer
b) Pulmonary function studies Explanation: Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC). Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs, and pulse oximetry are not the most accurate diagnostics for an airway obstruction.
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A male patient newly diagnosed with COPD tells the nurse, "I can't believe I have COPD, I only had a cough; are there other symptoms I should know about"? Which of the following is the nurse's best response? a) "You can also expect to experience a progressive weight gain." b) "As your COPD worsens, you will develop frequent respiratory infections." c) "There are no other symptoms; however, your cough may get worse as the disease progresses." d) "Other symptoms you may develop are shortness of breath on exertion, and sputum production."
answer
d) "Other symptoms you may develop are shortness of breath on exertion, and sputum production." Explanation: COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea on exertion. Patients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. Weight loss is common with COPD.
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Which of the following exposures accounts for most of the risk factors for COPD? a) Ambient air pollution b) Exposure to tobacco smoke c) Occupational exposure d) Passive smoking
answer
b) Exposure to tobacco smoke Explanation: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.
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The nurse is reviewing first-line pharmacotherapy for smoking abstinence with a patient diagnosed with COPD. The nurse correctly includes which of the following medications? Select all that apply. a) Nicotine gum b) Wellbutrin c) Zyban d) Chantix e) Catapres
answer
a) Nicotine gum, b) Wellbutrin, c) Zyban Explanation: First-line therapy includes nicotine gum, Zyban, and Wellbutrin. Second-line pharmacotherapy includes the antihypertensive agent clonidine (Catapres). However, the use of clonidine is limited by its side effects. Varenicline (Chantix), a nicotinic acetylcholine receptor partial agonist, may also assist in smoking cessation.
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Why would a patient with COPD report feeling fatigued? Select all that apply. a) The patient is using all expendable energy just to breathe. b) There is a gradual decrease in muscle function over time in a patient with COPD. c) There is a gradual decrease in lung function over time in a patient with COPD. d) The patient is using all expendable energy for activities of daily living (ADLs).
answer
a) The patient is using all expendable energy just to breathe., c) There is a gradual decrease in lung function over time in a patient with COPD. Explanation: The patient is using all expendable energy just to breathe. There is a gradual decrease in lung function, not muscle function, over time in a patient with COPD. In the patient with COPD, fatigue and feeling of exhaustion stem directly from the disease, not from activity level.
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Following are statements regarding medications taken by a patient diagnosed with COPD. Choose which statements correctly match the drug name to the drug category. Select all that apply. a) Ciprofloxacin is an antibiotic. b) Decadron is an antibiotic. c) Bactrim is a bronchodilator. d) Albuterol is a bronchodilator. e) Prednisone is a corticosteroid.
answer
a) Ciprofloxacin is an antibiotic., d) Albuterol is a bronchodilator., e) Prednisone is a corticosteroid. Explanation: Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone (Decadron) and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and cotrimoxazole (Bactrim) are antibiotics. These are all drugs that could be prescribed to a patient with COPD.
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A patient presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands there are goals of therapy that are achieved to improve the patient's condition. Which of the following are therapy goals? Select all that apply. a) Return the patient to his original functioning abilities. b) Teach the patient to suspend activity. c) Provide medical support for the current exacerbation. d) Treat the underlying cause of the event. e) Return the patient to his original functioning abilities.
answer
a) Return the patient to his original functioning abilities., a) Return the patient to his original functioning abilities., c) Provide medical support for the current exacerbation., d) Treat the underlying cause of the event. Explanation: The goal is to have a stable patient with COPD leading the most productive life possible. COPD cannot necessarily be cured, but it can be managed so that the patient can live a reasonably normal life. With adequate management, patients should not have to give up their usual activities.
question
Which of the following measures may increase complications for a patient with COPD? a) Decreased oxygen supply b) Administration of antibiotics c) Administration of antitussive agents d) Increased oxygen supply
answer
d) Increased oxygen supply Explanation: Administering too much oxygen can result in the retention of carbon dioxide. Patients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and increasing hypercapnia occurs. All the other measures are aimed at preventing complications.
question
Which of the following is true about both lung transplant and bullectomy? a) Both are aimed at treating end-stage emphysema. b) Both are aimed at improving the overall quality of life of a patient with COPD. c) Both are aimed at curing COPD. d) Both are used to treat patients with bullous emphysema.
answer
b) Both are aimed at improving the overall quality of life of a patient with COPD. Explanation: The treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a patient with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat patients with bullous emphysema.
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A nurse is caring for a male patient with COPD. While reviewing breathing exercises, the nurse instructs the patient to breathe in slowly through the nose, taking in a normal breath. Then, the nurse asks the patient to pucker his lips as if preparing to whistle. Finally, the patient is told to exhale slowly and gently through the puckered lips. The nurse teaches the patient this breathing exercise to accomplish which of the following? Select all that apply. a) Release trapped air in the lungs b) Strengthen the diaphragm c) Prevent collapse of the airways d) Condition the inspiratory muscles e) Control the rate and depth of respirations
answer
a) Release trapped air in the lungs, c) Prevent collapse of the airways, e) Control the rate and depth of respirations Explanation: The nurse is teaching the patient the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases trapped air in the lungs, and helps the patient control the rate and depth of respirations. This helps patients relax and get control of dyspnea and reduces the feelings of panic they experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training the patient will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.
question
A patient diagnosed with asthma is preparing for discharge. The nurse is educating the patient on the proper use of a peak flow meter. The nurse will instruct the patient to complete which of the following? a) Take and record peak flow readings three times daily. b) Move the indicator to the top of the numbered scale. c) If coughing occurs during the procedure, repeat it. d) Sit down while completing a peak flow reading.
answer
c) If coughing occurs during the procedure, repeat it. Explanation: Steps for using the peak flow meter correctly include (1) Moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing mouthpiece in mouth and closing lips around mouthpiece; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the patient coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.
question
A patient with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this patient includes which of the following? a) Implementing measures to clear pulmonary secretions b) Providing the patient with a low-calorie, high-fiber diet c) Teaching the family how to perform postural drainage d) Instructing the patient on the signs of respiratory infection
answer
a) Implementing measures to clear pulmonary secretions Explanation: Nursing management focuses on alleviating symptoms and helping patients clear pulmonary secretions. Although teaching the family how to perform postural drainage and instructing the patient on the signs of respiratory infection are important, they are not the nurse's primary focus. The presence of a large amount of mucus may decrease the patient's appetite and result in an inadequate dietary intake; therefore, the patient's nutritional status is assessed and strategies are implemented to ensure an adequate diet.
question
The nurse is assigned the care of a 30-year-old female patient diagnosed with cystic fibrosis (CF). Which of the following nursing interventions will be included in the patient's plan of care? a) Performing chest physiotherapy as ordered b) Restricting oral intake to 1,000 mL/day c) Discussing palliative care and end-of-life issues with the patient d) Providing the patient with a low sodium diet
answer
a) Performing chest physiotherapy as ordered Explanation: Nursing care includes helping patients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. The patient with CF also experiences increased salt content in sweat gland secretions; thus, it is important to ensure the patient consumes a diet that is adequate in sodium. As the disease progresses, the patient will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the patient terminally ill.
question
The nurse is reviewing metered-dose inhaler (MDI) instructions with a patient. Which of the following patient statements indicates the need for further instruction? a) "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." b) "I will take a slow, deep breath in after pushing down on the MDI." c) "I can't use a spacer or holding chamber with the MDI." d) "I will shake the MDI container before I use it."
answer
c) "I can't use a spacer or holding chamber with the MDI." Explanation: The patient can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining patient statements are accurate and indicate the patient understands how to use the MDI correctly.
question
The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent? a) 30% b) 50% c) 70% d) 90%
answer
d) 90% Explanation: The goal of supplemental oxygen therapy is to increase the baseline resting partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level and arterial oxygen saturation (SaO2) to at least 90%.
question
A patient is receiving theophylline (Theo-Dur) for long-term control and prevention of asthma symptoms. Patient teaching related to this medication will include which of the following? a) The importance of blood tests to monitor serum concentrations b) Taking the medication at least 1 hour prior to meals c) Development of hyperkalemia d) Monitoring liver function studies as prescribed
answer
a) The importance of blood tests to monitor serum concentrations Explanation: The nurse should inform patients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The patient is at risk of developing hypokalemia.
question
A patient is being treated in the ED for respiratory distress, coupled with pneumonia. The patient has no past medical history. However, the patient works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which of the following orders based on immediate needs for the patient? a) Completion of a 12-lead ECG b) Administration of corticosteroids and bronchodilators c) Administration of antibiotics d) Patient education: avoidance of irritants like smoke and pollutants
answer
c) Administration of antibiotics Explanation: Antibiotics are administered to treat respiratory tract infections. Chronic bronchitis is inflammation of the bronchi caused by irritants or infection. Hence, smoking cessation and avoiding pollutants are necessary to slow the accelerated decline of the lung tissue. However, the immediate priority in this case is to cure the infection, pneumonia. Corticosteroids and bronchodilators are administered to asthmatic patients when they show symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.
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When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperoxemia, hypocapnia, and hyperventilation b) Hypotension, hyperoxemia, and hypercapnia c) Hypercapnia, hypoventilation, and hypoxemia d) Hyperventilation, hypertension, and hypocapnia
answer
c) Hypercapnia, hypoventilation, and hypoxemia Rationale: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
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A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing
answer
d) Dyspnea and wheezing Rationale: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
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A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? a) 15-mm induration b) Reddened area c) 5-mm induration d) A blister
answer
a) 15-mm induration Rationale: A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.
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The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? a) Sudden onset in client who had compromised lung function b) Insidious onset in client who had compromised lung function c) Insidious onset in client who had normal lung function d) Sudden onset in client who had normal lung function
answer
d) Sudden onset in client who had normal lung function Rationale: Acute respiratory failure occurs suddenly in a client who previously had normal lung function.
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Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin D b) Vitamin E c) Vitamin C d) Vitamin B6
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d) Vitamin B6 Rationale: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
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The physician orders a patient to have 2 L/min of oxygen per nasal cannula. When calculating the correct FiO2 for this setting, which of the following would be correct? a) 36% b) 40% c) 32% d) 28%
answer
d) 28% Rationale: The correct calculation of a FiO2 for 2 L would be 28%. Three liters per minute equals 32% FiO2; 4 L/min equals 36% FiO2; and 5 L/min equals 40% FiO2.
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You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? a) Encourage increased fluid intake. b) Place client on bed rest. c) Offer nutritious snacks 2 times a day. d) Give antibiotics as ordered.
answer
a) Encourage increased fluid intake. Rationale: The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.
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A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Ineffective breathing pattern. b) Ineffective airway clearance. c) Impaired tissue integrity. d) Risk for falls.
answer
b) Ineffective airway clearance. Rationale: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
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Which of the following is a potential cause of histotoxic hypoxia? a) Fungi b) Virus c) Cyanide d) Bacteria
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c) Cyanide Rationale: Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of the tissues to use available oxygen. The other options are not potential causes of histotoxic hypoxia.
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A Class 1 with regards to TB indicates a) Exposure and no evidence of infection. b) Disease that is not clinically active. c) Latent infection with no disease. d) No exposure and no infection
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a) Exposure and no evidence of infection. Rationale: Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active.
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A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client who is receiving acetaminophen (Tylenol) for pain b) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago c) A client with a nasogastric tube d) A client who ambulates in the hallway every 4 hours
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c) A client with a nasogastric tube Rationale: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
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Ventilator-acquired pneumonia (VAP) is a type of hospital-acquired pneumonia (HAP) that is associated with which of the following interventions? a) Urinary catheterization b) Central line placement c) Endotracheal intubation d) Nasogastric suctioning
answer
c) Endotracheal intubation Rationale: VAP is a type of HAP that is associated with endotracheal intubation and mechanical ventilation. VAP is defined as pneumonia that develops in patients who have been receiving mechanical ventilation for at least 48 hours. Urinary catheterization, central line placement, and nasogastric suctioning are not associated with VAP.
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A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Impaired gas exchange b) Imbalanced nutrition: Less than body requirements c) Impaired oral mucous membranes d) Activity intolerance
answer
a) Impaired gas exchange Rationale: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.
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Which of the following terms refers to lung tissue that has become more solid in nature due to a collapse of alveoli or an infectious process? a) Empyema b) Consolidation c) Bronchiectasis d) Atelectasis
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b) Consolidation Rationale: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.
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A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Myocardial infarction (MI) b) Pneumothorax c) Pulmonary embolism d) Heart failure
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b) Pneumothorax Rationale: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
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After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 2 to 4 months b) 1 to 3 weeks c) 6 to 12 months d) 3 to 5 days
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c) 6 to 12 months Rationale: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
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A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) test stimulates a reddened response in some clients and requires a second test in 3 months. b) skin test doesn't differentiate between active and dormant tuberculosis infection. c) area of redness is measured in 3 days and determines whether tuberculosis is present. d) presence of a wheal at the injection site in 2 days indicates active tuberculosis.
answer
b) Skin test doesn't differentiate between active and dormant tuberculosis infection. Rationale: The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
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A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Decreased cardiac output b) Anxiety c) Impaired gas exchange d) Ineffective tissue perfusion (cardiopulmonary)
answer
c) Impaired gas exchange Rationale: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
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A 73-year-old client was admitted to the pulmonology unit with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. Which of the following primary conditions would most likely have caused the pleural effusion? a) Emphysema b) Sleep apnea c) Heart failure d) Asthma
answer
c) Heart failure Rationale: Pleural effusion may be a complication of pneumonia, lung cancer, TB, pulmonary embolism, and CHF.
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What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
answer
a) Draining secretions, air, and blood from the thoracic cavity is necessary. Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.
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A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? a) Keeping the door to the client's room open to observe the client b) Instructing the client to wear a mask at all times c) Putting on an individually fitted mask when entering the client's room d) Wearing a gown and gloves when providing direct care
answer
c) Putting on an individually fitted mask when entering the client's room Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times. pg.591
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A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Clubbing of fingers and toes b) Respiratory acidosis c) Paradoxical chest movement d) Chest pain on inspiration
answer
c) Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia. pg.612
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You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if the chest tube is clogged. b) See if the wall suction unit has malfunctioned. c) See if there are leaks in the system. d) See if a kink has developed in the tubing.
answer
c) See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected. pg.526
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You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a) Progressive loss of lung function associated with chronic disease b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function
answer
a) Progressive loss of lung function associated with chronic disease Explanation: In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect. pg.595
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You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Negative Homan's sign b) Pain in the feet c) Pain in the calf d) Inability to dorsiflex
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c) Pain in the calf Explanation: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis. pg.600
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Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? a) Constipation usually develops b) It is spread by fecal contamination c) Hypothermia will occur d) It is the most contagious during the second week of illness
answer
d) It is the most contagious during the second week of illness Explanation: Based on available information, SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes. pg.586
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You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? a) Provide employees with smoking cessation materials. b) Insist on adequate breaks for each employee. c) Fit all employees with protective masks. d) Give workshops on disease prevention.
answer
c) Fit all employees with protective masks. Explanation: The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases. pg.605
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Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions b) Do not allow visitors with respiratory infections c) Place suspected patients together d) Encourage breathing exercises
answer
d) Encourage breathing exercises Explanation: The nurse instructs the patient in lung-expanding breathing exercises to restore normal respiratory function. pg.595
question
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a) Bloody drainage is seemed in the collection chamber. b) Crackling is heard when skin around tube is touched. c) Skin around tube is pink. d) Absence of bloody drainage in the anterior/upper tube
answer
b) Crackling is heard when skin around tube is touched. Explanation: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers not serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid,whereas the anterior or upper tube is for air removal. pg.616
question
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Consume majority of fluid intake prior to bed. b) Wear tight-fitting clothing. c) Begin estrogen replacement. d) Tense and relax muscles in lower extremities.
answer
d) Tense and relax muscles in lower extremities. Explanation: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent the development of a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism. pg.601
question
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: a) "My tuberculosis isn't contagious after I take the medication for 24 hours." b) "I'll stop being contagious when I have a negative acid-fast bacilli test." c) "I'm contagious as long as I have night sweats." d) "I'm clear when my chest X-ray is negative."
answer
b) I'll stop being contagious when I have a negative acid-fast bacilli test." Explanation: A client with drug-resistant tuberculosis isn't contagious when he's had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce negative acid-fast test results for several days. The client won't have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they don't indicate whether the client is contagious. pg.588
question
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? a) Classes at community centers to teach about smoking cessation strategies b) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays c) Legislation that requires homes and apartments be checked for asbestos leakage d) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes
answer
a) Classes at community centers to teach about smoking cessation strategies Explanation: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor. pg.605
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A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? a) Perform nasopharyngeal suctioning. b) Initiate oxygen therapy. c) Administer a heparin bolus and begin an infusion at 500 units/hour. d) Administer analgesics as ordered.
answer
b) Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism. pg.601
question
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Activity intolerance b) Impaired oral mucous membranes c) Imbalanced nutrition: Less than body requirements d) Impaired gas exchange
answer
d) Impaired gas exchange Explanation: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client. pg.582
question
A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." b) "You must consume a diet rich in protein, such as chicken, fish, and beans." c) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." d) "You must consume a diet low in fat by limiting dairy products and concentrated sweets."
answer
b) "You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess. pg.592
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You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a) Fibrotic changes in lungs b) Hemorrhage c) Damage to surrounding tissues d) Lung contusion
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a) Fibrotic changes in lungs Explanation: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries. pg.606
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What dietary recommendations should a nurse provide a patient with a lung abscess? a) A diet low in calories b) A carbohydrate-dense diet c) A diet rich in protein d) A diet with limited fat
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c) A diet rich in protein Explanation: For a patient with pleural effusion, a diet rich in protein and calories is pivotal. A carbohydrate-dense diet or diets with limited fat are not advisable for a patient with lung abscess. pg.591
question
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following? a) Pneumothorax b) Hemothorax c) Pleural effusion d) Consolidation
answer
c) Pleural effusion Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature due to collapse of alveoli or infectious process. pg.593
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A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? a) A negative reaction always excludes the diagnosis of TB. b) The PPD can be read within 12 hours after the injection. c) A positive reaction indicates that the client has active tuberculosis (TB). d) A positive reaction indicates that the client has been exposed to the disease.
answer
d) A positive reaction indicates that the client has been exposed to the disease. Explanation: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease. pg.588
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The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Fever b) Headache c) Weight loss d) Shortness of breath
answer
d) Shortness of breath Explanation: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss. pg.604
question
Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is a) tertiary drug resistance. b) secondary drug resistance. c) primary drug resistance. d) multidrug resistance.
answer
c) primary drug resistance. Explanation: Primary drug resistance to one of the first-line antituberculotic agents is people who have not had previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in patients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance. pg.589
question
Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women? a) Large cell carcinoma b) Squamous cell carcinoma c) Small cell carcinoma d) Adenocarcinoma
answer
d) Adenocarcinoma Explanation: Adenocarcinoma presents more peripherally as peripheral masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree. pg.605
question
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Flail chest b) Cardiac tamponade c) Pulmonary contusion d) Tension pneumothorax
answer
d) Tension pneumothorax Explanation: Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation. pg.614
question
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: a) follow up with the physician in 2 weeks. b) turn and reposition himself every 2 hours. c) maintain fluid intake of 40 oz (1,200 ml) per day. d) continue to take antibiotics for the entire 10 days.
answer
d) continue to take antibiotics for the entire 10 days. Explanation: The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids. pg.583
question
On auscultation, which finding suggests a right pneumothorax? a) Inspiratory wheezes in the right thorax b) Absence of breath sounds in the right thorax c) Bilateral pleural friction rub d) Bilateral inspiratory and expiratory crackles
answer
b) Absence of breath sounds in the right thorax Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation. pg.614
question
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions. b) Do not allow visitors with respiratory infection. c) Encourage breathing exercises. d) Place suspected patients together.
answer
c) Encourage breathing exercises. Explanation: The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings. pg.595
question
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperventilation, hypertension, and hypocapnia b) Hypercapnia, hypoventilation, and hypoxemia c) Hypotension, hyperoxemia, and hypercapnia d) Hyperoxemia, hypocapnia, and hyperventilation
answer
b) Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems. pg.595
question
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Developing a list of people with whom the client has had contact c) Client teaching about the importance of TB testing d) Reviewing the risk factors for TB
answer
b) Developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development. pg.590
question
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. b) The client exhibits bronchial breath sounds over the affected area. c) The client exhibits restlessness and confusion. d) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
answer
a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation. pg.584
question
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: a) Significant b) Negative c) Nonreactive d) Not significant
answer
a) Significant Explanation: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant. pg.588
question
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? a) Uncertain b) Positive c) Borderline d) Negative
answer
d) Negative Explanation: The size of the induration determines the significance of the reaction. A reaction of 0-4 mm is not considered to be significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity. pg.588
question
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? a) Place client on bed rest. b) Offer nutritious snacks 2 times a day. c) Encourage increased fluid intake. d) Give antibiotics as ordered.
answer
c) Encourage increased fluid intake. Explanation: The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse. pg.583
question
A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Silica b) Coal dust c) Pollen d) Asbestos
answer
d) Asbestos Explanation: Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis. pg.605
question
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Decreased cardiac output b) Anxiety c) Ineffective tissue perfusion (cardiopulmonary) d) Impaired gas exchange
answer
d) Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange. pg.610
question
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Bronchitis b) Lung cancer c) Tracheobronchitis d) Acute respiratory distress syndrome
answer
d) Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis. pg.596
question
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? a) Respiratory alkalosis b) Productive cough c) Blood-tinged sputum d) Bradypnea
answer
c) Blood-tinged sputum Explanation: The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions. pg.613
question
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 1 to 3 weeks b) 6 to 12 months c) 2 to 4 months d) 3 to 5 days
answer
b) 6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis. pg.589
question
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin E b) Vitamin D c) Vitamin C d) Vitamin B6
answer
d) Vitamin B6 Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate. pg.589
question
A Class 1 with regards to TB indicates a) disease that is not clinically active. b) exposure and no evidence of infection. c) no exposure and no infection. d) latent infection with no disease.
answer
b) exposure and no evidence of infection. Explanation: Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active. pg.588
question
Which of the following is a key characteristic of pleurisy? a) Blood-tinged secretions b) Pain c) Dyspnea d) Anxiety
answer
b) Pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. pg.592
question
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Sore throat and abdominal pain b) Nonproductive cough and normal temperature c) Hemoptysis and dysuria d) Dyspnea and wheezing
answer
d) Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia. pg.577
question
What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
answer
a) Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect. pg.493
question
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client with a nasogastric tube b) A client who is receiving acetaminophen (Tylenol) for pain c) A client who ambulates in the hallway every 4 hours d) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago
answer
a) A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur. pg.577
question
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis
answer
b) Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect. pg.596
question
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Risk for falls. b) Ineffective breathing pattern. c) Ineffective airway clearance. d) Impaired tissue integrity.
answer
c) Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client. pg.582
question
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.35, PaCO2 48 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.46, PaO2 80 mm Hg d) pH 7.36, PaCO2 32 mm Hg
answer
b) pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. pg.595
question
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) test stimulates a reddened response in some clients and requires a second test in 3 months. c) presence of a wheal at the injection site in 2 days indicates active tuberculosis. d) skin test doesn't differentiate between active and dormant tuberculosis infection.
answer
d) skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis. pg.588
question
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Rapid onset of severe dyspnea b) Cyanosis c) Inspiratory crackles d) Bilateral wheezing
answer
a) Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event pg.596
question
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? a) Social isolation b) Deficient knowledge (disease process and treatment regimen) c) Impaired social interaction d) Anxiety
answer
b) Deficient knowledge (disease process and treatment regimen) Explanation: This client is exhibiting Deficient knowledge about the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, his question reflects sadness at the prospect of being separated from his family rather than anxiety about the disease. Because he has just been diagnosed and hasn't had a chance to demonstrate compliance, a nursing diagnosis of Social isolation isn't appropriate. A diagnosis of Impaired social interaction usually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis. pg.587
question
A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a) "I'll have to take these medications for 9 to 12 months." b) "The people I have contact with at work should be checked regularly." c) "I'll need to have scheduled laboratory tests while I'm on the medication." d) "It won't be necessary for the people I work with to take medication."
answer
b) "The people I have contact with at work should be checked regularly." Explanation: The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements. pg.587
question
The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? a) Sudden onset in client who had normal lung function b) Insidious onset in client who had normal lung function c) Insidious onset in client who had compromised lung function d) Sudden onset in client who had compromised lung function
answer
a) Sudden onset in client who had normal lung function Explanation: Acute respiratory failure occurs suddenly in a client who previously had normal lung function. pg.595
question
You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? a) Drug ingestion b) Chemical irritation c) Direct lung damage d) Aspiration
answer
b) Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome. pg.573
question
A positive Mantoux test indicates that a client: a) has produced an immune response. b) has an active case of tuberculosis. c) will develop full-blown tuberculosis. d) is actively immune to tuberculosis.
answer
a) has produced an immune response. Explanation: The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis. pg.588
question
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress? a) Chronic lung disease b) Normal lung function c) Loss of lung function d) Slow onset of symptoms
answer
b) Normal lung function Explanation: Acute respiratory failure occurs suddenly in clients who previously had normal lung function. pg.596
question
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? a) No fluid normally is present b) 5 - 15 ml c) 15 - 25 ml d) 20 - 30 ml
answer
b) 5 - 15 ml Explanation: Under normal conditions, approximately 5 to 15 mL of fluid between the pleurae prevent friction during pleural surface movement. pg.593
question
The nurse knows the mortality rate is high in lung cancer clients due to which factor? a) Increased exposure to industrial pollutants b) Increase in women smokers c) Few early symptoms d) Increased incidence among the elderly
answer
c) Few early symptoms Explanation: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to increase in number of women smokers, growing aging population, and exposure to pollutants but not indicative of mortality rates. pg.607
question
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a) "There are fibrous cysts in the lungs." b) "Early treatment can stop the progression of the disease." c) "The mucus-secreting glands are abnormal." d) "Allergic reactions cause inflammation in the lungs."
answer
c) "The mucus-secreting glands are abnormal." Explanation: Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis. pg.648
question
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Pneumothorax c) Heart failure d) Myocardial infarction (MI)
answer
b) Pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure. pg.613
question
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4? (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? a) The X-ray is inconclusive. b) A disease process is present. c) The ET tube must be pulled back. d) The ET tube must be advanced.
answer
b) A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4? above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back. pg.588
question
Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic b) Use a heat or cold application c) Turn onto the affected side d) Avoid using a pillow while splinting
answer
c) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side. The nurse also instructs the patient to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The patient can also splint the chest wall with a pillow when coughing. pg.593
question
A nurse is caring for a patient after a thoracentesis. Which of the following signs if noted in the patient should be reported to the physician immediately? a) "Patient has subcutaneous emphysema around needle insertion site." b) "Patient is becoming agitated and complains of pleuritic pain." c) "Patient is drowsy and complains of headache." d) "Patient has an oxygen saturation level of 93%."
answer
b) "Patient is becoming agitated and complains of pleuritic pain." Explanation: After a thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the patient may become anxious and develop dyspnea with increased use of the accessory muscles. pg.583
question
A client who is diagnosed with chronic respiratory failure will have which of the following symptoms? a) Dyspnea b) Hypercapnia c) Hypoxemia d) Ventilatory failure
answer
a) Dyspnea Explanation: Chronic respiratory failure develops over a long time period as the result of another condition. The most common diseases leading to chronic respiratory failure are COPD and neuromuscular disorders. A fall in arterial oxygen levels is a sign of acute respiratory failure. A rise in arterial CO2 is a sign of acute respiratory failure. Ventilatory failure develops in acute respiratory failure when the alveoli cannot adequately expand. pg.595
question
You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Aspiration b) Direct lung damage c) Chemical irritation d) Drug ingestion
answer
c) Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome. pg.573
question
A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? a) "Getting the flu can complicate pneumonia." b) "Influenza vaccine will prevent typical pneumonias." c) "Influenza is the major cause of death in the United States." d) "Viruses, like influenza, are the most common cause of pneumonia."
answer
d) "Viruses, like influenza, are the most common cause of pneumonia." Explanation: Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States. pg.573
question
A mediastinal shift occurs in which type of chest disorder? a) Traumatic pneumothorax b) Tension pneumothorax c) Cardiac tamponade d) Simple pneumothorax
answer
b) Tension pneumothorax Explanation: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. pg.614
question
For a patient with pleural effusion, what does chest percussion over the involved area reveal? a) Dullness over the involved area b) Absent breath sounds c) Fluid presence d) Friction rub
answer
a) Dullness over the involved area Explanation: Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. pg.594
question
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a) "Chest tube will allow air to be restored to the lung." b) "Chest tubes provide a route for medication instillation to the lung." c) "The tube will drain air from the space around the lung." d) "The tube will drain secretions from the lung."
answer
c) "The tube will drain air from the space around the lung." Explanation: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity. pg.614
question
Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? a) Fungal b) Streptococcal c) TB d) Pneumocystis
answer
d) Pneumocystis Explanation: Pneumocystis pneumonia incidence is greatest in patient with AIDS and patients receiving immunosuppressive therapy for cancer. pg.574
question
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy regimen? a) Within 48 hours after initiation of bacteriocidal drugs b) Results vary with each client, so it is difficult to predict c) After completion of 6 months of bacteriocidal drugs d) Two to 3 weeks after initiation of bacteriocidal drugs
answer
d) Two to 3 weeks after initiation of bacteriocidal drugs Explanation: The client needs to take the prescribed medications for approximately 2 to 3 weeks before discontinuing precautions against infecting others. Effectiveness of the drug therapy is determined by negative sputum smears obtained on three consecutive days. Although results can vary among clients, the majority respond to therapy within 2 to 3 weeks. pg.590
question
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years b) Daily doses of isoniazid, 300 mg for 6 months to 1 year c) Isolation until 24 hours after antitubercular therapy begins d) Nothing, until signs of active disease arise
answer
b) Daily doses of isoniazid, 300 mg for 6 months to 1 year Explanation: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis. pg.589
question
Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? a) pH 7.35 b) pH 7.28 c) PaCO 32 mm Hg d) PaO 80 mm Hg
answer
b) pH 7.28 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. pg.597
question
You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? a) Pain on inspiration b) Mucopurulent sputum c) Obvious trauma d) Shortness of breath
answer
b) Mucopurulent sputum Explanation: For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders but are not considered indicative of lung cancer. pg.607
question
The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Impaired Gas Exchange
answer
b) Ineffective Airway Clearance Explanation: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis. pg. 582
question
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Partial pressure of arterial carbon dioxide (PaCO2) b) pH c) Partial pressure of arterial oxygen (PaO2) d) Bicarbonate (HCO3-)
answer
c) Partial pressure of arterial oxygen (PaO2) Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed. pg.595
question
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Intubate the patient and control breathing with mechanical ventilation c) Schedule the patient for pulmonary surgery d) Increase oxygen administration
answer
b) Intubate the patient and control breathing with mechanical ventilation Explanation: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate. pg.597
question
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? a) Cardiac tamponade b) Flail chest c) Simple pneumothorax d) Pulmonary contusion
answer
b) Flail chest Explanation: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. pg.611
question
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a) Crackles b) Wheezes c) Rhonchi d) Decreased breath sounds
answer
d) Decreased breath sounds Explanation: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis. pg.593
question
Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Elevate the head of the bed b) Use a prescribed analgesic c) Use a heat application d) Turn onto the affected side
answer
d) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain. pg.593
question
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and assist in the diagnosis of an occupational lung disease? a) Cough and dyspnea b) Black-streaked sputum c) Tenacious secretions d) Barrel chest
answer
b) Black-streaked sputum Explanation: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time. pg.606
question
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "I'll stay in isolation for 6 weeks." b) "This disease may come back later if I am under stress." c) "I'll have to take the medication for up to a year." d) "I'll always have a positive test for tuberculosis."
answer
a) "I'll stay in isolation for 6 weeks." Explanation: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease. pg.587
question
The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer? a) Symptoms are often minimized by clients. b) There are no early symptoms of lung cancer. c) Symptoms often mimic other infectious diseases. d) Symptoms often do not appear until the disease is well established.
answer
d) Symptoms often do not appear until the disease is well established. Explanation: Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. Option A is correct, but it is not the best answer. Option B is incorrect because it is not a true statement. Option C is incorrect because lung cancer is not an infectious disease. pg.607
question
A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner? a) Apply vented dressing. b) Apply airtight dressing. c) Apply direct pressure to the wound. d) Clean the wound and leave open to the air.
answer
b) Apply airtight dressing. Explanation: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted. pg.613
question
Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? a) Tracheobronchitis b) Viral pneumonia c) Cardiovascular disease d) Staphylococcal pneumonia
answer
d) Staphylococcal pneumonia Explanation: Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease. Staphylococcal pneumonia is the most serious complication. Although tracheobronchitis is a complication of the flu, it is not the most serious one. Although cardiovascular disease is a complication of the flu, it is not the most serious one. Bacterial, not viral, pneumonia is a possible complication of the flu, although not its most serious one. pg.577
question
Approximately what percentage of people who are initially infected with TB develop active disease? a) 10% b) 40% c) 20% d) 30%
answer
a) 10% Explanation: Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate. pg.587
question
What are the conditions that make up Virchow's triad? Select all that apply. a) Hypocoagulability b) Disruption of the vessel lining c) Edema d) Hypercoagulability e) Venostasis
answer
a) Hypercoagulability b) Disruption of the vessel lining e) Venostasis Explanation: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad. pg.846
question
Following thoracic surgery, the care plan for a client at risk for impaired gas exchange would include which of the following? Select all that apply. a) Elevate head of bed 30°-40° as tolerated. b) Reinforce preoperative breathing exercises. c) Administer pain medications. d) Maintain accurate record of intravenous intake. e) Monitor vital signs frequently.
answer
e) Monitor vital signs frequently. b) Reinforce preoperative breathing exercises. a) Elevate head of bed 30°-40° as tolerated. Explanation: Nursing management for a client with the goal of maintaining optimal gas exchange includes assessing vital signs frequently, reinforcing preoperative instructions about deep breathing, coughing, and incentive spirometry, and elevating the head of the bed as tolerated. pg.528
question
Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections? a) Receiving vaccination b) Using prescribed opioids c) Using incentive spirometry d) Mobilizing early
answer
a) Receiving vaccination Explanation: Identifying the patients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages patients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis. pg.574
question
You've been invited to speak to the Hospital Guild of the hospital where you practice nursing. You've been asked to address "Communicable Diseases of Winter" and are speaking to a large group of volunteer women, most of whom are older than 60 years. What practices should you encourage in these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. a) Receiving vaccinations b) Techniques for incentive spirometry c) Hand antisepsis d) Using prescribed opioids
answer
a) Receiving vaccinations c) Hand antisepsis b) Techniques for incentive spirometry Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. Teaching the Guild members the proper method and times to wash their hands go a long way in disease prevention. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae. pg.571
question
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) empyema. b) Pneumocystis carinii pneumonia. c) infected chest tube wound site. d) lobar pneumonia.
answer
a) empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage. pg.594
question
A mechanically ventilated patient is receiving a combination of atracurium (Tracrium) and an opioid analgesic morphine. The nurse monitors the patient for which potential complication? a) Pulmonary hypertension b) Cor pulmonale c) Venous thromboemboli d) Pneumothorax
answer
c) Venous thromboemboli Explanation: Neuromuscular blockers predispose the patient to venous thromboemboli (VTE), muscle atrophy, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The patient may have discomfort or pain but be unable to communicate these sensations. pg.597
question
A 29-year-old client presents to the ED complaining of dyspnea on exertion and overall weakness. Her pulmonary arterial pressure is 40/15 mm Hg. These symptoms indicate that the client may have which of the following conditions? a) Atelectasis b) Restrictive lung disease c) Asthma d) Pulmonary arterial hypertension
answer
d) Pulmonary arterial hypertension pg.599
question
Which of the following types of lung cancer is characterized as fast growing and tending to arise peripherally? a) Bronchoalveolar carcinoma b) Adenocarcinoma c) Squamous cell carcinoma d) Large cell carcinoma
answer
d) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.605
question
Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall? a) Viral pneumonia b) Mycoplasmata pneumonia c) Legionnaires' disease d) Streptococcal (pneumococcal) pneumonia
answer
c) Legionnaires' disease Explanation: Legionnaires' disease accounts for 15% of community-acquired pneumonias. Streptococcal pneumonia demonstrates the highest occurrence in winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter. Viral pneumonia demonstrates the greatest incidence during winter months. pg.574
question
A 62-year-old female client arrives at the office complaining of dyspnea and fatigue. She tells the nurse that she's had a persistent productive cough for the last few months, which she attributes to a bout with the flu. The nurse suspects that this client may have which of the following? a) Pleurisy b) Lung abscess c) Pleural effusion d) Lung cancer
answer
d) Lung cancer Explanation: Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. The sputum is examined for malignant cells. Chest x-rays may or may not show a tumor. With pleurisy, the client's respirations become shallow secondary to excruciating pain. The client may have a dry cough, fatigue easily, and experience dyspnea. Fever, pain, and dyspnea are the most common symptoms of pleural effusion. Signs and symptoms of lung abscess include chills, fever, weight loss, chest pain, and a productive cough. pg.607
question
The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? a) pH 7.47, PaCO2 28, HCO3 30 b) pH 7.25, PaCO2 48, HCO3 24 c) pH 7.87, PaCO2 38, HCO3 28 d) pH 7.49, PaCO2 34, HCO3 25
answer
b) pH 7.25, PaCO2 48, HCO3 24 Correct Explanation: pH 7.25, PaCO2 48, HCO3 24 = respiratory acidosis pH 7.87, PaCO2 38, HCO3 28 = metabolic alkalosis pH 7.47, PaCO2 28, HCO3 30 = respiratory alkalosis pH 7.49, PaCO2 34, HCO3 25 = respiratory alkalosis pg.595
question
The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma b) Squamous cell carcinoma c) Bronchoalveolar carcinoma d) Adenocarcinoma
answer
a) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.606
question
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Measure the patient's pulse oximetry b) Record the observation c) Report the finding to the physician immediately d) Apply a compression dressing to the area
answer
b) Record the observation Explanation: Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. pg.614
question
The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? a) Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. b) Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. c) Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
answer
d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Explanation: In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Therefore options A, B, and C are incorrect. pg.598
question
A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Bloody, productive cough b) Diminished breath sounds c) Decreased respiratory rate d) Sucking sound at the site of injury
answer
d) Sucking sound at the site of injury Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds pg.614
question
A 68-year-old male client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The nurse knows that the surgical team places this catheter: a) To administer IV medication b) To ventilate the client c) To remove fluid from the lungs d) To remove air from the pleural space
answer
d) To remove air from the pleural space Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery—one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid. Chest tubes are placed to remove anteriorly air from the pleural space following thoracic surgery. The anesthesiologist ventilates the client during surgery. Postsurgery, a chest tube is placed anteriorly to remove air from the pleural space. pg.527
question
An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Mottling of the skin upon inspection b) Resonance upon percussion c) Wheezing upon auscultation d) Decreased chest wall excursion upon palpation
answer
d) Decreased chest wall excursion upon palpation Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. pg.593
question
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: a) acute respiratory distress syndrome (ARDS). b) chronic obstructive pulmonary disease (COPD). c) bronchial asthma. d) renal failure.
answer
a) acute respiratory distress syndrome (ARDS). Explanation: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation. pg.596
question
A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is: a) 1.4 L. b) unspecified. c) 2 L. d) 3 L.
answer
a) 1.4 L. Explanation: Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily. pg.582
question
Which of the following terms refers to lung tissue that has become more solid in nature due to a collapse of alveoli or an infectious process? a) Bronchiectasis b) Empyema c) Atelectasis d) Consolidation
answer
d) Consolidation Explanation: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space. pg.578
question
A patient suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which of the following interventions to improve oxygenation and provide comfort for the patient? a) Assist the patient up to a chair b) Force fluids for the next 24 hours c) Position the patient in the prone position d) Administer small doses of pancuronium (Pavulon)
answer
c) Position the patient in the prone position Explanation: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs. pg.597
question
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Apply a compression dressing to the area. b) Record the observation. c) Measure the patient's pulse oximetry. d) Report the finding to the physician immediately.
answer
a) Apply a compression dressing to the area. Explanation: Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. During surgery the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. pg.616
question
A 23-year-old male client who has recently started working in a coal mine confides that he is concerned about his long-term health. The nurse instructs the client which of the following ways to prevent occupational lung disease? Select all that apply. a) Do not smoke or quit smoking if currently smoking. b) Wear appropriate protective equipment when around airborne irritants and dusts. c) Schedule an annual lung x-ray to monitor his health. d) Try to find another occupation as soon as possible.
answer
a) Do not smoke or quit smoking if currently smoking. b) Wear appropriate protective equipment when around airborne irritants and dusts. Explanation: The nurse may instruct clients that the following precautions may help prevent occupational lung disease: not smoking, wearing appropriate protective equipment when around airborne irritants and dusts, scheduling lung function evaluation with spirometry as recommended, becoming educated about lung diseases, and paying attention to risk evaluation of the workplace to identify risks for lung disease. pg.605
question
When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) bruising. b) redness and induration. c) drainage. d) tissue sloughing.
answer
b) redness and induration. Explanation: The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus. pg.588
question
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first a) Makes a fist with one hand with the thumb outside the fist b) Exerts pressure against the worker's abdomen c) Stands behind the worker, who has hands across the neck d) Places both arms around the worker's waist
answer
c) Stands behind the worker, who has hands across the neck Explanation: The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking. pg. 538
question
Late complications of radiation therapy may include which of the following? Select all that apply. a) Edema b) Xerostomia c) Loss of taste d) Fibrosis e) Laryngeal necrosis
answer
e) Laryngeal necrosis a) Edema d) Fibrosis Explanation: Complications occurring late may include laryngeal necrosis, edema, and fibrosis. Loss of taste and xerostomia are symptoms of radiation therapy that may occur earlier in treatment. pg.560
question
The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following? a) Levofloxacin (Levaquin) b) Amoxicillin (Augmentin) c) Keflex (Cephalexin) d) Ceftin (Cefuroxime)
answer
b) Amoxicillin (Augmentin) Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones, such as levofloxacin (Levaquin) or moxifloxacin (Avelox), can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin (Keflex) and cefuroxime (Ceftin), are no longer recommended as they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS. pg.543
question
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: a) "I should sleep on my side all night long." b) "I need to keep my inhaler at the bedside." c) "I should eat a high-protein diet." d) "I should become involved in a weight loss program."
answer
d) "I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea. pg.553
question
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? a) "I have environmental allergies." b) "I used my voice in excess over the weekend." c) "I smoke a pack of cigarettes a day." d) "I was chewing ice chips all day long."
answer
d) "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. pg.551
question
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? a) Throat pain b) Difficulty talking c) Bleeding d) Difficulty swallowing
answer
c) Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop. pg.549
question
A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: a) Myalgias b) Headache c) Nausea d) Fever
answer
d) Fever Explanation: The signs and symptoms described are consistent with acute pharynigitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided. pg.547
question
Which assessment finding puts a client at increased risk for epistaxis? a) Cocaine use b) History of nasal surgery c) Use of a humidifier at night d) Hypotension
answer
a) Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis. pg.555
question
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following? a) Hemilaryngectomy b) Partial laryngectomy c) Total laryngectomy d) Supraglottic laryngectomy
answer
b) Partial laryngectomy Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea. pg.559
question
A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give? a) "You should rest, increase your fluids, and take Ibuprofen." b) "Antibiotics will be prescribed, which will make you feel better." c) "Have you tried a topic nasal decongestant; they work well." d) "Your symptoms should go away soon, just try to get some rest."
answer
a) "You should rest, increase your fluids, and take Ibuprofen." Explanation: Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient's signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks. pg.540
question
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? a) Provide meticulous mouth care every 4 hours. b) Monitor for signs of dysphagia. c) Encourage deep breathing every 2 hours. d) Caution against frequent coughing.
answer
c) Encourage deep breathing every 2 hours. Explanation: The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake. pg.563
question
A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question? a) "Have you strained your voice recently?" b) "Do you smoke cigarettes, cigars, or a pipe?" c) "Do you eat a lot of red meat?" d) "Do you eat spicy foods?"
answer
b) "Do you smoke cigarettes, cigars, or a pipe?" Explanation: Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness. pg.551
question
What client would be most in need of an endotracheal tube? a) Comatose clients b) Ambulatory clients c) Older adult clients d) A client status post tonsillectomy
answer
a) Comatose clients Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages. pg. 504
question
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? a) Radiation therapy b) Partial laryngectomy c) Laser surgery d) Total laryngectomy
answer
d) Total laryngectomy Explanation: In more advanced cases, total laryngectomy may be the treatment of choice. Partial laryngectomy, laser surgery, and radiation therapy are not the treatment of choice for advanced cases of laryngeal cancer. pg.559
question
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: a) Sleep with the head of bed elevated. b) Do not perform saline irrigations to the nares. c) You may drink 1 glass of alcohol daily. d) Caffeinated beverages are allowed.
answer
a) Sleep with the head of bed elevated. Explanation: General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses. pg.546
question
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to a) Seek medical help if he experiences inability to swallow b) Properly dispose of used tissues c) Place an ice collar on the throat to relieve soreness d) Stay in bed when experiencing a fever
answer
a) Seek medical help if he experiences inability to swallow Explanation: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority. pg.548
question
The nurse is providing discharge instructions to a patient following nasal surgery who has nasal packing. Which of the following discharge instructions would be most appropriate for the patient? a) Administer normal saline nasal drops as ordered. b) Take aspirin for nasal discomfort. c) Decrease the amount of daily fluids. d) Avoid sports activities for 6 weeks.
answer
d) Avoid sports activities for 6 weeks. Explanation: The nurse instructs the patient to avoid sports activities for 6 weeks. There is no indication for the patient to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The patient should take analgesic agents, such as acetaminophen or NSAIDs, (i.e., ibuprofen or naproxen) to decrease nasal discomfort, not aspirin. The patient does not need to use nasal drops when nasal packing is in place. pg.556
question
Stiffness of the neck or inability to bend the neck is referred to as which of the following? a) Aphonia b) Nuchal rigidity c) Dysphagia d) Xerostomia
answer
b) Nuchal rigidity Explanation: Nuchal rigidity is the stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing. pg.538
question
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Limit the amount of protein in the diet." b) "Family members should continue to talk to the client." c) "Oral intake of fluids should be limited for 1 week only." d) "Clean the tracheostomy tube with alcohol and water."
answer
b) "Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing. pg.563
question
You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply. a) Aspiration b) Infection c) Injury to the laryngeal nerve d) Penetration of the anterior tracheal wall e) Absence of secretions
answer
a) Aspiration b) Infection c) Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall. pg.565
question
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? a) Maintain the client in a low-Fowler's position. b) Encourage oral nutrition on the second postoperative day. c) Assess the tracheostomy cuff for leaks. d) Develop an alternate method of communication.
answer
d) Develop an alternate method of communication. Explanation: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema. pg.560
question
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? a) Assess capillary refill. b) Obtain vital signs. c) Auscultate lung sounds. d) Monitor heart rhythm.
answer
c) Auscultate lung sounds. Explanation: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data. pg. 507
question
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? a) Mechanical ventilation b) Bilevel positive airway pressure (BiPAP) c) Continuous positive airway pressure (CPAP) d) Oxygen by nasal cannula
answer
c) Continuous positive airway pressure (CPAP) Explanation: CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea. pg. 554
question
The nurse assesses a patient who is bleeding profusely from the nose. The nurse documents this finding as which of the following conditions? a) Dysphagia b) Rhinorrhea c) Xerostomia d) Epistaxis
answer
d) Epistaxis Explanation: Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Xerostomia refers to dryness of the mouth. Rhinorrhea refers to drainage of a large amount of fluid from the nose. Dysphagia refers to difficulties in swallowing. pg. 554
question
A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis? a) Provide a nasal splint. b) Apply direct continuous pressure. c) Place the client in a semi-Fowler's position. d) Apply a moustache dressing.
answer
b) Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction. pg.555
question
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? a) Referral for counseling b) Emotional support c) Family counseling d) Referral for vocational training
answer
b) Emotional support Explanation: Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling. pg. 561
question
Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery? a) Swimming b) Wearing a scarf over the stoma c) Hand-held showers d) Coughing
answer
a) Swimming Explanation: The nurse provides the patient and family with the following postoperative instructions:water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the patient to avoid swimming and to use a hand-held shower device when bathing. The nurse also suggests that the patient to wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange. pg.559
question
The nurse is caring for a patient who underwent a laryngectomy. Which of the following interventions will the nurse initially complete in an effort to meet the patient's nutritional needs? a) Offer plenty of thin liquids. b) Encourage sweet foods. c) Initiate enteral feedings. d) Liberally season foods.
answer
c) Initiate enteral feedings. Explanation: Postoperatively, the patient may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the patient is permitted to resume oral feedings, thin liquids are offered, and sweet food are avoided because they cause increased salivation and decrease the patient's appetite. The patient's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the patient usually accommodates to this change and olfactory sensation adapts; thus, seasonings are based on personal preferences. pg.563
question
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of a) 2 to12 days. b) 0 to 3 months. c) 20 to 30 days. d) 3 to 6 months.
answer
a) 2 to12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time period 0 to 3 months exceeds the incubation period. The time period 20 to 30 days exceeds the incubation period. The time period 3 to 6 months exceeds the incubation period. pg.542
question
A 62-year-old male client with a history of chronic laryngitis arrives at the clinic complaining of a hoarseness "he can't shake." The nurse is aware that this client may be at risk for which of the following conditions? a) Laryngeal cancer b) Peritonsillar abscess c) Adenoiditis d) Coryza
answer
a) Laryngeal cancer Explanation: The nurse knows that laryngeal cancer is most common in people 60 to 70 years of age, with men affected more frequently than are women. The client's history of chronic laryngitis may also predispose him to the development of laryngeal cancer. Sore throat, difficulty or pain on swallowing, fever, and malaise are the most common symptoms of adenoiditis. Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. This is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestions. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking. pg.558
question
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion? a) Simple b) Central c) Mixed d) Obstructive
answer
d) Obstructive Explanation: Obstructive sleep apnea occurs usually in men, and especially in men who are older and overweight. Types of sleep apnea do not include a simple characterization. Mixed sleep apnea is a combination of central and obstructive apnea with one apneic episode. In central sleep apnea, the patient demonstrates simultaneous cessation of both airflow and respiratory movements. pg.553
question
The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care? a) Restrict fluid intake. b) Apply pressure to the convex of the nose. c) Position the patient in the side-lying position. d) Apply an ice pack.
answer
d) Apply an ice pack. Explanation: Following a nasal fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the patient to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation. pg.556
question
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? a) "I was chewing ice chips all day long." b) "I used my voice in excess over the weekend." c) "I smoke a pack of cigarettes a day." d) "I have environmental allergies."
answer
a) "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. pg. 551
question
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is a) Deficient fluid volume related to increased fluid needs b) Ineffective airway clearance related to excess mucus production c) Acute pain related to upper airway irritation d) Deficient knowledge related to prevention of upper respiratory infections
answer
b) Ineffective airway clearance related to excess mucus production Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis. pg.540
question
A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client? a) "The ET tube will remain in place for at least a day postsurgery." b) "The ET tube will be inserted through an opening in your trachea." c) "The ET tube will be connected to a negative-pressure ventilator." d) "The ET tube will maintain your airway while you're under anesthesia."
answer
d) "The ET tube will maintain your airway while you're under anesthesia." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or comatose. pg. 504
question
Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy? a) Use enteral feedings after the procedure b) Season food to suit an increased sense of taste and smell c) Recommend the long-term use of zinc lozenges d) Offer plenty of thin liquids when intake resumes
answer
a) Use enteral feedings after the procedure Explanation: Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the patient may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended. pg.560
question
You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? a) Infection b) Postoperative bleeding c) Plugged tracheostomy tube d) Edema of the upper airway
answer
d) Edema of the upper airway Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube. pg.550
question
The nurse is caring for a female patient following a tonsillectomy and adenoidectomy. Two hours following the procedure, the patient begins to vomit large amounts of dark blood in frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse will do which of the following? a) Stay with the patient and monitor her closely. b) Obtain a light, mirror, gauze, curved hemostats. c) Prepare for a needle aspiration. d) Orally suction the patient, as needed.
answer
b) Obtain a light, mirror, gauze, curved hemostats. Explanation: If the patient vomits large amounts of dark blood at frequent intervals, or if the pulse rate and temperature rise, or the patient becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the patient's bedside. Needle aspiration is a procedure considered for patients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time. pg.549
question
A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions: a) "You are allowed to have hot tea or coffee." b) "Gargle vigorously to clean your throat." c) "You may have a sore throat for 1 week." d) "Gargle with a warm salt solution."
answer
d) "Gargle with a warm salt solution." Explanation: A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided. pg. 549
question
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? a) Hardened secretions b) Incrusted mucous membranes c) Erosion of the trachea d) Noisy breathing
answer
d) Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea. pg.549
question
The nurse is caring for a patient in the ICU with a nasotracheal tube. Because of the tube placement, the nurse understands that the patient is at risk for developing which of the following? a) Orbital cellulitis b) Severe epistaxis c) Sinus infection d) Subperiosteal abscess
answer
c) Sinus infection Explanation: Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the patient's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis. pg.544
question
The nurse is assessing a patient in the clinic, and upon physical assessment the patient demonstrates displacement of the sternum. This would be documented as which of the following conditions? a) Kyphoscoliosis b) Pigeon chest c) Funnel chest d) Barrel chest
answer
b) Pigeon chest Explanation: Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis. A barrel chest is seen in patients with emphysema and occurs as a result of over-inflation of the lungs. A funnel chest occurs when there is a depression in the lower portion of the sternum. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. pg.462
question
You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover? a) Visiting hours b) Alternative methods of communication c) Pain before surgery d) Post operative nutrition
answer
b) Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching. pg.560
question
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: a) sit upright, leaning slightly forward. b) blow his nose and then put lateral pressure on his nose. c) lie supine with his neck extended. d) hold his nose while bending forward at the waist.
answer
a) sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it. pg.555
question
The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? a) Crackles in the bases of the lungs b) Diminished breath sounds throughout c) Audible stridor without using a stethoscope d) Rhonchi in the bronchial region
answer
c) Audible stridor without using a stethoscope Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling. pg.472
question
The nurse is discussing immediate postoperative communication strategies with a patient scheduled for a total laryngectomy. Which of the following information will the nurse include? a) "After surgery you will have a sore throat, but will be able to speak." b) "A speech therapist will evaluate you and recommend a system of communication after surgery." c) "After surgery, you will have to use an electric larynx to communicate." d) "You can use writing or a communication board to communicate."
answer
d) "You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the patient must understand that the natural voice will be lost, but that special training can provide a means for communicating. The patient needs to know that until training is started, communication will be possible by using the call light, by writing, or by using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the patient prior to surgery and a method of immediate postoperative communication will be established. pg.563
question
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? a) Administer one intramuscular injection of penicillin. b) Ask an accompanying homeless friend to monitor the client's follow-up. c) Provide emphatic oral instructions for the client. d) Provide the client with oral penicillin that will last for 5 days.
answer
a) Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy. pg.547
question
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? a) Aphonia following a football game b) Epistaxis, twice last week c) Laryngitis following a cold d) Hoarseness for 2 weeks
answer
d) Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity. pg.551
question
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.
answer
100 Explanation: The volume of the IV medication is 50 mL. The time for infusion is 30 minutes or 0.5 hr. 50 mL/0.5 hr = 100 mL/1 hr. pg.523
question
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to a) Clean the medication container once each day. b) Blow the nose before applying medication into the nares. c) Tilt the head back when activating the spray of the medication. d) Wait 10 seconds before administering the second spray.
answer
b) Blow the nose before applying medication into the nares. Explanation: The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use. pg.541
question
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for a) Hypertension b) Nuchal rigidity c) Nausea d) Mild headache
answer
b) Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids. pg.544
question
A patient is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include a) hoarseness. b) a moist cough. c) a nonedematous uvula. d) a throat that feels worse in the evening.
answer
a) hoarseness. Explanation: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous. pg.551
question
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to a) Reassure the client that the nose is not fractured. b) Apply an ice pack to the nose. c) Administer prescribed oral ibuprofen (Motrin). d) Check the clear fluid for glucose.
answer
d) Check the clear fluid for glucose. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribiform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed. pg.556
question
Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy? a) Impaired verbal communication b) Imbalanced nutrition: Less than body requirements c) Anxiety and depression d) Ineffective airway clearance
answer
d) Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but they are not the priority diagnosis. pg.561
question
A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following? a) Respiratory failure (RF) b) Gastroesophageal reflux disease (GERD) c) Congestive heart failure (CHF) d) Chronic obstructive pulmonary disease (COPD)
answer
b) Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult. pg.539
question
A 72-year-old male client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. If laryngeal cancer is suspected, the nurse would be most likely to hear which of the following complaints from the client? a) Headaches in the morning b) Weight loss c) Discomfort when drinking cold liquids d) A feeling of swelling at the back of the throat
answer
d) A feeling of swelling at the back of the throat Explanation: After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may complain of burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache. pg.558
question
Which of the following clinical manifestations of hemorrhage is related to carotid artery rupture? a) Increased blood pressure b) Shallow respirations c) Dry skin d) Increased pulse rate
answer
d) Increased pulse rate Explanation: The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding. pg.564
question
Your client has had laryngeal surgery. What is as expected outcome in this client? a) The client's suture line remains intact. b) The client can swallow without difficulty. c) The client maintains an adequate caloric intake. d) The client's breathing patterns improve.
answer
c) The client maintains an adequate caloric intake. Explanation: The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line and swallowing abilities are evaluated in clients undergoing tonsillectomy and adenoidectomy. Improved breathing patterns are evaluated in the case of clients with trauma in the upper airway. pg.565
question
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? a) Cancer of the pharynx b) Cancer of the tonsils c) Laryngeal polyps d) Laryngeal cancer
answer
d) Laryngeal cancer Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils. pg.558
question
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? a) A nasal cannula b) A face mask c) A rigid shell d) A ventilator
answer
b) A face mask Explanation: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device. pg.494
question
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have a) trouble with your breathing" b) a foul odor to your breath" c) a persistent cough or sore throat" d) difficulty swallowing foods"
answer
c) a persistent cough or sore throat" Explanation: Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath. pg.551
question
Most cases of acute pharyngitis are caused by which of the following? a) Bacterial infection b) Viral infection c) Systemic infection d) Fungal infection
answer
b) Viral infection Explanation: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. pg.546
question
A first-line antibiotic utilized in the treatment of acute sinusitis includes a) Cefzil b) Ceftin c) Augmentin d) Ampicillin
answer
d) Ampicillin Explanation: First-line antibiotics include amoxicillin, ampicillin, and erythromycin. Second-line therapy includes Ceftin, Cefzil, and Augmentin. pg.543
question
The nurse is caring for a male patient diagnosed with rhinosinusitis. The physician has ordered the patient to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the patient that a common side effect of this medication includes which of the following? a) Epistaxis b) Headache c) Watery eyes d) Arthralgia
answer
a) Epistaxis Explanation: Common side effects of budesonide include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasms. pg.544
question
The nurse is caring for a patient receiving radiation therapy for laryngeal cancer. A late complication of radiation therapy includes which of the following? a) Pain b) Dysphasia c) Xerostomia d) Laryngeal necrosis
answer
d) Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy. pg.560
question
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage? a) Warm, moist skin b) Increased blood pressure c) Decreased pulse rate d) Rapid, deep respirations
answer
d) Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding. pg.564
question
A late complication of radiation therapy includes a) xerostomia. b) laryngeal necrosis. c) pain. d) dysphasia.
answer
b) laryngeal necrosis. Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy. pg.560
question
Which of the following nursing diagnoses best encompasses the anticipated psychosocial concerns of a client who is scheduled for a laryngectomy? a) Risk for infection b) Disturbed body image c) Risk for chronic low self-esteem d) Deficient knowledge
answer
b) Disturbed body image Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery. Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. Clients require information prior to their surgery to make appropriate decisions, but this is not considered a psychosocial concern. Clients are at high risk for infection following a laryngectomy, but this is not considered a psychosocial concern. Although chronic low self-esteem may develop following a laryngectomy, depending on the client's ability to cope, a more immediate concern would be related to disturbed body image. pg.561
question
A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to a) Report relief of pain to level 3 using a pain intensity scale of 1 to 10. b) Gargle with a warm saline solution frequently. c) Take acetaminophen with codeine when pain is 5 or above. d) Use a pain intensity rating scale of 0 to 10.
answer
a) Report relief of pain to level 3 using a pain intensity scale of 1 to 10. Explanation: The client statement of relief of pain to level 3 indicates improvement of the problem. The other options are actually interventions or actions that can help achieve a long-term goal of relief of pain. pg.552
question
The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications? a) Tylenol with codeine b) Tylenol c) Robitussin DM d) Penicillin
answer
d) Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are used more often and are as effective and less painful than injections. Penicillin injections are recommended only if there is a concern that the patient will not comply with therapy. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given. pg.547
question
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by a) Instructing the client to tilt the head back with ice applied to the nose b) Applying pressure to the nose for 1 to 2 minutes c) Pinching the upper and hard portion of the nose d) Telling the client to sit upright with the head tilted forward
answer
d) Telling the client to sit upright with the head tilted forward Explanation: Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes. pg.555
question
The nurse is instructing a client who is scheduled for a laryngectomy about methods of alaryngeal speech. Which of the following best describes tracheoesophageal puncture (TEP)? a) It requires the client to hold a throat vibrator against the neck. b) It will result in a low, gruff-sounding voice. c) It enables the client to form words with the lips. d) It requires the insertion of a prosthesis into the trachea.
answer
d) It requires the insertion of a prosthesis into the trachea. Explanation: TEP requires a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device. An artificial larynx is a throat vibrator held against the neck that projects sound into the mouth. With esophageal speech, the client forms words with the lips. Esophageal speech causes the voice quality to be lower pitched and gruff sounding. pg.560
question
The client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. The client is receiving humidified oxygen. A priority nursing diagnosis is: a) impaired gas exchange related to ventilation-perfusion inequality b) ineffective breathing pattern related to inflammatory effects of surgery c) ineffective airway clearance related to excess mucus production d) anxiety related to the effects of surgery and loss of voice
answer
c) ineffective airway clearance related to excess mucus production Explanation: All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority. pg.551
question
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? a) Chronic tonsilittis b) Laryngeal cancer c) Laryngeal polyps d) Chronic pharyngitis
answer
b) Laryngeal cancer Explanation: Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom. pg.558
question
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that: a) adenocarcinoma accounts for most cases of laryngeal cancer. b) inhaling polluted air isn't a risk factor for laryngeal cancer. c) laryngeal cancer occurs primarily in women. d) laryngeal cancer is one of the most preventable types of cancer.
answer
d) laryngeal cancer is one of the most preventable types of cancer. Explanation: Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer. pg.557
question
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? a) Magnetic resonance imaging (MRI) b) Transillumination of the sinus c) CBC with differential d) Nasal culture
answer
b) Transillumination of the sinus Explanation: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity. pg.545
question
When caring for a client who has just had a total laryngectomy, the nurse should plan to: a) encourage oral feedings as soon as possible. b) develop an alternative communication method. c) keep the tracheostomy cuff fully inflated. d) keep the client flat in bed.
answer
b) develop an alternative communication method. Explanation: A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position. pg.560
question
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about a) Cold compresses to the sinus cavities b) Administration of oral antibiotics c) Use of a dehumidifier d) Saline lavages to the nares
answer
d) Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated. pg.543
question
A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions: (Select all that apply.) a) Encourages the client to ingest sweet foods b) Provides thick liquids c) Obtains results of a swallow study d) Orders a regular diet tray e) Facilitates privacy while eating
answer
c) Obtains results of a swallow study b) Provides thick liquids Explanation: When a client is allowed to eat following a partial laryngectomy, a swallow study may be obtained first to determine the client's risk of aspiration. The client is started with thick liquids because they are easy to swallow. The nurse stays with the client during initial feedings to ensure safe ingestion. Solid foods are introduced as tolerated. The nurse encourages the client to avoid sweet foods, which increase salivation and suppress appetite. pg.563
question
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first? a) Test the nasal drainage for glucose. b) Have the client blow his nose. c) Look for a halo sign after the drainage dries. d) Contact the physician.
answer
a) Test the nasal drainage for glucose. Explanation: Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment. pg.556
question
Which of the following diagnostic tests is used to confirm the diagnosis of maxillary and frontal sinusitis? a) Sinus aspirates b) MRI c) CT scan d) Sinus x-rays
answer
a) Sinus aspirates Explanation: To confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen, sinus aspirates may be obtained. Flexible endoscopic culture techniques and swabbing of the sinuses have been used for this purpose. Sinus x-rays and CT scans may be obtained for patients with frontal headaches, in refractory cases, and if complications are suspected. pg.543
question
When a patient has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the patient very carefully because he or she is at high risk for a) dehydration. b) carotid artery hemorrhage. c) pulmonary embolism. d) pneumonia.
answer
b) carotid artery hemorrhage. Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient. pg.564
question
A client reports nasal congestion, sneezing, sore throat, and muscle aches. The nurse intervenes how? Select all answers that apply. a) Administer oral ibuprofen (Motrin). b) Recommend guaifenesin (Mucinex). c) Teach the client about handwashing. d) Refer the client to a physician for antibiotic therapy. e) Provide warm salt-water gargles.
answer
e) Provide warm salt-water gargles. a) Administer oral ibuprofen (Motrin). c) Teach the client about handwashing. b) Recommend guaifenesin (Mucinex). Explanation: Described signs and symptoms are consistent with viral rhinitis (the common cold). Management consists of symptomatic therapy, such as gargling with warm salt-water gargles, taking nonsteroidal anti-inflammatory medications (eg, ibuprofen), and using guaifenesin, which promotes removal of secretions. Handwashing is the most effective measure to prevent transmission of organisms. Antibiotics should not be used, because they are not effective against viruses and misuse of antibiotics have contributed to the development of antibiotic-resistant organisms. pg.540
question
The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall? a) Hypertrophic b) Atrophic c) Aphonia d) Chronic granular
answer
d) Chronic granular Explanation: Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane. pg.548
question
Another term for clergyman's sore throat is a) atrophic pharyngitis. b) aphonia. c) chronic granular pharyngitis. d) hypertrophic pharyngitis.
answer
c) chronic granular pharyngitis. Explanation: In clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane. pg.548
question
A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information: a) Severe pain when palpating the sinuses is normal. b) Dehumidify the air in the home. c) Make sure to follow antibiotic therapy. d) Avoid air travel.
answer
d) Avoid air travel. Explanation: Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection. pg.544
question
A patient presents to the ED with a suspected allergic reaction. The patient is experiencing laryngeal edema causing obstruction and is demonstrating retractions in the neck during inspirations. Which of the following is the nurse's priority intervention? a) Apply 100% oxygen via a face mask. b) Prepare for immediate tracheostomy. c) Prepare to administer subcutaneous epinephrine and corticosteroids. d) Prepare for endotracheal intubation with mechanical ventilation.
answer
c) Prepare to administer subcutaneous epinephrine and corticosteroids. Explanation: The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspirations and is an ominous sign of impending respiratory distress. The patient's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a patient with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the patient's laryngeal edema is the administration of the medications. pg.551
question
A nurse is teaching a client with recurrent rhinosinusitis and instructs the client to take the following medication at the first sign of symptoms: a) oxymetazoline (Afrin) nasal spray b) acetaminophen (Tylenol) c) guaifenesin (Mucinex) d) naproxen (Aleve)
answer
c) guaifenesin (Mucinex) Explanation: The client should take a decongestant (eg, guaifenesin) at the first sign of recurrence of rhinosinusitis to promote drainage of the sinus cavities and prevent bacterial infection. Medications that the client may take later in the illness for pain relief include acetaminophen and nonsteroidal antinflammatory drugs, such as naproxen. Over-the-counter nasal sprays (eg, Afrin) may cause rebound congestion. pg.541
question
A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to: a) Take a hypnotic medication at hours of sleep. b) Eliminate alcohol ingestion. c) Use nasal oxygen at night. d) Sleep on the back.
answer
b) Eliminate alcohol ingestion. Explanation: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea. pg.554
question
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? a) "Keep the stoma moist." b) "Keep the stoma uncovered." c) "Have a family member perform stoma care initially until you get used to the procedure." d) "Keep the stoma dry."
answer
a) "Keep the stoma moist." Explanation: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. pg.563
question
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal? a) The client will have decreased pain. b) The client will remain alert and oriented. c) The client will have decreased edema. d) The client will have increased tissue perfusion.
answer
c) The client will have decreased edema. Explanation: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply. pg.556
question
Your client has just been diagnosed with laryngeal cancer. The client asks you what causes laryngeal cancer. What would be your best response? a) "Research has shown that habitual resting of the voice contributes to laryngeal cancer." b) "Research has shown that heredity contributes to having laryngeal cancer." c) "A carcinogen associated with laryngeal cancer is allergies." d) "A carcinogen associated with laryngeal cancer is carbon monoxide."
answer
b) "Research has shown that heredity contributes to having laryngeal cancer." Explanation: In addition, chronic laryngitis, habitual overuse of the voice, and heredity may contribute. Carbon monoxide has not been associated with laryngeal cancer. Allergies are not a carcinogen. pg.558
question
A patient has undergone a laryngectomy. The nurse notes evidence of wound breakdown. The nurse understands that the patient is at a high risk for developing which of the following? a) Pneumonia b) Dehydration c) Carotid hemorrhage d) Pulmonary embolism
answer
c) Carotid hemorrhage Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. If wound breakdown occurs, the patient must be monitored carefully and identified as at high risk for carotid hemorrhage. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient. pg.564
question
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? a) Sudden restlessness b) Copious mucous secretions c) Harsh cough d) Rhonchi in lung fields
answer
a) Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions. pg.517
question
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to a) Use a room vaporizer to loosen secretions. b) Report decreased congestion. c) Assume an upright position to facilitate drainage. d) Increase fluid intake.
answer
b) Report decreased congestion. Explanation: A report from the client of decreased congestion indicates improvement of the problem. The other options are actually interventions or actions that the client can undertake to achieve a long-term goal of a patent airway. pg.552
question
You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply. a) Tobacco b) Alcohol c) Age d) Region of country you live in e) Industrial pollutants
answer
b) Alcohol a) Tobacco e) Industrial pollutants Explanation: Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with laryngeal cancer. pg.558
question
A client who has been diagnosed with an early glottis cancer would most likely undergo which type of surgery? a) Laser microsurgery b) Partial laryngectomy c) Total laryngectomy d) Vocal cord stripping
answer
a) Laser microsurgery Explanation: In early glottis cancer, early stage lesions are treated and removed with a laser process. This would be the surgical treatment for early stage vocal cord lesions. This surgery is done to treat early-stage laryngeal cancer when only one cord is involved. This surgery is done when the cancer extends beyond the vocal cords. pg.559
question
The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply. a) Increased fluids b) Antibiotics c) Antitussives d) Saline gargles e) Antiemetics f) Rest
answer
a) Increased fluids c) Antitussives d) Saline gargles f) Rest Explanation: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus. pg.541
question
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? a) Gently blow the nose to eliminate nasal secretions. b) Use an anti-allergy medication to decrease rhinitis. c) Administer an over-the-counter decongestant. d) Place a warm cloth over the sinus area of the forehead.
answer
c) Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best. pg.542
question
Late symptoms of laryngeal cancer include which of the following. Select all that apply. a) Dysphagia b) Burning in throat c) Dyspnea d) Sore throat e) Persistent hoarseness
answer
a) Dysphagia c) Dyspnea e) Persistent hoarseness Explanation: Later symptoms include dysphagia, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Earlier, the patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. pg.561
question
Which of the following methods most resembles normal speech following a total laryngectomy? a) Esophageal speech b) Blom-Singer voice prosthesis c) Lip speaking d) Electrolarynx held at neck
answer
b) Blom-Singer voice prosthesis Explanation: The Blom-Singer voice prosthesis most resembles normal speech. With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. With electrolarynx, a battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words. Lip speaking is available during the immediate postoperative period. It does not resemble normal speech. pg.560
question
The nurse is assessing a patient for obstructive sleep apnea (OSA). Which of the following are signs and symptoms of OSA? Select all that apply. a) Pulmonary hypotension b) Loud snoring c) Polycythemia d) Evening headaches e) Insomnia
answer
c) Polycythemia b) Loud snoring e) Insomnia Explanation: Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, corpulmonale, polycythemia, and enuresis. pg.554
question
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by a) Removing the oral airway before the gag reflex has returned for client comfort b) Placing the client prone with the head turned to the side c) Maintaining a warm compress around the client's neck area d) Sitting the client in the semi-Fowler's position
answer
b) Placing the client prone with the head turned to the side Explanation: The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area. pg.549
question
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? a) Psychological status b) Airway patency c) Level of consciousness d) Pain level
answer
b) Airway patency Explanation: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation. pg.565
question
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? a) "Wear a tight cloth at the stoma to prevent anything from entering it." b) "Keep the humidity in your house low." c) "Swimming is good exercise after this surgery." d) "Cover the stoma whenever you shower or bathe."
answer
d) "Cover the stoma whenever you shower or bathe." Explanation: The nurse should instruct the client to gently cover the stoma with a loose plastic bib, or even a hand, when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. The client should keep his house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming, because it's possible for water to enter the stoma and then enter the client's lung, causing him to drown without submerging his face. pg.563
question
A patient comes to the health care provider's office for an annual physical. The patient reports having a persistent, nagging cough. Which questions does the nurse asked first about the symptom?
answer
When did the cough start?
question
when blood passes through the lungs, what happens to the oxygen?
answer
It diffuses from the alveoli into the red blood cells.
question
Which substances from cigarette smoke have been implicated in the development of serious lung diseases?
answer
Nicotine. Tar. Carbon monoxide.
question
A patient reports smoking a pack of cigarettes a day for nine years. He then quits for two years, and then smoked two packs a day for the last 30 years. What are the pack years for this patient?
answer
69 years
question
which is an example of third-hand passive smoking?
answer
Exposure to smoke on the clothes of a smoker.
question
Pulmonary function tests are scheduled for a patient with a history of smoking who reports dyspnea and chronic cough. What will patient teaching information about this procedure include?
answer
the patient will breathe through the mouth and wear a nose clip during the test.
question
the nurse is providing care for a patient who would like to quit smoking. Which important teaching points must be included when teaching this patient?
answer
Talk with your healthcare provider about nicotine replacement therapies. Ask for help from family and friends who have quit smoking. Remove all ashtrays, cigarettes, pipes, cigars, and lighters from your home to decrease the temptation to smoke. If you are used to having a cigarette after eating, get up from the table as soon as you're finished eating.
question
The healthcare provider has prescribed varenicline -Chantix for the patient who wishes to quit smoking. What specific priority teaching must the nurse provide for the patient and his family?
answer
Be sure to report any changes in behavior or thought processes to healthcare provider.
question
In which situation with the oxygen dissociation curve shift to the left?
answer
increased pH -alkalosis.
question
which respiratory changes occur as a result of aging?
answer
Dilation of alveolar ducts. decreased ability to cough. Diffusion capacity decreases.
question
A patient is scheduled to have a pulmonary function test (PFT). which type of information does the nurse include in the nursing history so that PFT results can be appropriately determined?
answer
age, gender, race, height, weight, and smoking status.
question
Which description best explains residual volume (RV)?
answer
amount of air remaining in the lungs at the end of full force exhalation.
question
the nurse is caring for an older adult who uses a wheelchair and spends over half of each day in bed. Which intervention is important in promoting pulmonary hygiene related to age and decreased mobility?
answer
Encourage the patient to turn, cough, and deep breathe.
question
The nurse is assessing a middle aged patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which questions assist the nurse in determining what these changes are related to?
answer
Do you have anemia? When did you first notice the symptoms? Do you or have you ever smoked cigarettes? Are you coughing up any colored sputum?
question
A patient who received a bronchoscopy was NPO (nothing by mouth) for sever hours before the test. now a few hours after the test, the patient is hungry would like to eat a meal. What does the nurse do before allowing the patient to eat?
answer
check for a gag reflex before allowing the patient to eat.
question
after a bronchoscopy procedure, the patient coughs up sputum which contains blood. what is the best nursing action at this time?
answer
Assess vital signs and respiratory status and notify the provider of the findings.
question
Before a bronchoscopy procedure, the patient received benzocaine spray as a topical anesthetic to numb the oropharynx. The nurse is assessing the patient after the procedure. which findings suggest that the patient is developing methemoglobinemia?
answer
the patient does not respond to supplemental oxygen.
question
The nurse is caring for several patients who had diagnostic testing for respiratory disorders. Which diagnostic test has the highest risk for the post procedure complication of pneumothorax?
answer
percutaneous lung biopsy.
question
a patient's pulse oximetry reading his 89%. What is the nurse's first priority action?
answer
Assess the patient for respiratory distress and recheck the oximeter reading.
question
A patient demonstrates labored, shallow respirations and a respiratory rate of 32/minute with a pulse oximetry reading of 85%. what is the priority nursing intervention?
answer
Start oxygen via nasal canola at 2 L / minute.
question
which factors or conditions cause a decreased (below normal) PETCO2 level due to abnormal ventilation?
answer
Hypotension. Apnea. Hypothermia.
question
The nurses reviewing ABG results from an 86-year-old patient. Which results would be considered normal findings for a patient of this age?
answer
Normal pH, decreased PaO2, normal PaCO2
question
upon performing a lung sound assessment of the anterior chest, the nurse hears moderately loud sounds on inspiration that are equal in length with expiration. In what area is this lung sound considered normal?
answer
primary bronchi
question
which sounds in the smaller bronchioles and the alveoli indicate normal lung sounds?
answer
Soft, low rustling; like wind in the trees.
question
what is the characteristic normal lung sounds that should be heard throughout the lung fields?
answer
Soft sound, long inspiration, short quiet expiration.
question
upon assessing the lungs, the nurse hears short, discrete popping sounds "like hair being rolled between fingers near the ear" in the bilateral lower lobes. How is this assessment documented?
answer
Fine crackles.
question
The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented?
answer
Orthopnea.
question
what conditions shift the curve to the right, meaning hemoglobin will dissociate oxygen?
answer
Increased carbon dioxide concentration. Decreased tissue concentration of glucose breakdown products. Decreased tissue pH ( acidosis).
question
what observations does the nurse make when performing a general assessment of a patient's lungs and thorax?
answer
symmetry of chest movement. Rate, rhythm, and depth of respirations. Use of accessory muscles for breathing. Comparison of the anteroposterior diameter with the lateral diameter. Assessment of chest expansion and respiratory excursion.
question
Which assessment finding is an objective sign of chronic oxygen deprivation?
answer
Clubbing of fingernails and a barrel shaped chest.
question
The nurse is palpating a patient's chest and identifies an increased tactile fremitus or vibration of the chest wall produced when the patient speaks. What does the nurse do next?
answer
Observe the patient for other findings associated with a pneumothorax.
question
the nurse reviews the complete blood count results for the patient who has chronic obstructive pulmonary disease (COPD) and lives in a high mountain area. What lab results does the nurse expect to see for this patient?
answer
Increased red blood cells.
question
The nurse is inspecting a patient's chest and observes an increase in anteroposterior diameter of the chest. When is this an expected finding?
answer
In older adult patients.
question
While percussing a patient's chest and lung fields, the nurse notes a high, loud, musical, drum like sound similar to tapping a cheek that is puffed out with air. What is the nurses priority action?
answer
Assess the patient for air hunger or pain at the end of the inhalation and exhalation.
question
What is the best position for a patient to assume for a thoracentesis?
answer
Sitting up, leaning forward on the overbed table.
question
which procedure has a risk for the complication of pneumothorax?
answer
thoracentesis.
question
a patient has undergone a percutaneous lung biopsy. After the procedure, what test may be ordered to confirm that there is no Pneumothorax?
answer
computed tomography. Chest x-ray.
question
The respiratory therapist consults with and reports to the nurse that a patient is producing frothy pink sputum. What does the nurse suspect is occurring with this patient?
answer
Pulmonary edema.
question
A patient who had a thoracentesis is now experiencing the following clinical manifestations: rapid shallow respirations, rapid heart rate, and pain on the affected side that is worse at the end of inhalation. What complication does the nurse suspect this patient has developed?
answer
Pneumothorax.
question
For what reasons would a patient have a bronchoscopy?
answer
obtain samples for cultures. Diagnose pulmonary disease. Obtain samples for biopsy.
question
The nurse has just received a patient from the recovery room who is somewhat drowsy, but is capable of following instructions. Pulse oximetry has dropped from 95% to 90%. What is the priority nursing intervention?
answer
Administer oxygen at 2 L a minute by nasal cannula, then reassess.
question
What is a pulse oximeter used to measure?
answer
hemoglobin saturation.
question
which aspect of PFTs would be considered a normal result in the older adult?
answer
Decline in forced expiratory volume in 1 second.
question
In the older adult with chronic pulmonary disease, there is a loss of elastic recoiling of the lung and decreased chest wall compliance. What is the result of this occurance?
answer
There is an increase in anteroposterior ratio.
question
In the older adult, there is a decreased number of functional alveoli. To assist the patient to compensate for this change related to aging, what does the nurse do?
answer
Encourage the patient to ambulate and change positions.
question
The nurse teaches the patient about the impact of cigarette smoking on the lower respiratory tract. Which statement by the patient indicates an understanding of the information?
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Using nicotine replacement therapy will increase my chances of success.
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A patient reports fatigue and shortness of breath when getting up to walk to the bathroom; however, the pulse oximetry reading is 99%. The nurse identifies a diagnosis of activity intolerance. Which laboratory value is consistent with the patient's subjective symptoms?
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Hemoglobin of 9 g/dL. (normal 12-16)
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the nurse is performing a respiratory assessment including pulse oximetry on several patients. Which conditions or situations may cause an artificially low reading?
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Anemia. Peripheral artery disease.
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A patient who had neck surgery for removal of a tumor reports " not being able to breathe very well." The nurse observes that the patient has decreased chest movement and an elevated pulse. A bronchoscopy is ordered. For what reason did the provider order a bronchoscopy for this patient?
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Visualize the larynx (airway structures) to use as a guide for intubation.
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the patient returns to the unit after bronchoscopy. In addition to respiratory status assessment, which assessment does the nurse make in order to prevent aspiration?
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Presence or absence of gag reflex.
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The nurse here's fine crackles during a long assessment of the patient who is in the initial postoperative period. Which nursing intervention helps relieve this respiratory problem?
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Encourage coughing and deep breathing.
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A patient having respiratory difficulty has a pH of 7.48. What is the nurses best interpretation of this value?
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Alkalosis.
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The nurse is performing a respiratory assessment on an older adult patient. Which questions are appropriate to ask when using Gordon's Functional Health Pattern Assessment approach?
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How has your general health been? Do you now or have you ever smoked? Have you had any colds this past year? Do you have sufficient energy to do what you like to do?
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Tissue oxygen delivery through dissociation from hemoglobin is based on which factor?
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Tissues' need for oxygen.
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The nurse makes observations about several respiratory patients' abilities to perform activities of daily living in order to quantify the level of dyspnea. Which patient is considered to have class V dyspnea?
answer
Limited to bed or chair and experiences shortness of breath at rest.
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The nurse is reviewing the arterial blood gas results for a 25-year-old trauma patient who has new onset of shortness of breath and demonstrates shallow and irregular respirations. The arterial blood gas results are: pH 7.26; PCO2 47%; PO2 89%; HCO 324. What imbalanced does the nurse suspect this patient has?
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Respiratory acidosis.
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The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? a) Swallow reflex b) Ability to deep breathe c) Medication allergies d) Presence of carotid pulse
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Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
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The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? a) Increased temperature of the room b) Diagnosis of peripheral vascular disease c) Reduced lighting in the room d) Placement of the probe on an earlobe
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Diagnosis of peripheral vascular disease Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.
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The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to? a) Orthopnea b) Bradypnea c) Tachypnea d) Dyspnea
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Orthopnea Explanation: Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.
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While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? a) Rhonchi b) Pleural friction rub c) Wheezes d) Crackles
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Wheezes Explanation: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma
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A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Tidal volume b) Maximal voluntary ventilation c) Functional residual capacity d) Vital capacity
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Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.
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The amount of air inspired and expired with each breath is called: a) tidal volume. b) residual volume. c) vital capacity. d) dead-space volume.
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tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.
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The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? a) Adult respiratory distress syndrome b) Acute respiratory obstruction c) Asthma d) Pneumothorax
answer
Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
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The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as: a) Pigeon chest b) Barrel chest c) Funnel chest d) Kyphoscoliosis
answer
Barrel chest Explanation: Barrel chest occurs as a result of lung hyperinflation, as in emphysema. There is an increase in the anteroposterior diameter of the thorax so that it approximates a 1:1 ratio. In a patient with emphysema, the costal angle will also be greater than 90 degrees.
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The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? a) Excessive capillary refill b) Absent distal pulses c) Raised temperature in the affected limb d) Flushed feeling in the client
answer
Absent distal pulses Explanation: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.
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A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? a) Central sulcus b) The pons c) Wernicke's area d) The frontal lobe
answer
The pons Explanation: The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
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a. Frontal
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1. A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus? a. Frontal b. Ethmoidal c. Maxillary d. Sphenoidal
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c. Decreased gag reflex d. Increased presence of collagen in alveolar walls e. Decreased presence of mucus
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2. When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (select all that apply) a. Decreased alveolar duct diameter b. Increased presence of mucus c. Decreased gag reflex d. Increased presence of collagen in alveolar walls e. Decreased presence of mucus
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c. Ventilation exceeds perfusion
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3. A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does the is mean for the patient? a. Perfusion exceeds ventilation b. There is an absence of perfusion and ventilation c. Ventilation exceeds perfusion d. Ventilation matches perfusion
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d. 95 mm Hg
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4. A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? a. 40 mm Hg b. 75 mm Hg c. 80 mm Hg d. 95 mm Hg
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c. Previous history of lung disease in the patient or family d. Occupational and environmental influences e. Previous history of smoking
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5. The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (select all that apply) a. Financial ability to pay the bill b. Social support c. Previous history of lung disease in the patient or family d. Occupational and environmental influences e. Previous history of smoking
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d. Pleurisy
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6. A patient comes to the emergency department complaining of a knifelike pain when taking deep breath. What does this type of pain likely indicate to the nurse? a. Bacterial pneumonia b. Bronchogenic carcinoma c. Lung infarction d. Pleurisy
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a. Cyanosis
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7. The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? a. Cyanosis b. Dyspnea c. Restlessness d. Confusion
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a. Barrel chest
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8. The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient? a. Barrel chest b. Funnel chest c. Kyphoscoliosis d. Pigeon chest
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c. Wheezes
answer
9. The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard? a. Rales b. Crackles c. Wheezes d. Rhonchi
question
c. Collapsed alveoli
answer
10. The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard? a. Asthma b. Bronchospasm c. Collapsed alveoli d. Pulmonary edema
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b. Emphysema
answer
11. During a pre-admission assessment, for what diagnosis would the nurse expect to find increased tactile fremitus and hyperresonant percussion sounds? a. Bronchitis b. Emphysema c. Atelectasis d. Pulmonary edema
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b. PaCO2
answer
12. The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? a. PaO2 b. PaCO2 c. pH d. SaO2
question
a. Initially, clear the nose and throat c. Take a few deep breaths before coughing d. Use diaphragmatic contractions to aid in the expulsion of sputum
answer
13. The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? a. Initially, clear the nose and throat b. Spit surface mucus and saliva into a sterile specimen container c. Take a few deep breaths before coughing d. Use diaphragmatic contractions to aid in the expulsion of sputum e. Rinse with mouthwash prior to providing the specimen
question
c. Fluoroscopy
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14. A physician wants a study of diaphragmatic motion because the suspected pathology. What does the nurse anticipate the physician will most likely order? a. Barium swallow b. Bronchogram c. Fluoroscopy d. Tomogram
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a. A mask will be placed over the nose and mouth during the test b. The patient will be expected to lie under the camera c. The imaging time will amount to 20 to 40 minutes
answer
15. The nurse is instructing a patient who is scheduled for perfusion lung scan. What should be included in the information about the procedure? (select all that apply.) a. A mask will be placed over the nose and mouth during the test b. The patient will be expected to lie under the camera c. The imaging time will amount to 20 to 40 minutes d. The patient will be expected to be NPO for 12 hours prior to the procedure e. An injection will be placed into the lung during the procedure.
question
b. Orthopnea
answer
16. The nurse is performing an assessment for a patient with congestive heart failure. The nurse asked if the patient has difficulty breathing in any position other than upright. What is the nurse referring to? a. Dyspnea b. Orthopnea c. Tachypnea d. Bradypnea
question
a. Angiotensin converting enzyme (ACE) inhibitors
answer
17. The nurse is interviewing a patient who says he has dragged, irritating cough that is not "bringing up anything". What medication should the nurse question the patient about taking? a. Angiotensin converting enzyme (ACE) inhibitors b. Aspirin c. Bronchodialators d. Cardiac glycosides
question
c. Clubbing of the fingers
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18. What finding by the nurse May indicate that patient has chronic hypoxia? a. Crackles b. Peripheral edema c. Clubbing of the fingers d. Cyanosis
question
b. Cyanosis
answer
19. The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? a. Clubbing of fingers b. Cyanosis c. Crackles d. Restlessness
question
d. Biot's respirations
answer
20. The nurse is performing in the sentiment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal 3 to 4 breaths followed by a 60-second period apnea. How does the nurse document the respirations? a. Cheyne-Stokes b. Tachypnea c. Bradypnea d. Biot's respirations
