Med-Surge Modules 5 & 6 Exam: Respiratory
Lewis Medical-Surgical Nursing: Chapters 26, 27, 28, 30, 32, 33, 34 ATI RN adult medical surgical nursing unit 3
Terms in this set (66)
When caring for a pt w/ acute bronchitis, the nurse will prioritize:
A. auscultating lung sounds
B. encouraging fluid restriction
C. administering antibiotic therapy
D. teaching the patient to avoid cough supressants
A. auscultating lung sounds
Fluids should be encouraged, 90% of bronchial infections are viral and thus antibiotics are not useful (unless there's a prolonged infection associated with system symptoms), cough suppressants are often part of supportive therapy for bronchitis.
For which pts w/ pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)?
A. pt w/ seizures
B. pt with head injury
C. Pt who had thoracic surgery
D. Pt who had an MI
E. Pt who is receiving nasogastric tube feeding
A. Pt with seizures
B. Pt with head injury
E. Pt who is receiving NG feeding
Pg. 524 Correct answers: a, b, e
Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., as a result of seizure, anesthesia, head injury, stroke, or alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
An appropriate nursing intervention for a pt w/ pneumonia w/ the nursing dx of ineffective airway clearance r/t thick secretions and fatigue would be to:
a. perform postural drainage q hour
b. provide analgesics as ordered to provide pt comfort
c. administer 02 as prescribed to maintain optimal 02 levels
d. teach the pt to cough effectively to bring secretions to the mouth
d. teach pt to cough effectively to bring secretions to mouth
Rationale: A forced expiratory technique (i.e., huff coughing) clears secretions with less change in pleural pressure and less likelihood of bronchial collapse. Before the patient attempts coughing, the nurse should ensure the patient is breathing deeply from the diaphragm. The nurse should place hands on the patient's lower lateral chest wall and then ask the patient to breathe deeply through the nose. The nurse's hands should move outward, which represents a breath from the diaphragm.
A pt w/ TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the pt be taught? (select all the apply)
a. expect routine TST to evaluate infection
b. visitors will not be allowed while in airborne isolation
c. take all meds for full length of time to prevent MDR-TB
d. wear a standard isolation mask if leaving airborn infection isolation room
e. maintain precautions in airborne infection isolation room by coughing into a paper tissue
pg 533Correct answers: c, d, e
Rationale: To reduce antibiotic-resistant tuberculosis, patients must take multiple drugs for 2 to 6 months or longer. If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others. Teach patients to cover the nose and mouth with paper tissue every time they cough, sneeze, or produce sputum. If a person has a positive reaction to the tuberculin skin test, he or she need not be tested again because the sensitivity to tuberculin persists throughout life. Nurses and visitors must wear high-efficiency particulate air (HEPA) masks when entering the patient's room.
When caring for a pt at risk for pulmonary embolism, the nurse prioritizes
a. maintaining the pt on bed rest
b. using sequential compression devices
c. encouraging the pt to cough and deep breath
d. teaching the pt how to use IS
Correct answer: b
Rationale: Deep vein thrombosis (DVT) is the primary cause of pulmonary embolism. Preventing DVT with the use of sequential compression devices, early ambulation, and prophylactic use of anticoagulant medications would thus be a priority nursing intervention.
When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)?
A.Have trouble falling asleep?
B.Need to urinate during the night?
C. Awaken abruptly during the night?
D. Sleep more than 8 hours per night?
E. Need to sleep with the head elevated?
Have trouble falling asleep- Correct
Awaken abruptly during the night- Correct
Need to sleep with the head elevated-Correct
The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.
What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia?
B. Spinal curvatures
C. Respiratory pattern
D. Fingernails and their base
Fingernails and their bas- Correct
Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
5 minutes Correct
After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure?
A. Monitor the patient for laryngeal edema.
B. Assess the patient's level of consciousness.
C. Monitor and manage the patient's level of pain.
D. Assess the patient's heart rate and blood pressure.
Monitor the patient for laryngeal edema. Correct
Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what?
C. Pulmonary edema
D. Respiratory acidosis
Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.
The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring?
D. Pleural effusion
is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.
The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient?
A. Restlessness, tachypnea, tachycardia, and diaphoresis
B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis
C. Combativeness, retractions with breathing, cyanosis, and decreased output
D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue
Restlessness, tachypnea, tachycardia, and diaphoresis Correct
With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.
When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient?
B. Increased urination
C. Decreased heart rate
D. Rapid respiratory rate
Rapid respiratory rate Correct
When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.
After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality?
A. Decreased response to hypercapnia
B. Decreased number of functional alveoli
C. Increased calcification of costal cartilage
D. Decreased respiratory defense mechanisms
Decreased respiratory defense mechanisms Correct
These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.
The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation?
C. Arterial blood gases
D. Pulmonary function tests
Arterial blood gases Correct
Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural spaCe. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds?
C. Coarse crackles
Coarse crackles Correct
Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.
The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient?
A. Cough sound, sputum production, pattern
B. Frequency, a family history, hematemesis
C. Smoking, medications, residence location
D. Weight loss, activity tolerance, orthopnea
Cough sound, sputum production, pattern Correct
The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.
During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency?
A. Trachea moved to the left
B. Increased tactile fremitus
C. Decreased tactile fremitus
D. Diminished chest movement
Trachea moved to the left Correct
Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.
The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level?
C. Dark skin color
D. Thick acrylic nails
Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.
In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)?
B. Tripod position
C. Kussmaul respirations
D. Accessory muscle use
E. Increased AP diameter
Tripod position- Correct
Accessory muscle use Correct
Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order?
B. Pulmonary angiogram
C. CT scan of the patient's chest
D. Positron emission tomography (PET)
Positron emission tomography (PET) Correct
PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.
Which patient is exhibiting an early clinical manifestation of hypoxemia?
A. A 48-year-old patient who is intoxicated and acutely disoriented to time and place
B. A 72-year-old patient who has four new premature ventricular contractions per minute
C. A 67-year-old patient who has dyspnea while resting in the bed or in a reclining chair
D. A 94-year-old patient who has renal insufficiency, anemia, and decreased urine output
A 72-year-old patient who has four new premature ventricular contractions per minute Correct
Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.
The nurse is obtaining a focused respiratory assessment of a 44-year-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess?
A. Auscultation of bilateral breath sounds
B. Percussion of anterior and posterior chest wall
C. Palpation of the chest bilaterally for tactile fremitus
D. Inspection for anterior and posterior chest expansion
Auscultation of bilateral breath sounds Correct
Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.
A 67-year-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds?
A. "Bibasilar rhonchi present on inspiration."
B. "Diminished breath sounds in the bases of both lungs."
C. "Fine crackles posterior right and left lower lung fields."
D. "Expiratory wheezing scattered throughout the lung fields."
"Fine crackles posterior right and left lower lung fields." Correct
Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.
A frail 82-year-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields?
A. Bases of the posterior chest area
B. Apices of the posterior lung fields
C. Anterior chest area above the breasts
D. Midaxillary on the left side of the chest
Bases of the posterior chest area Correct
Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case the nurse should start at the bases.
The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction?
A. Acid-fast bacilli cultured at the injection site
B. 15-mm area of redness at the TST injection site
C. 11-mm area of induration at the TST injection site
D. Wheal formed immediately after intradermal injection
11-mm area of induration at the TST injection site Correct
An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.
To encourage the release of surfactant, the nurse encourages the pt to:
A. Take deep breaths
B. Cough 5x/hour to prevent aveolar collapse
C. Decrease fluid intake to reduce fluid accumulation in the alveoli
D. Sit w/ head of bed elevated to promote air movement through the pores of Kohn
Correct answer: a
Rationale: Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion.
A pt w/ a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on her knowledge that air moves into the lungs because of:
A. contraction of the accessory muscles
B. increased carbon dioxide and decreased oxygen in the blood
C. stimulation of the respiratory muscles by the chemorecptors
D. decrease in intrathoracic pressure relative to pressure at the airway
Correct answer: d
Rationale: During inspiration, the diaphragm contracts, increasing intrathoracic volume and pushing the abdominal contents downward. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, which enables air to enter the lungs.
The nurse can best determine adequate arterial oxygenation of the blood by assessing
a. heart rate
b. hemoglobin level
c. arterial oxygen tension
d. arterial carbon dioxide tension
Correct answer: c
Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2).
When teaching a pt about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss?
a. alveolar macrophages
b. impaction of particles
c. reflex bronchoconstriction
d. mucociliary clearance mechanism
Correct answer: a
Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages.
A student nurse asks the RN what can be measured by ABGs. The RN tells the student that ABGs can measure: (select all that apply)
a. acid-base balance
b. oxygenation status
c. acidity of the blood
d. glucose bound to hemoglobin
e. bicarbonate (HCO3) in arterial blood
Correct answers: a, b, c, e
Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, the partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), and bicarbonate (HCO3-) in arterial blood.
To detect early s/s of inadequate oxygenation, the nurse would examine the pt for
a. dyspnea and hypotension
b. apprehension and restlessness
c. cyanosis and cool, clammy skin
d. increased urine output and diaphoresis
Correct answer: b
Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability.
When assessing activity-exercise patterns related to respiratory health, the nurse inquires about
a. dyspnea during rest or exercise
b. recent weight loss or weight gain
c. ability to sleep through the entire night
d. willingness to wear oxygen equipment in public
Correct answers: c, e
Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Small airways in the lung bases close earlier during expiration. As a consequence, more inspired air is distributed to the lung apices, ventilation is less well matched to perfusion, and the PaO2 is lowered
When auscultating the chest of an older pt in respiratory distress, it is best to
a. begin listening at the apices
b. begin listening at the lung bases
c. begin listening on the anterior chest
d. ask the pt to breathe through the nose with the mouth
Correct answer: a
Rationale: In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise.
Which assessment finding of the respiratory system does the nurse interpret as abnormal?
a. inspiratory chest expansion of 1 in
b. percussion resonance over the lung bases
c. symmetric chest expansion in the lower lung fields
d. bronchial breath sounds in the lower lung fields
Correct answer: d
Rationale: Bronchial or bronchovesicular sounds heard in the peripheral lung fields are abnormal breath sounds.
The nurse is preparing the pt for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the pt for which test?
c. pulmonary angiography
d. sputum culture and sensitivity
Correct answer: a
Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first?
a. Test the drainage for the presence of glucose.
b. Suction the nose to maintain airway clearance.
c. Document the findings and continue monitoring.
d. Apply a drip pad and reassure the patient this is normal.
Test the drainage for the presence of glucose. Correct
Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply)?
a. Tilt patient's head backwards.
b. Apply ice compresses to the nose.
c. Tilt head forward while lying down.
d. Pinch the entire soft lower portion of the nose.
e. Partially insert a small gauze pad into the bleeding nostril.
b. Apply ice compresses to the nose. Correct
d. Pinch the entire soft lower portion of the nose. Correct
First aid measures to control epistaxis include placing the patient in a sitting position, leaning forward. Pinching the soft lower portion of the nose or inserting a small gauze pad into the bleeding nostril should stop the bleeding within 15 minutes. Tilting the head back or forward does not stop the bleeding, but rather allows the blood to enter the nasopharynx, which could result in aspiration or nausea/vomiting from swallowing blood. Lying down also will not decrease the bleeding.
When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment?
a. Patient comfort
b. Airway patency
c. Incisional drainage
d. Blood pressure and heart rate
b. Airway patency Correct
Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.
When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin?
c. French fries
d. White grape juice
a. Cola Correct
When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice with which to start.
The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident?
a. Hypersensitivity to eggs
b. Age greater than 80 years
c. History of upper respiratory infections
d. Chronic obstructive pulmonary disease (COPD)
Hypersensitivity to eggs Correct
Although current vaccines are highly purified, and reactions are extremely uncommon, a hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.
Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy?
a. Assessing the need for suctioning
b. Suctioning the patient's oropharynx Correct
c. Assessing the patient's swallowing ability
d. Maintaining appropriate cuff inflation pressure
Suctioning the patient's oropharynx Correct
Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.
A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement?
a. Apply an external splint to the nose.
b. Insert plastic nasal implant surgically.
c. Humidify the air for mouth breathing.
d. Maintain surgical packing in the nose.
d. Maintain surgical packing in the nose. Correct
A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.
The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply)?
a. Cover the nose when coughing.
b. Obtain an influenza vaccination.
c. Stay at home when symptomatic.
d. Drink non-caffeinated fluids daily.
e. Obtain antibiotic therapy promptly.
a. Cover the nose when coughing. Correct
b. Obtain an influenza vaccination. Correct
c. Stay at home when symptomatic. Correct
Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.
The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis?
b. Fever, chills
c. Dust allergy
d. Maxillary pain
Maxillary pain Correct
The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.
The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?
a. Nasal packing
b. Epistaxis balloon
c. Gastrostomy tube
d. Peripheral skin care
Gastrostomy tube Correct
Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.
A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?
a. Bilateral erythema of especially large tonsils
b. Temperature 102.2° F, diaphoresis, and chills
c. Contraction of neck muscles during inspiration Correct
d. β-hemolytic streptococcus in the throat culture
Contraction of neck muscles during inspiration Correct
Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.
The nurse teaches a 66-year-old man with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required?
a. "I should avoid using ibuprofen (Motrin) for pain and discomfort."
b. "It is important for me to take my blood pressure medication every day."
c. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes."
d. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."
"If I get a nosebleed, I will lie down flat and raise my feet above my heart." Correct
A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure would be to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin or nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.
The nurse teaches a 20-year-old female patient who is prescribed budesonide (Rhinocort) intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement?
a. "My liver function will be checked with blood tests every 2 to 3 months."
b. "The medication will decrease the congestion within 3 to 5 minutes after use."
c. "I may develop a serious infection because the medication reduces my immunity."
d. "I will use the medication every day of the season whether I have symptoms or not."
"I will use the medication every day of the season whether I have symptoms or not." Correct
Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, and not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.
The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine?
a. "Are you allergic to chicken?"
b. "Could you be pregnant now?"
c. "Did you ever have influenza?"
d. "Have you ever had hepatitis B?"
"Could you be pregnant now?" Correct
The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 years to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.
A pt was seen in the clinic for an episode of epistaxis, which was controlled with placement of anterior nasal packing. During discharge teaching, the nurse instructs the pt to:
a. use aspirin for pain relief
b. remove the packing later that day
c. skip the next dose of antihypertensive medication
d. avoid vigorous nose blowing and strenuous acitivity
Correct answer: d
Rationale: The nurse should teach the patient about home care before discharge: to avoid vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks; to sneeze with the mouth open; and to avoid the use of aspirin-containing products or nonsteroidal antiinflammatory drugs (NSAIDs).
A pt is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the collaborative management will include: (select all that apply)
a. antiviral agents to treat influenza
b. treatment with antibiotics starting ASAP
c. a throat culture or rapid strep antigen test
d. supportive care, including cool, bland liquids
e. comprehensive hx to determine possible etiology
Correct answers: c, d, e
Rationale: The goals of nursing management are infection control, symptom relief, and prevention of secondary complications. Medications are not prescribed until the etiology is known. Unnecessary use of antibiotics leads to the development of antibiotic-resistant organisms. A thorough history and a throat culture help identify the cause. The nurse should encourage the patient with pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx; citrus juices are often irritating.
While in the recovery room, a pt with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply?
a. notify the physician immediately
b. place the pt in the prone position to facilitate drainage
c. instill 3 mL of normal saline into the tracheostomy tube to loose secretions
d. continue your assessment of the pt, including O2 saturation, RR and breath sounds
Correct answer: d
Rationale: Immediately after surgery, the patient with a laryngectomy requires frequent suctioning by means of the laryngectomy tube. Secretions typically change in amount and consistency over time. Secretions may initially be copious and blood-tinged secretions and then diminish and thicken. Normal saline bolus through the tracheostomy tube is not recommended to assist with removal of thickened secretions because it causes hypoxia and damage to the epithelial cells.
When caring fora pt with acute bronchitis, the nurse will prioritize:
a. auscultating lung sounds
b. encouraging fluid restriction
c. administering antibiotic therapy
d. teaching the pt to avoid cough suppressants
Correct answer: a
Rationale: Assessment of lung sounds is a priority nursing intervention for patients with bronchitis. Evidence of consolidation would indicate progression of bronchitis to pneumonia, which would necessitate a change in treatment. Fluid intake and use of cough suppressants should be encouraged. Antibiotic treatment is generally not indicated
To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)?
a. Maintain adequate fluid intake.
b. Splint the chest when coughing. c. Maintain a 30-degree elevation.
d. Maintain a semi-Fowler's position.
e. Instruct patient to cough at end of exhalation.
a. Maintain adequate fluid intake. Correct
b. Splint the chest when coughing. Correct
e. Instruct patient to cough at end of exhalation.* Correct
Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment?
a. Hyperthermia related to infectious illness
b. Ineffective thermoregulation related to chilling
c. Ineffective breathing pattern related to pneumonia
d. Ineffective airway clearance related to thick secretions
Hyperthermia related to infectious illness Correct
Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?
a. Basilar crackles
b. Respiratory rate of 28
c. Oxygen saturation of 85%
d. Presence of greenish sputum
Basilar crackles Correct
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.
Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?
a. Hyperresonance on percussion
b. Vesicular breath sounds in all lobes
c. Increased vocal fremitus on palpation
d. Fine crackles in all lobes on auscultation
c. Increased vocal fremitus on palpation Correct
A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
What is the priority nursing intervention in helping a patient expectorate thick lung secretions?
a. Humidify the oxygen as able.
b. Administer cough suppressant q4hr.
c. Teach patient to splint the affected area.
d. Increase fluid intake to 3 L/day if tolerated.
D. Increase fluid intake to 3 L/day if tolerated. Correct
Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse?
a. "I will seek immediate medical treatment for any upper respiratory infections."
b. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks."
c. "I will increase my food intake to 2400 calories a day to keep my immune system well."
d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." Correct
The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient?
a. Orthostatic blood pressures
b. Sputum culture and sensitivity
c. Pulmonary function evaluation
d. Serum laboratory studies ordered for AM
Sputum culture and sensitivity Correct
The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.
When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication?
d. Cough suppressant
a. Antibiotic Correct
Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.
A 73-year-old female patient who lives alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, if observed by the nurse, indicates that the patient is likely to be hypoxic?
a. Sudden onset of confusion
b. Oral temperature of 102.3o F
c. Coarse crackles in lung bases
d. Clutching chest on inspiration
Sudden onset of confusion Correct
Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.
Which patient is at highest risk of aspiration?
a. A 58-year-old patient with absent bowel sounds 12 hours after abdominal surgery
b. A 67-year-old patient who had a cerebrovascular accident with expressive dysphasia
c. A 26-year-old patient with continuous enteral tube feedings through a nasogastric tube
d. A 52-year-old patient with viral pneumonia and coarse crackles throughout the lung fields
c. a 26 yo with continuous enteral feedings through a nasogastric tube Correct
Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.
The nurse cares for a 50-year-old patient with pneumonia that has been unresponsive to two different antibiotics. Which task is most important for the nurse to complete before administering a newly prescribed antibiotic?
a. Teach the patient to cough and deep breathe.
b. Take the temperature, pulse, and respiratory rate.
c. Obtain a sputum specimen for culture and Gram stain.
d. Check the patient's oxygen saturation by pulse oximetry.
c. Obtain a sputum specimen for culture and Gram stain. Correct
A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.
A 24-year-old male with a gunshot wound to the right side of the chest walks into the emergency department while leaning on another young man. The patient exhibits severe shortness of breath and decreased breath sounds on the right side. Which action should the nurse take immediately?
a. Cover the chest wound with a nonporous dressing taped on three sides.
b. Pack the chest wound with sterile saline soaked gauze and tape securely.
c. Stabilize the chest wall with tape and initiate positive pressure ventilation.
d. Apply a pressure dressing over the wound to prevent excessive loss of blood.
a. Cover the chest wound with a nonporous dressing taped on three sides. Correct
The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration the dressing pulls against the wound preventing air from entering the pleural space. During expiration the dressing is pushed out and air escapes through the wound and from under the dressing.
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