Combo with Nclex Review: Hypertension and 3 others

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Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is:
1. Decrease in heart rate.
2. Lessening of fatigue.
3. Improvement in blood sugar levels.
4. Increase in urine output.

1.
The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.

A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply.
1. Dry mouth.
2. Hyperkalemia.
3. Impotence.
4. Pancreatitis.
5. Sleep disturbance.

1, 3, 5.
Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.

A client with hypertensive emergency is being treated with sodium nitroprusside (Nipride). In a dilution of 50 mg/ 250 mL, how many micrograms of Nipride are in each milliliter? ________________________ mcg.

200 mcg
First, calculate the number of milligrams per milliliter: Next, calculate the number of micrograms in each milligram: CN: Pharmacological and parenteral

In teaching the hypertensive client to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions? Select all that apply.
1. Plan regular times for taking medications.
2. Arise slowly from bed.
3. Avoid standing still for long periods.
4. Avoid excessive alcohol intake.
5. Avoid hot baths.

2, 3.
Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.

An industrial health nurse at a large printing plant finds a male employee's blood pressure to be elevated on two occasions 1 month apart and refers him to his private physician. The employee is about 25 lb overweight and has smoked a pack of cigarettes daily for more than 20 years. The client's physician prescribes atenolol (Tenormin) for the hypertension. The nurse should instruct the client to:
1. Avoid sudden discontinuation of the drug.
2. Monitor the blood pressure annually.
3. Follow a 2-g sodium diet.
4. Discontinue the medication if severe headaches develop.

1.
Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician's order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.

The nurse teaches a client, who has recently been diagnosed with hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs?
1. Mixed green salad with blue cheese dressing, crackers, and cold cuts.
2. Ham sandwich on rye bread and an orange.
3. Baked chicken, an apple, and a slice of white bread.
4. Hot dogs, baked beans, and celery and carrot sticks.

3.
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.

A client's job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following?
1. Muscle aches.
2. Thirst.
3. Lethargy.
4. Orthostatic hypotension.

4.
Possible dizziness from orthostatic hypotension when rising from a crouched or bent position increases the client's risk of being injured by the equipment. The nurse should assess the client's blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as orthostatic hypotension. The client should not be experiencing lethargy.

An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
1. Giving the client a written exercise program.
2. Explaining the exercise program to the client's spouse.
3. Reassuring the client that he or she can do the exercise program.
4. Tailoring a program to the client's needs and abilities.

4.
Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.

The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
1. Review the negative effects of smoking on the body.
2. Discuss the effects of passive smoking on environmental pollution.
3. Establish the client's daily smoking pattern.
4. Explain how smoking worsens high blood pressure.

3.
A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following?
1. 120/ 90 mm Hg.
2. 130/ 85 mm Hg.
3. 140/ 90 mm Hg.
4. 160/ 80 mm Hg.

3.
American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol:
1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.
2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate.
3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

1.
Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II.

The most important long-term goal for a client with hypertension would be to:
1. Learn how to avoid stress.
2. Explore a job change or early retirement.
3. Make a commitment to long-term therapy.
4. Lose weight.

3.
Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.

The client has had hypertension for 20 years. The nurse should assess the client for?
1. Renal insufficiency and failure.
2. Valvular heart disease.
3. Endocarditis.
4. Peptic ulcer disease.

1.
Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undeteced high blood pressure?
1. Cerebrovascular accidents (CVAs).
2. Liver disease.
3. Myocardial infarction.
4. Pulmonary disease.

1.
Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.

A client treated for hypertension with furosemide (Lasix), atenolol (Tenormin), and ramipril (Altace) develops a second degree heart block Mobitz type 1. Which of the following actions should the nurse take?
1. Administer a 250 mL fluid bolus.
2. Withhold the atenolol.
3. Prepare for cardioversion.
4. Set up for an arterial line.

2.
The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing. There is no indication for a fluid bolus, cardioversion, or arterial line.

1. A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the health care provider immediately about
a. a pulse oximetry reading of 90%.
b. a peak expiratory flow rate of 240 ml/min.
c. decreased breath sounds and wheezing.
d. a respiratory rate of 26 breaths/min.

C
Rationale: Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated. The other data indicate that the patient needs ongoing monitoring and assessment but do not indicate a need for immediate treatment.

Cognitive Level: Application Text Reference: pp. 608, 612, 614
Nursing Process: Assessment NCLEX: Physiological Integrity

2. The nurse recognizes that intubation and mechanical ventilation are indicated for a patient in status asthmaticus when
a. ventricular dysrhythmias and dyspnea occur.
b. loud wheezes are audible throughout the lungs.
c. pulsus paradoxus is greater than 40 mm Hg.
d. fatigue and an O2 saturation of 88% develop.

D
Rationale: Although all of the assessment data indicate the need for rapid intervention, the fatigue and hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort and needs mechanical ventilation. The initial treatment for the other clinical manifestations would initially be administration of rapidly acting bronchodilators and oxygen.

Cognitive Level: Application Text Reference: pp. 612-613
Nursing Process: Assessment NCLEX: Physiological Integrity

3. An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that
a. Advair is a combination of long-acting and slow-acting bronchodilators.
b. the two drugs work together to block the effects of histamine on the bronchioles.
c. one drug decreases inflammation, and the other is a bronchodilator.
d. the combination of two drugs works more quickly in an acute asthma attack.

C
Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid; they work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly.

Cognitive Level: Application Text Reference: pp. 621
Nursing Process: Implementation NCLEX: Physiological Integrity

4. The health care provider has prescribed triamcinolone (Azmacort) metered-dose inhaler (MDI) two puffs every 8 hours and pirbuterol (Maxair) MDI 2 puffs four times a day for a patient with asthma. In teaching the patient about the use of the inhalers, the best instruction by the nurse is
a. "Use the Maxair inhaler first, wait a few minutes, then use the Azmacort inhaler."
b. "Using a spacer with the MDIs will improve the inhalation of the medications."
c. "To avoid side effects, the inhalers should not be used within 1 hour of each other."
d. "To maximize the effectiveness of the drugs, inhale quickly when using the inhalers."

B
Rationale: More medication reaches the bronchioles when a spacer is used along with an MDI. There is no evidence that using a bronchodilator before a corticosteroid inhaler is helpful. The medications can be used at the same time. The patient should inhale slowly when using an MDI.

Cognitive Level: Application Text Reference: p. 621
Nursing Process: Implementation NCLEX: Physiological Integrity

5. When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to
a. avoid eating or drinking for 4 hours before the forced expiratory volume in 1 second (FEV1)/forced expiratory volume (FEV) test.
b. take oral corticosteroids at least 2 hours before the examination.
c. withhold bronchodilators for 6 to 12 hours before the examination.
d. use rescue medications immediately before the FEV1/FEV testing.

C
Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

Cognitive Level: Application Text Reference: p. 614
Nursing Process: Planning NCLEX: Physiological Integrity

6. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. A common etiologic factor for this nursing diagnosis in patients with asthma is
a. anxiety about dyspnea.
b. side effects of medications.
c. work of breathing.
d. fear of suffocation.

C
Rationale: The activity intolerance patients with asthma experience is related to the increased effort needed to breathe when airways are inflamed and narrowed and interventions are focused on decreasing inflammation and bronchoconstriction. The other listed etiologies are not as appropriate for this diagnosis but would be appropriate for diagnoses seen in patients with asthma, such as social isolation, knowledge deficit, and anxiety.

Cognitive Level: Application Text Reference: pp. 612, 624
Nursing Process: Diagnosis NCLEX: Physiological Integrity

7. Which finding would be the best indication to the nurse that the patient having an acute asthma attack was responding to the prescribed bronchodilator therapy?
a. Wheezes are more easily heard.
b. The oxygen saturation is 89%.
c. Vesicular breath sounds resolve.
d. The respiratory effort decreases.

A
Rationale: Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working. An oxygen saturation level less than 90% indicates continued hypoxemia. Vesicular breath sounds are normal. A decreased respiratory effort may indicate that the patient is becoming too fatigued to breathe effectively and needs mechanical ventilation.

Cognitive Level: Application Text Reference: p. 617
Nursing Process: Evaluation NCLEX: Physiological Integrity

8. A patient who has mild persistent asthma uses an albuterol (Proventil) inhaler for chest tightness and wheezing has a new prescription for cromolyn (Intal). To increase the patient's management and control of the asthma, the nurse should teach the patient to
a. use the cromolyn when the albuterol does not relieve symptoms.
b. use the cromolyn to prevent inflammatory airway changes.
c. administer the cromolyn first for chest tightness or wheezing.
d. administer the albuterol regularly to prevent airway inflammation.

B
Rationale: Cromolyn is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms Albuterol is used as a rescue medication in mild persistent asthma and will not decrease inflammation.

Cognitive Level: Application Text Reference: p. 620
Nursing Process: Implementation NCLEX: Physiological Integrity

9. During assessment of a patient with a history of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce
a. laryngospasm.
b. pulmonary edema.
c. airway narrowing.
d. alveolar distention.

C
Rationale: The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading to airway narrowing. Treatment for laryngospasm or pulmonary edema would not be appropriate. There are no medications used to treat alveolar distention.

Cognitive Level: Comprehension Text Reference: pp. 608, 611-612
Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient with an acute attack of asthma comes to the emergency department, where ABGs are drawn. The nurse determines the patient is in the early phase of the attack, based on the ABG results of
a. pH 7.0, PaCO2 50 mm Hg, and PaO2 74 mm Hg.
b. pH 7.4, PaCO2 32 mm Hg, and PaO2 70 mm Hg.
c. pH 7.36, PaCO2 40 mm Hg, and PaO2 80 mm Hg.
d. pH 7.32, PaCO2 58 mm Hg, and PaO2 60 mm Hg.

B
Rationale: The initial response to hypoxemia caused by airway narrowing in a patient having an acute asthma attack is an increase in respiratory rate, which causes a drop in PaCO2. The other PaCO2 levels are normal or elevated, which would indicate that the attack was progressing and that the patient is decompensating.

Cognitive Level: Application Text Reference: pp. 614, 626
Nursing Process: Assessment NCLEX: Physiological Integrity

11. While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse instructs the patient to
a. take and record peak flow readings when having asthma symptoms or an attack.
b. increase the doses of long-term control medications for peak flows in the red zone.
c. use the flow meter each morning after taking asthma medications.
d. empty the lungs and then inhale rapidly through the mouthpiece.

A
Rationale: It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting 2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation.

Cognitive Level: Application Text Reference: pp. 625, 628
Nursing Process: Implementation NCLEX: Physiological Integrity

12. A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of emphysema. The patient denies any history of smoking. The nurse will anticipate teaching the patient about
a. 1-antitrypsin testing.
b. use of the nicotine patch.
c. continuous pulse oximetry.
d. effects of leukotriene modifiers.

A
Rationale: When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema.

Cognitive Level: Application Text Reference: p. 632
Nursing Process: Planning NCLEX: Physiological Integrity

13. When teaching a patient with chronic obstructive pulmonary disease (COPD) about reasons to quit smoking, the nurse will explain that long-term exposure to tobacco smoke leads to a
a. weakening of the smooth muscle lining the airways.
b. decrease in the area available for oxygen absorption.
c. lesser number of red blood cells for oxygen delivery.
d. decreased production of protective respiratory secretions.

B
Rationale: Tobacco smoke leads to an increase in proteolytic enzymes, which break down alveolar walls and lead to less alveolar surface area for gas exchange. Bronchial smooth muscle is not weakened by chronic smoking. Polycythemia is a common compensatory mechanism for patients with COPD. The quantity of respiratory secretions increases as a result of smoking.

Cognitive Level: Application Text Reference: p. 633
Nursing Process: Implementation NCLEX: Physiological Integrity

14. Which of these is the best goal for the patient admitted with chronic bronchitis who has a nursing diagnosis of ineffective airway clearance?
a. Patient denies having dyspnea.
b. Patient's mental status is improved.
c. Patient has a productive cough.
d. Patient's O2 saturation is 90%.

C
Rationale: The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively. The other goals may be appropriate for the patient with COPD, but they do not address the problem of ineffective airway clearance.

Cognitive Level: Application Text Reference: p. 660
Nursing Process: Evaluation NCLEX: Physiological Integrity

15. A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mm Hg, PaCO2 55 mm Hg, and SaO2 86%. The nurse recognizes these values as evidence of
a. normal acid-base balance with hypoxemia.
b. normal acid-base balance with hypercapnia.
c. respiratory acidosis.
d. respiratory alkalosis.

C
Rationale: The elevated PaCO2 and low pH indicate respiratory acidosis. The patient is hypoxemic and hypercapnic, but the pH indicates acidosis, not a normal acid-base balance.

Cognitive Level: Comprehension Text Reference: p. 650
Nursing Process: Assessment NCLEX: Physiological Integrity

16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements for a patient with COPD. An appropriate intervention for this problem is to
a. have the patient exercise for 10 minutes before meals.
b. offer high calorie snacks between meals and at bedtime.
c. assist the patient in choosing foods with a lot of texture.
d. increase the patient's intake of fruits and fruit juices.

B
Rationale: Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.

Cognitive Level: Application Text Reference: pp. 649,652
Nursing Process: Planning NCLEX: Physiological Integrity

17. A patient is seen in the clinic with COPD. Which information given by the patient would help most in confirming a diagnosis of chronic bronchitis?
a. The patient tells the nurse about a family history of bronchitis.
b. The patient denies having any respiratory problems until the last 6 months.
c. The patient's history indicates a 40 pack-year cigarette history.
d. The patient complains about having a productive cough every winter for 2 months.

D
Rationale: A diagnosis of chronic bronchitis is based on a history of having a productive cough for several months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

Cognitive Level: Application Text Reference: p. 629
Nursing Process: Assessment NCLEX: Physiological Integrity

18. The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by
a. loosening secretions so that they may be coughed up more easily.
b. promoting maximal inhalation for better oxygenation of the lungs.
c. preventing airway collapse and air trapping in the lungs during expiration.
d. decreasing anxiety by giving the patient control of respiratory patterns.

C
Rationale: Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents collapse of the airways, allowing for more complete exhalation. Although loosening of secretions, improving inhalation, and decreasing anxiety are desirable outcomes for the patient with COPD, pursed-lip breathing does not directly impact these.

Cognitive Level: Comprehension Text Reference: p. 646
Nursing Process: Implementation NCLEX: Physiological Integrity

19. The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress, based on the assessment finding of
a. a pulse oximetry reading of 86%.
b. dyspnea and respiratory rate of 36.
c. use of the accessory respiratory muscles.
d. the presence of crackles in both lungs.

A
Rationale: The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry. The other data would support a diagnosis of risk for impaired gas exchange.

Cognitive Level: Application Text Reference: pp. 650-651
Nursing Process: Diagnosis NCLEX: Physiological Integrity

20. When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for
a. elevated temperature.
b. complaints of chest pain.
c. jugular vein distension.
d. clubbing of the fingers.

C
Rationale: Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension. The other clinical manifestations may occur in the patient with other complications of COPD but are not indicators of cor pulmonale.

Cognitive Level: Application Text Reference: pp. 635-636
Nursing Process: Assessment NCLEX: Physiological Integrity

21. When a patient with COPD is receiving oxygen, the best action by the nurse is to
a. avoid administration of oxygen at a rate of more than 2 L/min.
b. minimize oxygen use to avoid oxygen dependency.
c. administer oxygen according to the patient's level of dyspnea.
d. maintain the pulse oximetry level at 90% or greater.

D
Rationale: The best way to determine the appropriate oxygen flow rate is by monitoring the patient's oxygenation either by ABGs or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level.

Cognitive Level: Application Text Reference: p. 640
Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient with COPD asks the home health nurse about home oxygen use. The nurse should teach the patient that long-term home O2 therapy
a. can improve the patient's prognosis and quality of life.
b. may cause oxygen dependency in patients with COPD.
c. is used only for patients who have severe end-stage respiratory disease.
d. should never be used at night because the patient cannot monitor its effect.

A
Rationale: Research supports the use of home oxygen to improve quality of life and prognosis. Oxygen dependency is not an issue for patients with COPD. Although most patients using home oxygen have SpO2 levels less than 89% on room air, it would not be appropriate to tell the patient that he or she was at the end stage of the disease. Oxygen use at night can improve sleep quality and is frequently recommended.

Cognitive Level: Application Text Reference: p. 644
Nursing Process: Implementation NCLEX: Physiological Integrity

23. A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse
a. give a high enough flow rate to keep the bag from collapsing.
b. use an appropriate adaptor to ensure adequate oxygen delivery.
c. drain moisture condensation from the oxygen tubing every hour.
d. keep the air entrainment ports clean and unobstructed.

D
Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.

Cognitive Level: Comprehension Text Reference: p. 642
Nursing Process: Implementation NCLEX: Physiological Integrity

24. Postural drainage with percussion and vibration is ordered bid for a patient with chronic bronchitis. The nurse will plan to
a. carry out the procedure 3 hours after the patient eats.
b. maintain the patient in the lateral positions for 20 minutes.
c. perform percussion and vibration before placing the patient in the drainage position.
d. give the ordered albuterol (Proventil) after the patient has received the therapy.

A
Rationale: Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 to 15 minutes. Percussion and vibration are done after the postural drainage. Bronchodilators are administered before chest physiotherapy.

Cognitive Level: Application Text Reference: p. 647
Nursing Process: Planning NCLEX: Physiological Integrity

25. When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe COPD, the nurse should teach the patient that an appropriate exercise goal is to
a. exercise until shortness of breath occurs.
b. walk for a total of 20 minutes daily.
c. limit exercise to activities of daily living (ADLs).
d. walk until pulse rate exceeds 150.

B
Rationale: The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).

Cognitive Level: Application Text Reference: p. 653
Nursing Process: Planning NCLEX: Physiological Integrity

26. A patient with severe COPD tells the nurse, "I wish I were dead! I cannot do anything for myself anymore." Based on this information, the nurse identifies the nursing diagnosis of
a. hopelessness related to presence of long-term stress.
b. anticipatory grieving related to expectation of death.
c. ineffective coping related to unknown outcome of illness.
d. disturbed self-esteem related to physical dependence.

D
Rationale: The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although hopelessness, anticipatory grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the patient does not mention long-term stress, death, or an unknown outcome as being concerns.

Cognitive Level: Application Text Reference: p. 655
Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

27. A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange?
a. Sitting up at the bedside in a chair and leaning slightly forward
b. Resting in bed with the head elevated to 45 to 60 degrees
c. In the Trendelenburg's position with several pillows behind the head
d. Resting in bed in a high-Fowler's position with the knees flexed

A
Rationale: Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg's position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

Cognitive Level: Application Text Reference: p. 634
Nursing Process: Implementation NCLEX: Physiological Integrity

28. A patient with COPD tells the nurse, "At home, I only have to use an albuterol (Proventil) inhaler. Why did the doctor add an ipratropium (Atrovent) inhaler while I'm in the hospital? The appropriate response by the nurse is
a. "Atrovent will dilate the airways and allow the Proventil to penetrate more deeply."
b. "Atrovent is being used to decrease airway inflammation and sputum production."
c. "Atrovent works differently to dilate the bronchi, and the two drugs together are more effective."
d. "Atrovent is a potent bronchodilator and patients need to be hospitalized when receiving it."

C
Rationale: Combining bronchodilators improves effectiveness. Atrovent does not have to be used before Proventil, it does not decrease airway inflammation, and it does not require hospitalization.

Cognitive Level: Application Text Reference: p. 640
Nursing Process: Implementation NCLEX: Physiological Integrity

29. The nurse has completed teaching a patient about MDI use. Which patient statement indicates that further patient teaching is needed?
a. "I will shake the MDI each time before giving the medication."
b. "I will take a slow, deep breath in after pushing down on the MDI."
c. "I will float the canister in water to decide whether I need to get a new MDI."
d. "I will attach a spacer to the MDI to make it easier for me to use."

C
Rationale: This method is no longer recommended as a means of determining whether the medication needs replacement. The other patient statements are accurate and indicate the patient understands how to use the MDI.

Cognitive Level: Application Text Reference: p. 622
Nursing Process: Evaluation NCLEX: Physiological Integrity

30. A 23-year-old with cystic fibrosis (CF) is admitted to the hospital. Which intervention will be included in the plan of care?
a. Schedule sweat chloride test to evaluate the effectiveness of therapy.
b. Arrange for a hospice nurse to visit with the patient regarding home care.
c. Place the patient on a low-sodium diet to prevent cor pulmonale.
d. Perform chest physiotherapy every 4 hours to mobilize secretions.

D
Rationale: Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.

Cognitive Level: Application Text Reference: p. 658
Nursing Process: Planning NCLEX: Physiological Integrity

31. A 26-year-old patient has had CF since birth and has severe lung changes and cor pulmonale as a result of the disease. An appropriate expected outcome is that the patient will
a. engage in aerobic exercise without dyspnea.
b. be weaned from home oxygen use.
c. achieve a realistic attitude toward treatment.
d. develop no CF-related complications.

C
Rationale: The patient's severe lung disease and cor pulmonale are late complications of CF, and a realistic attitude about what outcome can be expected from treatment is an appropriate outcome. Exercising without dyspnea and weaning from home oxygen therapy are not realistic outcomes for this patient with end-stage disease. The patient already has multiple CF-related complications and is likely to continue to develop complications.

Cognitive Level: Application Text Reference: pp. 657-658
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

32. A 19-year-old male patient with CF and his wife are considering having a child. Which statement by the patient indicates that the nurse's teaching has been effective?
a. "We will plan on having genetic counseling before we make a decision."
b. "My erectile dysfunction will make it more difficult to have a child."
c. "It is likely that I will die before any children we have are grown."
d. "There should not be any problems as long as I take my medications."

A
Rationale: Children of patients with CF are either CF carriers or have the disease. Most men with CF are sterile, but erectile dysfunction is not associated with CF. The life expectancy for CF is getting longer, with a mean age of 35. Despite appropriate therapy, the couple is likely to experience problems becoming pregnant.

Cognitive Level: Application Text Reference: p. 659
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

33. The nurse caring for a patient with CF recognizes that the manifestations of the disease are caused by the pathophysiologic processes of
a. inflammation and fibrosis of lung tissue.
b. altered function of exocrine glands.
c. failure of the mucus-producing goblet cells.
d. thickening and fibrosis of the pleural linings.

B
Rationale: CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs, pancreas, and sweat glands. Damage to lung tissue develops late in the disease. The goblet cells continue to produce mucus.

Cognitive Level: Comprehension Text Reference: pp. 655-656
Nursing Process: Assessment NCLEX: Physiological Integrity

34. All of these orders are received for a patient having an acute asthma attack. Which one will the nurse administer first?
a. IV methylprednisolone (Solu-Medrol) 60 mg
b. triamcinolone (Azmacort) 2 puffs per MDI
c. salmeterol (Serevent) 50 mcg per DPI
d. albuterol (Ventolin) 2.5 mg per nebulizer

D
Rationale: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.

Cognitive Level: Application Text Reference: p. 620
Nursing Process: Implementation NCLEX: Physiological Integrity

35. Which statement by the COPD patient indicates that the nurse's teaching about nutrition has been effective?
a. "I will drink lots of fluids with my meals."
b. "I will have ice cream as a snack every day."
c. "I should exercise for 15 minutes before meals."
d. "I should avoid much meat or dairy products."

B
Rationale: High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.

Cognitive Level: Application Text Reference: p. 649
Nursing Process: Evaluation NCLEX: Physiological Integrity

36. When teaching the patient with COPD about exercise, which information should the nurse include?
a. "Stop exercising if you start to feel short of breath."
b. "Use the bronchodilator before you start to exercise."
c. "Breathe in and out through the mouth while you exercise."
d. "Upper body exercise should be avoided to prevent dyspnea."

B
Rationale: Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

Cognitive Level: Application Text Reference: p. 653
Nursing Process: Implementation NCLEX: Physiological Integrity

37. The nurse has received a change-of-shift report about these patients with COPD. Which patient should the nurse assess first?
a. A patient with loud expiratory wheezes
b. A patient who has a cough productive of thick, green mucus
c. A patient with jugular vein distension and peripheral edema
d. A patient with a respiratory rate of 38

D
Rationale: A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient.

Cognitive Level: Application Text Reference: pp. 612, 626
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment

38. Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse?
a. The patient says that the asthma symptoms are worse every spring.
b. The patient's only asthma medications are albuterol (Proventil) and salmeterol (Serevent).
c. The patient uses cromolyn (Intal) before any aerobic exercise.
d. The patient's heart rate increases after using the albuterol (Proventil) inhaler.

B
Rationale: Long-acting 2-agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

Cognitive Level: Application Text Reference: pp. 615, 621
Nursing Process: Assessment NCLEX: Physiological Integrity

39. When taking an admission history of a patient with possible asthma who has new-onset wheezing and shortness of breath, the nurse will be most concerned about which information?
a. The patient has a history of pneumonia 2 years ago.
b. The patient takes propranolol (Inderal) for hypertension.
c. The patient uses acetaminophen (Tylenol) for headaches.
d. The patient has chronic inflammatory bowel disease.

B
Rationale: -blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy.

Cognitive Level: Application Text Reference: p. 610
Nursing Process: Assessment NCLEX: Physiological Integrity

40. A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse's first action should be to
a. determine when the dyspnea started.
b. obtain the forced expiratory flow rate.
c. listen to the patient's breath sounds.
d. ask about inhaled corticosteroid use.

C
Rationale: Assessment of the patient's breath sounds will help to determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with a FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

Cognitive Level: Application Text Reference: p. 626
Nursing Process: Assessment NCLEX: Physiological Integrity

41. After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states,
a. "I will use my corticosteroid inhaler as soon as I start to get short of breath."
b. "I will only turn the home oxygen level up after checking with the doctor first."
c. "My medications are working if I wake up short of breath only once during the night."
d. "No changes in my medications are needed if my peak flow is at 80% of normal."

D
Rationale: Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea.

Cognitive Level: Application Text Reference: p. 628
Nursing Process: Evaluation NCLEX: Physiological Integrity

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort

D
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

Cognitive Level: Application Text Reference: p. 568
Nursing Process: Diagnosis NCLEX: Physiological Integrity

2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first?
a. Azithromycin (Zithromax)
b. Acetaminophen (Tylenol)
c. Guaifenesin (Robitussin)
d. Codeine phosphate (Codeine)

A
Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

Cognitive Level: Application Text Reference: pp. 563, 566
Nursing Process: Implementation NCLEX: Physiological Integrity

3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
a. hyperresonance on percussion.

b. increased vocal fremitus on palpation.
c. fine crackles in all lobes on auscultation.
d. asymmetric chest expansion on inspection.

B
Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia.

Cognitive Level: Application Text Reference: p. 565
Nursing Process: Assessment NCLEX: Physiological Integrity

4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
a. splint the chest when coughing.
b. maintain fluid restrictions.
c. wear the nasal oxygen cannula.
d. try the pursed-lip breathing technique.

A
Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia.

Cognitive Level: Application Text Reference: p. 568
Nursing Process: Implementation NCLEX: Physiological Integrity

5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia?
a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F
b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours
c. 50-year-old patient who has an oxygen saturation of 91% on room air
d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56

C
Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge.

Cognitive Level: Application Text Reference: p. 563
Nursing Process: Planning NCLEX: Physiological Integrity

6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is
a. hyperthermia related to infectious illness.
b. ineffective airway clearance related to thick secretions.
c. impaired transfer ability related to weakness.
d. impaired gas exchange related to respiratory congestion.

D
Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

Cognitive Level: Application Text Reference: p. 566
Nursing Process: Diagnosis NCLEX: Physiological Integrity

7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next?
a. Check the patient's pulse rate.
b. Obtain an oxygen saturation.
c. Notify the health care provider.
d. Document the change.

B
Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status.

Cognitive Level: Application Text Reference: p. 565
Nursing Process: Implementation NCLEX: Physiological Integrity

8. Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states,
a. "I will increase my food intake to 3000 calories a day."
b. "I will need to use home oxygen therapy for 3 months."
c. "I will seek medical treatment for any upper respiratory infections."
d. "I will do deep-breathing and coughing exercises for the next 6 weeks."

D
Rationale: Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical treatment only when they fail to resolve in 7 days.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
a. turn and reposition immobile patients at least every 2 hours.
b. position patients with altered consciousness in lateral positions.
c. monitor frequently for respiratory symptoms in patients who are immunosuppressed.
d. provide for continuous subglottic aspiration in patients receiving enteral feedings.

B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonias in immune compromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.

Cognitive Level: Application Text Reference: p. 567
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. Increased vocal fremitus is palpable over the right chest.
c. The patient coughs up small amounts of green mucous.
d. The patient's white blood cell (WBC) count is 9000/µl.

D
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Evaluation NCLEX: Physiological Integrity

11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant
a. turns the patient over to the right side.
b. splints the patient's chest during coughing.
c. elevates the patient's head to 45 degrees.
d. assists the patient to get up to the bathroom.

A
Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Implementation NCLEX: Physiological Integrity

12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen?
a. After the patient rinses the mouth with mouthwash
b. As soon as the order is received from the health care provider
c. Right after the patient gets up in the morning
d. After the skin test is administered

C
Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Implementation NCLEX: Physiological Integrity

13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until
a. the chest x-ray shows resolution of the tuberculosis.
b. three sputum smears for acid-fast bacilli are negative.
c. TB medications have been taken for 6 months.
d. sputum cultures on 3 consecutive days are negative.

B
Rationale: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after use.
d. covers the mouth and nose when coughing.

D
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan?
a. "Take vitamin B6 daily to prevent peripheral nerve damage."
b. "Read a newspaper daily to check for changes in vision."
c. "Schedule an audiometric examination to monitor for hearing loss."
d. "Avoid wearing soft contact lenses to avoid orange staining."

A
Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications.

Cognitive Level: Application Text Reference: p. 573
Nursing Process: Planning NCLEX: Physiological Integrity

16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
a. yellow-tinged skin.
b. changes in hearing.
c. orange-colored urine.
d. thickening of the nails.

A
Rationale: Noninfectious hepatitis is a toxic effect of INH, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

Cognitive Level: Application Text Reference: pp. 572-573
Nursing Process: Implementation NCLEX: Physiological Integrity

17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Giving the patient written instructions about how to take the medications
b. Teaching the patient about the high risk for infecting others unless treatment is followed
c. Arranging for a daily noontime meal at a community center and give the medication then
d. Educating the patient about the long-term impact of TB on health

C
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.

Cognitive Level: Application Text Reference: pp. 572, 575
Nursing Process: Implementation NCLEX: Physiological Integrity

18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the knowledge that
a. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly.
b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the medications.
c. twice-weekly administration may be used to improve compliance with the treatment regimen.
d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.

A
Rationale: After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive sputum smear. Twice-weekly medication administration is not one of the options for therapy. INH and rifampin are used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by negative sputum smears.

Cognitive Level: Application Text Reference: pp. 571-572
Nursing Process: Implementation NCLEX: Physiological Integrity

19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
a. use and side effects of INH.
b. standard four-drug therapy for TB.
c. need for annual repeat TB skin testing.
d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.

A
Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient's tolerance of the drug by
a. cooling the solution to 80° F before administration.
b. keeping the patient flat in bed for 1 hour after the infusion is completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d. giving diphenhydramine (Benadryl) 1 hour before starting the infusion.

D
Rationale: Administration of an antihistamine before giving the amphotericin B will reduce the incidence of hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated. Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration in the patient receiving this drug.

Cognitive Level: Application Text Reference: p. 575
Nursing Process: Implementation NCLEX: Physiological Integrity

21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?
a. "How long have you lived in the United States?"
b. "Is there any family history of TB?"
c. "Have you received the BCG vaccine for TB?"
d. "Do you take any over-the-counter (OTC) medications?"

C
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test; another method for screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other information may also be valuable but is not as pertinent to the decision about doing TB skin testing.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Assessment NCLEX: Physiological Integrity

22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
a. washes the hands before entering the patient's room.
b. puts on a surgical face mask before visiting the patient.
c. brings food from a "fast-food" restaurant to the patient.
d. hands the patient a tissue from the box at the bedside.

B
Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Implementation NCLEX: Physiological Integrity

23. The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for
a. shortness of breath.
b. chest pain.
c. elevated temperature.
d. barrel-chest.

A
Rationale: The nurse will monitor for the earliest signs of occupational lung disease, which are dyspnea and a cough. The other symptoms are also consistent with occupational lung disease but would occur much later, after significant lung involvement has occurred.

Cognitive Level: Application Text Reference: pp. 577-578
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

24. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation.

D
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Tarceva may be used to in patients who have lung cancer, but not to reduce risk for developing tumors.

Cognitive Level: Application Text Reference: pp. 582, 584
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

25. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Tell me what you know about the various treatments available."
c. "Surgery is the treatment of choice for stage I lung cancer."
d. "Did you have bad experiences with previous surgeries?"

B
Rationale: More assessment of the patient's concerns about surgery is indicated; an open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery.

Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity

26. An hour after a left upper lobectomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 ml of bloody drainage and a large air leak. Which action should the nurse take first?
a. Assist the patient to deep breathe and cough.
b. Milk the chest tube gently to remove any clots.
c. Medicate the patient with the ordered morphine.
d. Notify the surgeon about the large air leak.

C
Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 ml is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.

Cognitive Level: Application Text Reference: p. 594
Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon, maybe this week." The best response by the nurse is
a. "Are you afraid that the treatment for your cancer will not be effective?"
b. "Can you tell me what it is that makes you think you will die so soon?"
c. "Would you like to talk to the hospital chaplain about your feelings?"
d. "Do you think that taking an antidepressant medication would be helpful?"

B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity

28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should
a. position the patient so that the right chest is dependent.
b. administer high-flow oxygen using a non-rebreathing mask.
c. cover the sucking chest wound with an occlusive dressing.
d. tape a nonporous dressing on three sides over the chest wound.

D
Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of tension pneumothorax.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Implementation NCLEX: Physiological Integrity

29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
a. a large air leak in the water-seal chamber.
b. 400 ml of blood in the collection chamber.
c. severe pain with each deep patient inspiration.
d. subcutaneous emphysema at the insertion site.

B
Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about
a. complaints of severe pain.
b. heart rate of 110 beats/min.
c. a large bruised area on the chest.
d. paradoxic chest movement.

D
Rationale: Paradoxic chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Cognitive Level: Application Text Reference: pp. 586, 588
Nursing Process: Assessment NCLEX: Physiological Integrity

31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if
a. the breath sounds on one side are decreased.
b. there are wheezes audible throughout both lungs.
c. there is a sucking sound with each patient breath.
d. paradoxic movement of the chest is noted.

A
Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Assessment NCLEX: Physiological Integrity

32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to
a. have the patient use the incentive spirometer.
b. medicate the patient with the ordered morphine.
c. splint the patient's chest during coughing.
d. assist the patient to sit up at the bedside.

B
Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

Cognitive Level: Application Text Reference: pp. 591, 594
Nursing Process: Implementation NCLEX: Physiological Integrity

33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to
a. document the presence of a large air leak.
b. obtain and attach a new collection device.
c. notify the health care provider of a possible pneumothorax.
d. take no further action with the collection device.

C
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.

Cognitive Level: Application Text Reference: p. 591
Nursing Process: Implementation NCLEX: Physiological Integrity

34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes
a. positioning on the right side.
b. chest tubes to water-seal chest drainage.
c. bedrest for the first 24 hours.
d. frequent use of an incentive spirometer.

D
Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis.

Cognitive Level: Application Text Reference: pp. 596-597
Nursing Process: Planning NCLEX: Physiological Integrity

35. A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis?
a. Audible crackles at both lung bases
b. 3+ edema in the lower extremities
c. Loud murmur at the mitral area
d. High systemic BP

B
Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal tenderness would be expected. Lung crackles, a murmur, and numbness and tingling are not caused by cor pulmonale.

Cognitive Level: Application Text Reference: p. 602
Nursing Process: Assessment NCLEX: Physiological Integrity

36. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action?
a. The international normalized ratio (INR) is prolonged.
b. The central line is disconnected.
c. The oxygen saturation is 90%.
d. The BP is 88/56.

B
Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

Cognitive Level: Application Text Reference: p. 601
Nursing Process: Assessment NCLEX: Physiological Integrity

37. A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if
a. the patient reports decreased exertional dyspnea.
b. the blood pressure is less than 140/90 mm Hg.
c. the heart rate is between 60 and 100 beats/minute.
d. the patient's chest x-ray indicates clear lung fields.

A
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Cognitive Level: Application Text Reference: p. 601
Nursing Process: Evaluation NCLEX: Physiological Integrity

38. A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to
a. position the patient sitting upright on the edge of the bed and leaning forward.
b. instruct the patient about the importance of incentive spirometer use after the procedure.
c. start a peripheral intravenous line to administer the necessary sedative drugs.
d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours.

A
Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure and there are no restrictions on oral intake, since the patient is not sedated or unconscious.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Planning NCLEX: Physiological Integrity

39. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states
a. "I will make an appointment to see the doctor every year."
b. "I will not turn the home oxygen up higher than 2 L/minute."
c. "I will be careful to use sterile technique with my central line."
d. "I will write down my medications and spirometry in a journal."

D
Rationale: After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant and patients would not usually have a central IV line.

Cognitive Level: Application Text Reference: p. 604
Nursing Process: Evaluation NCLEX: Physiological Integrity

40. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next?
a. Listen to the patient's lungs.
b. Check the patient's O2 saturation.
c. Have the patient cough forcefully.
d. Notify the patient's health care provider.

A
Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. The re is no indication that the oxygen saturation has decreased The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

Cognitive Level: Application Text Reference: p. 597
Nursing Process: Assessment NCLEX: Physiological Integrity

41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give?
a. The skin test will determine if you have a tuberculosis infection.
b. The skin test will indicate whether you have active tuberculosis.
c. The skin test is used to decide which antibiotic therapy will work best.
d. The skin test is done prior to notification of the public health department.

A
Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns.

Cognitive Level: Application Text Reference: p. 571
Nursing Process: Implementation NCLEX: Physiological Integrity

42. All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider?
a. The patient has many abdominal bruises.
b. The patient's BP is 90/46.
c. The activated partial thromboplastin time is 2 times the patient baseline.
d. The patient's stool is dark green and liquid.

B
Rationale: The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be monitored for gastrointestinal bleeding, which would be indicated by black or red stools.

Cognitive Level: Application Text Reference: p. 600
Nursing Process: Assessment NCLEX: Physiological Integrity

43. In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription after having a pulmonary embolus, the nurse will include information about
a. where to schedule activated partial thromboplastin time testing.
b. avoidance of a high protein diet.
c. how to obtain enteric-coated aspirin.
d. foods that are high in vitamin K.

D
Rationale: The patient who is taking Coumadin should have a consistent vitamin K intake, since vitamin K interferes with the effect of the medication. INR testing, rather than aPTT testing, is used to monitor for a therapeutic level of Coumadin. Aside from vitamin K, there are no other dietary requirements associated with Coumadin use. Aspirin should be avoided when taking anticoagulant medications because of the effect on platelet function.

Cognitive Level: Application Text Reference: p. 600
Nursing Process: Planning NCLEX: Physiological Integrity

44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?
a. BP is 150/90.
b. Pain level is 5/10 with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory rate is 24 when lying flat.

C
Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Assessment NCLEX: Physiological Integrity

45. All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first?
a. Obtain blood cultures from two sites.
b. Give ciprofloxin (Cipro) 400 mg IV.
c. Send to radiology for chest radiograph.
d. Administer aspirin suppository.

A
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last.

Cognitive Level: Application Text Reference: p. 566
Nursing Process: Implementation NCLEX: Physiological Integrity

46. The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first?
a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30 minutes
b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a temperature of 100.2° F
c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour previously
d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes

C
Rationale: Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Planning NCLEX: Physiological Integrity

47. A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse's first action should be to
a. elevate the head of the bed.
b. administer the ordered pain medication.
c. notify the patient's health care provider.
d. offer emotional support and reassurance.

A
Rationale: The patient has symptoms consistent with a pulmonary embolism; elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

Cognitive Level: Application Text Reference: p. 599
Nursing Process: Implementation NCLEX: Physiological Integrity

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
1. Infection.
2. Confusion.
3. Ineffective coughing and deep breathing.
4. Difficulty chewing solid foods.

3.
In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
1. Elevate the head of the bed 30 to 45 degrees.
2. Encourage the client to cough and deep breathe.
3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the physician.

1.
Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

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

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

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

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

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

2.
A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.

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

3.
It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1.
Docusate sodium (Colace) is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.

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

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

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

2, 1, 3, 4.
The nurse should instruct the client to first relax the neck and shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through pursed lips.

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should:
1. Apply a 100% non-rebreather mask.
2. Assess the vital signs.
3. Reposition the client.
4. Prepare for intubation.

2.
Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.

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

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

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

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

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

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

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

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

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

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

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

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

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/ L. The nurse should assess the client for?
1. Cyanosis.
2. Flushed skin.
3. Irritability.
4. Anxiety.

2.
The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
1. Friction between the cilia.
2. Force of gravity.
3. Sweeping motion of cilia.
4. Involuntary muscle contractions.

2.
The principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of cilia is not sufficient to move secretions. Muscle contractions do not move secretions within the lungs.

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

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

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

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

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

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

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
1. High oxygen concentrations will cause coughing and dyspnea.
2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
3. Increased oxygen use will cause the client to become dependent on the oxygen.
4. Administration of oxygen is contraindicated in clients who are using bronchodilators.

2.
Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.

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

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

The nurse administers theophylline (Theo-Dur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
1. Suppression of the client's respiratory infection.
2. Decrease in bronchial secretions.
3. Relaxation of bronchial smooth muscle.
4. Thinning of tenacious, purulent sputum.

3.
Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

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

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

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

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

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

4.
In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur). Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis and obtaining a chest X-ray. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first?
1. Albuterol (Proventil) nebulizer.
2. Chest x-ray.
3. Ipratropium (Atrovent) inhaler.
4. Sputum culture.

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

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

3.
Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

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

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

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

1.
Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

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

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

Which of the following is an appropriate expected outcome for an adult client with well-controlled asthma?
1. Chest X-ray demonstrates minimal hyperinflation.
2. Temperature remains lower than 100 ° F (37. 8 ° C).
3. Arterial blood gas analysis demonstrates a decrease in PaO2.
4. Breath sounds are clear.

4.
Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.

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

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

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

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

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

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

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