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NCLEX resp ?'s and answers
Terms in this set (63)
1.The nurse reinforcing health maintenance strategies for the client with COPD should include which of the following items?
1.Yearly influenza immunizations
2.Annual tuberculin skin test
3.Limitation of physical activity
Answer 1. Pt with COPD are highly susceptible to respiratory infection such as flu, so they should be immunized yearly. Pt w/COPD should undergo a progressive rehab program to ^ their activity tolerance. Fluid restriction if not needed w/COPD unless there is fluid retention from another etiology
The nurse who is explaining the pathophysiology of COPD to a client includes that alveolar destruction results in which of the following?
1. Decreased surface for gas exchange
2. ^ dead space air
3. Heavy secondary smoke exposure during childhood
4. Use of smokeless tobacco during childhood
Answer 1.The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area available for gas exchange. Destruction of the alveoli is not related to ^ dead space air, pulmonary emboli, or chronic dilation. With COPD there is progressive narrowing of bronchioles.
The nurse explains to a client and family that the development of COPD in young adults is likely caused by which of the following?
1. hereditary deficiency of alpha-1antitrypsin.
2. Onset of smoking during childhood
3. Heavy secondary smoke exposure during childhood
4.Use of smokeless tobacco during childhood
Answer 1. symptoms of COPD typically appear in the 5th & 6th decades of life following chronic abuse to pulmonary tissues by smoking or environmental pollutants. Onset of the physiological changes compatible w/COPD is most often associated w/hereditary deficiency of alpha-1-antitrypsin, an enzyme that protects the ling tissue against loss of elasticity. Onset of heavy smoking during childhood and heavy 2ndhand exposure during childhood are not typically associated with early onset of physiological alterations of COPD. Use of smokeless tobacco during childhood is associated w/ development of oral cancer.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause:
a. Nasal congestion
1. Answer B. Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is:
Answer C. Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
a. Nausea or vomiting
b. Abdominal pain or diarrhea
c. Hallucinations or tinnitus
d. Lightheadedness or paresthesia
Answer D. The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for:
a. Patients with an acute asthma attack
b. Patients with narcolepsy
c. Patients under age 6
d. Elderly patients
Answer D. Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm?
a. Kinking of the ventilator tubing
b. A disconnected ventilator tube
c. An endotracheal cuff leak
d. A change in the oxygen concentration without resetting the oxygen level alarm
Answer A. Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm.
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
a. Leg movement
b. Finger movement
c. Lip movement
d. Fighting the ventilator
Answer D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.
On auscultation, which finding suggests a right pneumothorax?
a. Bilateral inspiratory and expiratory crackles
b. Absence of breaths sound in the right thorax
c. Inspiratory wheezes in the right thorax
d. Bilateral pleural friction rub.
Answer B. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation
Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present?
a. Acid-base balance
b. Arterial Blood
c. Arterial oxygen saturation
8. Answer B. A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
a. Activity intolerance related to fatigue
b. Anxiety related to actual threat to health status
c. Risk for infection related to retained secretions
d. Impaired gas exchange related to airflow obstruction
Answer D. A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important
Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:
a. Contralateral side in a simple pneumothorax
b. Affected side in a hemothorax
c. Affected side in a tension pneumothorax
d. Contralateral side in hemothorax
Answer D. The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
a. Monitor fluctuations in the water-seal chamber
b. Clamp the chest tube once every shift
c. Encourage coughing and deep breathing
d. Milk the chest tube every 2 hours
8. Answer C. When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
a. Encourage oral feeding as soon as possible
b. Develop an alternative communication method
c. Keep the tracheostomy cuff fully inflated
d. Keep the patient flat in bed
Answer B. A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the patient in semi-fowler's position
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
a. Drawing blood for a hematocrit and hemoglobin level
b. Applying a dressing over the wound and taping it on three sides
c. Preparing a chest tube insertion tray
d. Preparing to start an I.V. line
Answer B. The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
a. Encouraging the patient to drink three glasses of fluid daily
b. Keeping the patient in semi-fowler's position
c. Using a high-flow venture mask to deliver oxygen as prescribe
d. Administering a sedative, as prescribe
Answer C. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:
a. Cardiogenic pulmonary edema
b. Respiratory alkalosis
c. Increased pulmonary capillary permeability
d. Renal failure
Answer C. ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?
a. Restricting fluid intake to 1,000 ml per day
b. Enforcing absolute bed rest
c. Teaching the patient how to perform controlled coughing
d. Administering prescribe sedatives regularly and in large amounts
Answer C. Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?
a. Do nothing, because this is an expected finding
b. Immediately clamp the chest tube and notify the physician
c. Check for an air leak because the bubbling should be intermittent
d. Increase the suction pressure so that the bubbling becomes vigorous
Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
a. Inform the physician
b. Continue to monitor the client
c. Reinforce the occlusive dressing
d. Encourage the client to deep-breathe
Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect
Nurse Ryan caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
a. Call the physician
b. Place the tube in bottle of sterile water
c. Immediately replace the chest tube system
d. Place a sterile dressing over the disconnection site
Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:
a. Exhale slowly
b. Stay very still
c. Inhale and exhale quickly
d. Perform the Valsalva maneuver
Answer D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.
While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to:
a. Call the physician to reinsert the tube
b. Grasp the retention sutures to spread the opening
c. Call the respiratory therapy department to reinsert the tracheotomy
d. Cover the tracheostomy site with a sterile dressing to prevent infection
Answer B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate 24 breaths/min
Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
a. A low respiratory rate
b. Diminished breath sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury
Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?
b. A hyperinflated chest noted on the chest x-ray
c. Increased oxygen saturation with exercise
d. A widened diaphragm noted on the chest x-ray
Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced
An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
a. Face tent
b. Venturi mask
c. Aerosol mask
d. Tracheostomy collar
Answer B. The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of mucoid sputum
Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?
b. Sputum culture
c. Chest x-ray
d. Tuberculin skin test
Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
a. 1 L/min
b. 2 L/min
c. 6 L/min
d. 10 L/min
Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:
a. Promote oxygen intake
b. Strengthen the diaphragm
c. Strengthen the intercostal muscles
d. Promote carbon dioxide elimination
Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
b. Low arterial PaO2
c. Elevated arterial PaO2
d. Decreased respiratory rate
Answer B. The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
2. Respirations of 28
3. Pulse of 80
4. Temperature of 99°F
1. Hemoptysis is the only abnormal finding. All of the others are within normal range for someone who has undergone an invasive procedure
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
1. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
2. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
3. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
4. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
1. Postural drainage should be scheduled before or between meals and close to bedtime
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the
1. Use a sterile tube each time and suction for 30
2. Use sterile technique and turn the suction off as the catheter is introduced
3. Use clean technique and suction for 10 seconds
4. Discard the catheter at the end of every shift
2. Suctioning should be done under sterile
technique for no more than 10 seconds. The
suction should be off as the tube is inserted and applied intermittently as it is withdrawn
During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
1. Release the suction by opening the vent
2. Continue suctioning to remove the obstruction
3. Increase the pressure
4. Suction deeper
1. Suction should not be applied as the suction tube is inserted, because this will cause the suction tube to appear to attach to the tracheal wall and create a pulling sensation
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
1. "Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your
thumb and forefinger."
2. "Lay down and tilt your head backward. Grasp
the end of your nose between your fingers."
3. "Sit up and lean backwards. Put pressure on
the side of your nose with your hand."
4. "Lie down with your head lower than your
feet. Grasp as much of your nose as possible between your fingers."
1. This position will help to stop bleeding
without causing aspiration of any blood dripping down the back of the throat
A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness?
1. "I have always enjoyed hot Mexican-style food."
2. "I have smoked three packs of cigarettes a day for the last 40 years."
3. "I used to work in a factory that burned coal."
4. "I sang in the church choir every Sunday until my voice got hoarse last year."
2.Cigarette smoking is the greatest risk factor for development of laryngeal cancer
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
1. Establish a means of communication.
2. Prepare the bowel by administering enemas
3. Teach the client to use an artificial larynx.
4. Demonstrate the technique for suctioning a laryngectomy tube
1. Establishing a means of communication is the highest priority. Teaching the client to use an artificial larynx is a postoperative task. Because the laryngectomy tube will be temporary, the client will not need to learn to suction. That is a nursing function
A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to:
1. prevent excessive drying of secretions.
2. facilitate oxygen diffusion of the blood.
3. prevent depression of the respiratory drive.
4. compensate for increased airway resistance
3. The stimulus to breathe in a person with COPD is a low oxygen level rather than a carbon dioxide level, as in normal persons. If high-flow oxygen were given, the oxygen level would increase, and the respiratory drive would cease
An adult is admitted with chronic obstructive pulmonary disease (COPD). The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset
of which of the following?
2. Cor pulmonale
3. Cardiogenic shock
4. Left-sided heart failure
2. Distended neck veins and peripheral edema are signs of right-sided heart failure or cor pulmonale-heart failure due to pulmonary causes
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102 F., respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
1. promote thoracic expansion.
2. prevent the development of atelectasis.
3. decrease metabolic needs.
4. prevent infection of others
3. Bed rest will reduce metabolic needs in
this client who has pneumonia and is having difficulty meeting oxygenation needs. Semiupright position, not bed rest, will promote thoracic expansion. Isolation prevents infection of others. Deep breathing will help to prevent the development of atelectasis
An adult is to have a tracheostomy performed. What is the nursing priority?
1. Shave the neck
2. Establish a means of communication
3. Insert a Foley catheter
4. Start an IVcidng
2. The nursing priority is to establish a means of communication because she will not be able to speak after the tracheostomy is performed
Which nursing action is essential during tracheal suctioning?
1. Using a lubricant such as petroleum jelly
2. Administering 100% oxygen before and after suctioning
3. Making sure the suction catheter is open or on during insertion
4. Assisting the client to assume a supine position during suctioning
2. One hundred percent oxygen is given before and after suctioning to help prevent hypoxia. Petroleum-based lubricants are not water-soluble and should never be used near an airway. Saline is used as a lubricant. The suction catheter is off during insertion to avoid traumatizing the tissues. The client should be in a semi-sitting position during suctioning. Supine predisposes to aspiration
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
1. The clients lungs have expanded.
2. There is an obstruction in the tubing coming from the client.
3. There is a mechanical problem in the pump.
4. Air is leaking into the drainage apparatus
2. Cessation of bubbling in the water seal bottle means either an obstruction in the tubing or reexpansion of the lung. This is the night of insertion of the tube. It takes at least 24 hours and often two to three days for the lung to reexpand
An adult has a chest drainage system. The clients wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
1. go get petrolatum gauze and apply over the
2. place her/his hand firmly over the wound.
3. apply a sterile 4 x 4 dressing.
4. reinsert the chest tube.
2. The nurse's primary goal has to be to stop air from entering the thoracic cavity and causing the lung to collapse again. Placing a hand firmly over the wound will accomplish this. Answer 1 is wrong, because the nurse should not leave the client. Petrolatum gauze would be ideal, but the nurse should not leave the client. Answer 3 is wrong because a sterile 4 x 4 dressing allows air to enter the thoracic cavity. The nurse should not reinsert the chest tube
An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest x-ray. This indicated that at that time the client:
1. was less susceptible to a tuberculosis infection than the year before.
2. had acquired some degree of passive immunity to tuberculosis.
3. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis.
4. was harboring a mild tuberculosis infection in an organ other than the lung
3. A positive PPD test indicates that the client has come in contact with the organism and fought it. A negative chest x-ray indicates that the client won the fight and does not at that time have active tuberculosiss.
An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which of the following symptoms would suggest a toxic effect of INH?
1. Paroxysmal tachycardia
2. Erythema multiforme
3. Peripheral neuritis
4. Tinnitus and deafness
3. Peripheral neuritis is a toxic effect of INH.
Tinnitus and deafness are side effects of
An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. He is also receiving pyridoxine (vitamin B6). Why is this medication prescribed for him?
1. Pyridoxine is bacteriostatic against
2. To enhance his general nutritional status
3. To prevent side effects of INH
4. Pyridoxine acts to increase the effects of streptomycin
3. Pyridoxine (vitamin B6) prevents the
development of peripheral neuritis toxicity of INH.
The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
2. Para-aminosalicylic (PAS) acid
3. Isoniazid (INH)
4. Ethambutol (Myambutol)
3. INH is the drug of choice for chemoprophylaxis. All of the other drugs listed can be used in the treatment of tuberculosis
A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis?
1. He drinks raw milk.
2. He cleans chicken houses.
3. He handles fertilizer frequently.
4. He stepped on a rusty nail recently
2. Histoplasma capsulatum is a fungus that grows in chicken and pigeon manure. Drinking raw milk might cause "milk fever." Handling fertilizer could cause "white lung," a COPD illness. Stepping on a nail might cause tetanus.
The nurse is caring for a client who is admitted with histoplasmosis. What drug is most likely to be prescribed for this client?
4. Amphotericin B
4. Amphotericin B is the drug of choice to treat histoplasmosis
An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
1. Keep him NPO for eight hours
2. Prepare him to go to the operating room
3. Explain the procedure to him
4. Administer anticholinergic and analgesic as
3. The nurse should explain the procedure to the client and obtain a permit if one has not already been signed. Thoracentesis is usually done at the bedside. NPO is not necessary. Anticholinergics and analgesics are not ordered.
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
1. "The most difficult time of the day for me is the first hour after waking up in the morning."
2. "I feel best in the morning after a good night's sleep."
3. "I seem to have more energy after eating a big meal."
4. "I don't know why, but I get my "second wind" at night and don't want to go to bed."
1. Morning is a difficult time for persons with
COPD because secretions have accumulated during the night. They have to do a great deal of hacking and coughing to clear their air passages in the morning. The client with COPD is apt to be short of breath after a big meal because he is an abdominal breather. Most clients with COPD do not get a "second wind" at night. They need a lot of rest
The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time?
1. Stimulate the client until the client responds.
2. Increase the oxygen from the ordered 6 L to 10 L.
3. Assess the client again in 15 minutes.
4. Notify the charge nurse of the change in the clients mental status
4. The change in the clients status is significant and indicates hypoxia. The charge nurse or physician must be notified quickly. Stimulating a severely hypoxic client is not appropriate.Increasing the oxygen from 6 L to 10 L is not likely to change the clients status. The licensed practical nurse (LPN) should notify the charge nurse now, not in 15 minutes
A clients PPD test is positive, and a chest x-ray is negative. What is the best interpretation of these data?
1. The clients resistance to tuberculosis is low.
2. The client has been exposed to the organism but has not developed the disease.
3. The client has tuberculosis, but it is not serious.
4. The client has active tuberculosis
2. A positive PPD test indicates antibodies against tuberculosis. A positive PPD test and a negative x-ray indicate that the client has been exposed to tuberculosis but has not developed the disease. These findings do not give information regarding the client's resistance. The negative x-ray indicates that the client does not have active tuberculosis
Which type of breath sound is medium-pitched and continuous, occurs over the upper third of the sternum in the interscapulare area, and is equally audible during inspiration and expiration?
Answer C. Bronchovesicular breath sounds demonstrate these characteristics
Your pt's ABG analysis shows a pH < 7.35, bicarbonate > 26mEq/L, & Paco2 > 45mmHg. He;s diaphoretic, has tachycardia, & is restless. which condition does he probably have/
A. resp alkalosis
B. resp acidosis
C. metabolic alkalosis
D. metabolic acidosis
Answer B. the pt w/resp acidosis can display all of these signs and symptoms and can also have headache, confusion, apprehension, and a flushed face
When suctioning a pt you should:
A. apply suction intermittently as the catheter is inserted
B. suction the pt for longer than 10 second each time.
C. oxygenate the pt's lungs b4 and after sunctioning
D. aooly suction continuously while inserting the catheter
Answer C. The pt should be oxygenated before and after suctioning to educe the rick of hypoxemia. avoid suctioning for longer than 10 seconds and apply suctions intermittently as you withdraw-not insert- the catheter.
TB is transmitted through:
A. Inhalation of infected droplets
B. contact with blood
C. the fecal oral route
D. skin-to-skin conatct
Answer A. TB spreads by inhalation of droplet nuclei when as infected person coughs or sneezez
When caring for a pt admitted after a motor vehicle wreck, the nurse knows that which of the following could interfere with effective respiration? Select all that apply
1. facial injury w/possible fractures
2. rib fracture
3. a concussion
4. torn knee cartilage
5. a cardiac contusion
The nurse caring for a pt who is in a coma positions the pt on his/her side w/the head elevated to help prevent aspiration because:
1. the esophageal sphincter relaxes in comatose pts
2. the cough reflex is lost in comatose pts
3. the pt will gag frequently on oral secretions
4. this position facilitates mouth care and feeding
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