Resp Chapter 31 – Flashcards
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A patient is admitted to a respiratory unit with a diagnosis of left lower lobe pneumonia. The nursing assessment reveals the patient to be febrile and experiencing a weak, congested-sounding cough. The patient has moist crackles throughout the lung fields. Based on the data provided, which nursing diagnosis is most appropriate?
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Ineffective Airway Clearance
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The nurse is caring for a patient with pneumonia. Which laboratory test would best help the nurse to monitor the condition of this patient?
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White blood cell (WBC) count, arterial blood gases (ABGs
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A patient is unable to maintain a clear airway effectively with coughing and has a respiratory rate of 22/min with coarse crackles bilaterally. Which intervention should the nurse provide first?
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Assess the patient's coughing technique
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The nurse is reviewing data collected on a patient with a respiratory disorder. Which factor should the nurse identify that places the patient at risk for lung cancer?
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Smoking and exposure to radon gas
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A patient with lung cancer who is scheduled to begin a course of radiation therapy asks the nurse, "How will they know if I'm cured?" The nurse's best response is based on which understanding of the disease process?
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Radiation in lung cancer is most often used to increase comfort, not cure disease
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A patient with lung cancer develops pleural effusion. Which explanation by the nurse would help the patient understand this problem?
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"Fluid has collected in the space between your lungs and the sac surrounding your lungs."
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A patient diagnosed with a pleural effusion is very dyspneic. With which procedure should the nurse anticipate assisting?
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Thoracentesis
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The nurse is providing discharge teaching for a patient with newly diagnosed asthma. What should be included in the discharge teaching?
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"Symptoms are caused by inflammation in the lining of your airways."
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The nurse is providing routine follow-up care for a young adult with asthma who has been on a 3-month course of maintenance therapy. Which activity would best help the nurse to determine if the patient's treatment plan was effective?
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Examine daily tracking records of the peak expiratory flow rate.
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A summer camp worker reports to the camp nurse with complaints of shortness of breath and audible wheezing. Which inhaled medication should the nurse provide?
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Albuterol (Proventil)
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While reinforcing discharge teaching for a patient with emphysema, which patient statement indicates that teaching was effective?
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"Air gets trapped when damage to the air sacs makes it hard for air to move in and out."
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A patient with chronic obstructive pulmonary disease is prescribed methylprednisolone (Solu-Medrol). For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem?
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Improve the oxygen-carrying capacity of hemoglobin
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A nurse is providing home care for a patient with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?
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Oxygen 4 L/min per nasal cannula
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A patient prescribed theophylline for asthma has a theophylline level of 3 mcg/dL. What should the nurse do?
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Notify the physician.
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The nurse enters the room of a patient who is acutely short of breath. Which action should the nurse take first?
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Encourage use of pursed-lip breathing.
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The nurse is providing care for a patient prescribed tiotropium (Spiriva). Which statement should be included in the patient education?
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"Do not swallow the capsules."
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The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease. Which medication can help reduce acute dyspnea associated with this disease?
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V morphine
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A patient's arterial blood gas analysis shows a PaCO2 of 62 mm Hg. What action should the nurse take?
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Notify the RN; this is abnormally high
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A patient with chronic obstructive pulmonary disease works with the nurse to set a goal of ambulating to the bathroom with oxygen. Which statement best documents progress toward this goal?
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"Ambulated to bathroom with oxygen, dyspnea level 3 on a 0-to-10 scale."
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A patient with cystic fibrosis has ineffective airway clearance. What intervention would worsen this problem?
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Bedrest
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The nurse is assisting in the preparation of content that focuses on respiratory health for a community health fair. What should the nurse include as a major risk factor for many respiratory problems?
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Smoking
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A patient has difficulty raising pulmonary secretions, and the nurse writes a nursing diagnosis of "Ineffective Airway Clearance related to weak cough and fatigue." What would best help the patient maintain a clear airway?
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Instruct in abdominal and pursed-lip breathing.
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A patient with a lung infection has blood-tinged sputum. What term should the nurse use to document this finding?
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Hematemesis
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A nurse performs purified protein derivative and Candida skin tests on a patient suspected of TB. After 48 hours, what finding at the injection sites should the nurse document as a positive result?
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Induration
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A patient with suspected TB is prescribed a Candida skin test. What should the nurse explain as the purpose of this test?
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Provides a control test
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The nurse is reviewing the health histories for an assigned group of patients. Which patient should the nurse identify as being the most at risk for TB?
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The patient with acquired immunodeficiency syndrome
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The nurse is reviewing medication orders for a patient with TB. Which drugs should the nurse expect to have prescribed for this patient?
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Isoniazid and rifampin
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A patient with TB who is in respiratory isolation must go to the x-ray department. Which action should the nurse take?
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Place a mask over the patient's nose and mouth.
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The nurse teaches a patient with TB about drug therapy. Which patient statement indicates that teaching has been effective?
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"I will probably need to be on antibiotic therapy for 6 months to 2 years."
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A patient with TB takes the prescribed drugs until the bottle runs out and then feels better and does not refill the prescription. The home health nurse explains that continuing the drugs is important for which reason?
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"You must take all the drugs to prevent development of resistant bacteria."
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The nurse is beginning morning care after receiving report. Which patient should the nurse monitor most closely for symptoms of a pulmonary embolism (PE)?
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A patient with a deep vein thrombosis in the leg
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The nurse answers a call light and finds the patient gasping for breath and looking very anxious. Based on the patient's history, the nurse believes the patient may be experiencing a pulmonary embolism (PE). Which action should the nurse take first?
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Call for help and start oxygen.
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A patient is diagnosed with a pulmonary embolism. Which medication should the nurse anticipate administering to this patient?
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Heparin
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A patient with a pneumothorax has a chest drainage system. The family asks when the chest tube will be removed. What should the nurse respond to the family?
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"When tidaling stops and lung sounds are equal on both sides, the tube can be removed."
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The nurse auscultates the lung sounds of a patient with a pneumothorax every 4 hours. What is the nurse listening for during this auscultation?
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Evidence of bilateral lung sounds
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A patient is diagnosed with respiratory failure. Which acid-base abnormality should the nurse expect the patient to demonstrate?
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Respiratory acidosis
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An LPN is collecting data on a patient recovering from thoracic surgery. Vital signs following surgery were: blood pressure 156/94 mm Hg, pulse 100 beats/min, respirations 14/min, and temperature 97.4°F (approximately 36.3°C). Which new finding should the nurse report immediately to the physician?
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Blood pressure 110/76 mm Hg
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The nurse develops a plan for impaired gas exchange for a patient with end-stage chronic obstructive pulmonary disease (COPD). Which finding best helps the nurse to know when the goal has been reached?
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The patient's oxygen saturation is 92%.
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A patient asks the nurse what can be done to prevent the development of lung cancer. What measure should the nurse explain as the most effective way to prevent this disease?
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Avoid smoking.
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The nurse is assisting in the preparation of an inservice on infections. What should the nurse include as being the most common cause of death from infection?
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Pneumonia
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A patient has a positive response to a Candida test, in addition to a positive purified protein derivative (PPD) skin test. Which interpretation of these results is correct?
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The patient's PPD test is reliable.
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The nurse is reviewing the health statuses for assigned patients to determine the risk for pneumonia. Which type of pneumonia occurs most often as a nosocomial infection in hospitalized patients, very young patients, and older patients?
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Bronchopneumonia
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The nurse is caring for a patient with long-standing bronchiectasis. Which manifestation should the nurse report immediately?
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Distended neck veins and dependent edema
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The nurse is assisting with the development of content on lung diseases to be provided during an upcoming health fair. What should the nurse include as being the disease that one-third of the world's population is currently infected?
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TB
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An older adult patient who reports difficulty breathing and a productive cough and has a low-grade fever is admitted to the hospital for diagnosis and treatment. Which new-onset symptom should take priority?
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Confusion
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The nurse is concerned that a patient with a chronic low oxygen saturation level should be wearing home oxygen. Which oxygenation level should be used to make this decision?
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88%
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A patient is having a therapeutic thoracentesis to remove pleural fluid. What volume of pleural fluid should the nurse recognize as being abnormal?
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30 mL
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A patient is diagnosed with a pulmonary embolism. To be effective, how soon should thrombolytic agents be administered?
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4 to 6 hours
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The nurse observes a newly admitted patient in the hospital room and determines that data collection should be focused on chronic obstructive pulmonary disease. What did the nurse observe to make this decision?
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The patient is sitting in the tripod position.
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According to Centers for Disease Control and Prevention (CDC) guidelines, which individuals should the nurse consider as being positive for the TB skin test? (Select all that apply.)
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b. A 5-mm induration in an HIV-infected individual c. A 10-mm induration in a child younger than 4 years old e. A 10-mm induration in an individual with no risk factors for TB
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The nurse is caring for a patient with a suspected pulmonary embolism. Which diagnostic tests or procedures should the nurse expect to be prescribed for this patient? (Select all that apply.)
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a. D-dimer c. Angiogram e. Ventilation-perfusion lung scan f. Spiral computed tomography (CT) scan
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A nurse is providing care for a patient with Ineffective Airway Clearance. Which are appropriate interventions to address this problem? (Select all that apply.)
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a. Weigh patient every day. b. Teach patient proper use of an incentive spirometer. c. Place patient in supine position and turn every 2 hours. d. Assess respiratory rate and pattern every 4 hours and prn. e. Encourage patient to deep breathe and cough every 2 hours. f. Administer guaifenesin (Mucinex) every 4 to 6 hours prn as ordered.
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The nurse needs to collect a sputum specimen for culture from a patient with a chronic cough. What actions should the nurse take when collecting this specimen? (Select all that apply.)
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a. Obtain the specimen first thing in the morning b. Obtain the specimen before the patient eats breakfast
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The nurse is assisting in the planning of care for a patient with chronic obstructive pulmonary disease. What should be the goals of care for this patient? (Select all that apply.)
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a. Smoking cessation b. Improve activity tolerance c. Prevent disease progression e. Prevent and treat exacerbations
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A young adult is admitted with manifestations associated with cystic fibrosis. What should the nurse expect to find when collecting data from this patient? (Select all that apply.)
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b. Finger clubbing c. Body mass index 16 d. Thick sputum production e. Complaints of frequent foul-smelling stool
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A patient is prescribed long-term anticoagulant therapy as treatment for pulmonary emboli. What should the nurse ensure the patient is instructed before being discharged home? (Select all that apply.)
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a. Wear shoes at home. b. Use an electric razor. c. Use a soft toothbrush.
