LA#7 ( Respiratory) Chapters 28, 30, 31 in Med Surg Flashcards
(137 cards)
1
Q
A patient in severe respiratory distress is admitted to the medical unit at the hospital. During the admission assessment of the patient, what should the nurse do?
a. Perform a comprehensive health history with the patient to determine the extent of prior respiratory problems.
b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions.
c. Delay any physical assessment of the patient, and ask family members about the patient’s history of respiratory problems.
d. Perform a physical assessment of the respiratory system, and ask specific questions related to this episode of respiratory distress.
A
ANS: D
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later.
2
Q
A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 95%. Which action should the nurse take next?
a. Complete a head-to-toe assessment.
b. Place the patient on high-flow oxygen.
c. Start rewarming the patient.
d. Obtain arterial blood gases.
A
ANS: B
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic.
3
Q
The physician performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, how should the nurse position the patient?
a. Supine with the head of the bed elevated 45 degrees
b. On his left side with his right arm extended above his head
c. Sitting upright with his arms supported on an overbed table
d. On his left side in the Trendelenburg’s position with both arms extended
A
ANS: C
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier.
4
Q
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have which one of the following?
a. Kussmaul’s respirations
b. Slow, shallow respirations
c. A low oxygen saturation (SpO2)
d. A decrease in PVO2
A
ANS: A
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
5
Q
While caring for a patient who has a 30-pack-year history of smoking, the nurse recognizes that the patient most likely has decreased respiratory defences due to which of the following conditions?
a. Impaired cough reflex
b. Impaired mucociliary clearance
c. Impaired reflex bronchoconstriction
d. Impaired ability to filter particles from the air
A
ANS: B
Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap particles and move them out of the lung.
6
Q
An 80-year-old patient breathing room air has an arterial blood gas analysis. Which of the following results does the nurse interpret as normal?
a. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
b. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%
c. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
d. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
A
ANS: B
All of the values, pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%, are normal.
7
Q
A patient with amyotrophic lateral sclerosis (ALS) is admitted to the hospital with dyspnea. During palpation of the patient’s thorax, what would the nurse expect to find?
a. Diminished expansion
b. Asymmetrical expansion
c. Normal expansion of 2.5 cm
d. Unequal, diminished expansion
A
ANS: A
Expansion is symmetrical but diminished in conditions that produce a hyperinflated or barrel-shaped chest or in neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal cord lesions).
8
Q
On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes. How should the nurse document this finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
A
ANS: A
Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, “bubbling” sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
9
Q
A patient with chronic obstructive pulmonary disease (COPD) has a barrel chest. What would the nurse expect the results of a chest X-ray to reveal?
a. Fluid in the alveoli
b. Air in the pleural space
c. Overinflation of the alveoli with air
d. Consolidation of lung tissue with mucus and exudates
A
ANS: C
A barrel chest results from lung hyperinflation and is a common finding in patients with COPD.
10
Q
When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile fremitus?
a. Percuss over the entire posterior chest.
b. Use the fingertips to assess for vibration.
c. Place the palms of the hands on the chest wall.
d. Auscultate while the patient says “ninety-nine.”
A
ANS: C
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as “ninety-nine.”
11
Q
On auscultation of a patient’s lungs, the nurse hears short, low-pitched, ‘bubbling’ sounds in the right and left lower lung areas. How should the nurse document this finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
A
ANS: B
Crackles are low-pitched, “bubbling” sounds. Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
12
Q
A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, what should the nurse do?
a. Keep the patient on bed rest for 8 hours.
b. Keep the patient on nothing by mouth (NPO) status until the gag reflex returns.
c. Check vital signs every 15 minutes for 2 hours.
d. Encourage fluid intake to promote elimination of the contrast media.
A
ANS: B
Because a local anaesthetic is used to suppress the gag or cough reflex during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food.
13
Q
Which of the following is an age-related change in the respiratory system?
a. Increased elastic recoil of the lungs
b. Increase in chest wall compliance
c. Increase in anteroposterior diameter
d. Increase in functional alveoli
A
ANS: C
Many older adults have a barrel-shaped thorax as a result of an increased anteroposterior diameter.
14
Q
While auscultating a patient’s chest as the patient takes a deep breath, the nurse hears loud, high-pitched, “blowing” sounds at both lung bases. How will the nurse document these sounds?
a. Adventitious sounds
b. Abnormal sounds
c. Vesicular sounds
d. Normal sounds
A
ANS: B
The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base.
15
Q
In analyzing the results of a patient’s blood gas analysis, the nurse will be most concerned about which of the following?
a. Arterial oxygen tension (PaO2) of 60 mm Hg
b. Arterial oxygen saturation (SaO2) of 91%
c. Arterial carbon dioxide (PaCO2) of 47 mm Hg
d. Arterial bicarbonate level (HCO3-) of 27 mmol/L
A
ANS: A
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation.
16
Q
While assessing a patient with respiratory problems, what should the nurse specifically ask about?
a. Smoking habits
b. Alterations in sexual activity
c. The course of the patient’s illness
d. Occupational exposure to heavy lifting
A
ANS: A
An important aspect of a patient respiratory history, especially one with respiratory problems, is the history of smoking and smoking habits.
17
Q
While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 94% to 85% when the patient ambulates in the hall. What does the nurse determine from this response?
a. Supplemental oxygen should be used when the patient exercises.
b. Arterial blood gas determinations should be done to verify the SpO2.
c. This finding is a normal response to activity, and the patient should continue to be monitored.
d. The oximetry probe should be moved from the finger to the earlobe for an accurate SpO2 during activity.
A
ANS: A
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising.
18
Q
Which of the following is a normal partial pressure of oxygen value at sea level?
a. 60 mm Hg
b. 75 mm Hg
c. 90 mm Hg
d. 105 mm Hg
A
ANS: C
The normal partial pressure of oxygen at sea level is 80 to 100 mm Hg.
19
Q
The nurse is observing a student who is auscultating a patient’s lungs. Which action by the student indicates that the nurse should intervene?
a. The student compares breath sounds from side to side.
b. The student starts at the base of the posterior lung and moves to the apices.
c. The student places the stethoscope over the scapulae and then auscultates.
d. The student listens only over the posterior part of the chest.
A
ANS: C
The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.
20
Q
When assessing the respiratory system of a 78-year-old patient, which of these findings indicates that the nurse should take immediate action?
a. Barrel-shaped chest
b. Weak cough effort
c. Audible crackles in the lower two thirds of the posterior chest
d. Hyperresonance across both sides of the chest
A
ANS: C
Crackles in the lower two thirds of the lungs indicate that the patient may have an acute problem such as congestive heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the physician.
21
Q
When performing an assessment of the patient’s respiratory system, the nurse uses the following illustrated technique to evaluate which of the following respiratory functions?
a. Chest expansion
b. Tactile fremitus
c. Accessory muscle use
d. Diaphragmatic excursion
A
ANS: A
When assessing chest expansion on the posterior chest, the nurse will place the hands at the level of the tenth rib, position the thumbs until they meet over the spine, and have the patient breathe deeply.
22
Q
What is the normal volume of total lung capacity?
a. 1.0 L
b. 2.0 L
c. 3.5 L
d. 6.0 L
A
ANS: D
The normal total lung capacity volume is 6 L.
23
Q
A patient is admitted to the emergency department complaining of sudden-onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for which of the following?
a. Chest X-ray
b. Ventilation–perfusion scan
c. Bronchoscopy
d. Positron emission tomography scan
A
ANS: B
A ventilation–perfusion scan is used primarily to check for the presence of a pulmonary embolus. There is no specific preparation or aftercare.
24
Q
Which of the following is a measure of the elasticity of the lung?
a. Inspiration
b. Compliance
c. Elastic recoil
d. Oxygen–hemoglobin dissociation curve
A
ANS: B
Compliance (distensibility) is a measure of the elasticity of the lungs and the thorax.
25
Which of the following is an early symptom of inadequate oxygenation?
a. Dyspnea at rest
b. Hypotension
c. Tachypnea
d. Cyanosis
ANS: C
| Tachypnea is an early symptom of inadequate oxygenation. Dyspnea at rest, hypotension, and cyanosis are all late signs.
26
Which is the most common infection causing acute pharyngitis?
a. Fungal
b. Viral
c. Acute follicular
d. Peritonsillar
ANS: B
| Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.
27
When the nurse removes a nasogastric tube that has been in place for 7 days postoperatively, the patient develops a nosebleed. To control the bleeding, what should the nurse do?
a. Pinch the soft lower portion of the nose for 10 to 15 minutes.
b. Place the patient in a sitting position with the head hyperextended.
c. Apply ice compresses to the patient’s forehead and back of the neck.
d. Pack the nares with ribbon gauze to apply pressure to the source of the bleeding.
ANS: A
| The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.
28
In teaching the patient with allergic rhinitis about management of the condition, what should the nurse explain?
a. Identification and avoidance of triggers of the symptoms are important to avoid reactions.
b. Allergic reactions can be prevented if oral antihistamines are taken before exposure to allergens.
c. Corticosteroid nasal sprays are the only topical drugs recommended for treatment of hay fever.
d. Prescription antihistamine drugs should be requested because over-the-counter preparations are ineffective for allergic rhinitis.
ANS: A
| The most important intervention is to assist the patient to identify and avoid potential allergens.
29
A woman calls the clinic and tells the nurse that her mother, an older adult, has had a cold for the past week. The woman is worried that pneumonia will develop. After the nurse discusses care of upper respiratory infections and prevention of secondary infections, which of the following responses by the woman alerts the nurse that additional teaching is needed?
a. “I should encourage my mother to drink a lot of juices and other fluids.”
b. “I should watch for changes in nasal secretions or the sputum she coughs up.”
c. “I can give my mother aspirin or acetaminophen to make her more comfortable.”
d. “I can encourage my mother to continue to use nasal decongestant spray until the congestion is gone.”
ANS: D
The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion.
30
When doing nutrition-related teaching with a patient who has acute pharyngitis, what should the nurse tell the patient to avoid ingesting?
a. Orange Jell-o
b. Vanilla ice cream
c. Grape popsicles
d. Orange juice
ANS: D
Cool, bland liquids and gelatin will not irritate the pharynx; citrus juices are to be avoided, as they can be irritating to the throat.
31
To which one of the following patients should the nurse strongly recommend an influenza immunization in the autumn each year?
a. A 24-year-old woman who has an allergy to penicillin
b. A 42-year-old man who has a history of smoking for 20 years
c. A 36-year-old man who had pneumonia when he was in university
d. A 30-year-old woman who takes corticosteroids for rheumatoid arthritis
ANS: D
It is recommended that patients who are immunocompromised receive yearly influenza vaccinations. The corticosteroid use by the 30-year-old patient increases that person’s risk for infection.
32
The nurse determines that complications of influenza are developing in a patient who experiences which of the following?
a. Myalgia and headache
b. Diffuse crackles in the lungs
c. Sore throat and productive cough
d. A fever of 38°C with chills
ANS: B
The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment.
33
The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of these assessments will require the most immediate nursing action?
a. The patient’s temperature is 38.3°C.
b. The nose appears red and swollen.
c. The patient’s oxygen saturation is 89%.
d. The patient complains of pain rated as 7 on a 10-point scale.
ANS: C
Older patients with nasal packing are at risk for aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications.
34
Which of the following is the most commonly used voice prosthesis?
a. Electrolarynx
b. Blom-Singer
c. Cooper-Rand
d. Artificial larynx
ANS: B
| The most commonly used voice prosthesis is the Blom-Singer.
35
A registered nurse is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the registered nurse to intervene?
a. The student preoxygenates the patient for 2 minutes before suctioning.
b. The student applies suction for 10 seconds while withdrawing the catheter.
c. The student puts on clean gloves and uses a sterile catheter to suction.
d. The student inserts the catheter about 12.7 cm into the tracheostomy tube.
ANS: C
| Sterile gloves and a sterile catheter are used when suctioning a tracheostomy.
36
When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to swallow, what is it most important to do?
a. Deflate the cuff during the patient’s inhalation.
b. Clean the inner cannula of the tracheostomy tube.
c. Suction the mouth and trachea before deflation of the tube.
d. Measure the amount of air removed from the cuff during deflation.
ANS: C
The patient’s mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions.
37
A home care nurse is completing a follow-up visit with a patient who has recently undergone a radical neck dissection. The nurse will assess the patient for signs and symptoms of which of the following emotional concerns?
a. Anxiety
b. Anorexia
c. Depression
d. Speech impediment
ANS: C
Depression is common in the patient who has had a radical neck dissection; therefore, the nurse should assess for its presence when providing follow-up home care.
38
A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Initially, what should the nurse do?
a. Call the physician.
b. Attempt to reinsert the tracheostomy tube.
c. Position the patient in a lateral position with the neck extended.
d. Cover the stoma with a sterile dressing, and ventilate the patient with a manual bag-mask until the physician arrives.
ANS: B
| The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s airway.
39
A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech. What is it important that the nurse do?
a. Place the decannulation cap in the tube before cuff deflation.
b. Assess the patient’s ability to swallow without risk of aspiration.
c. Remove the inner cannula of the tracheostomy tube after deflating the cuff.
d. Connect oxygen at 4 to 6 L/min to the second pigtail tubing of the tracheostomy tube.
ANS: B
Because the cuff is deflated when using a fenestrated tube, the patient’s risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube.
40
When inflating the cuff on a tracheostomy tube to the appropriate level, the best nursing action will be which of the following?
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Verify the health care provider’s order for the amount of cuff pressure required.
c. Fill the balloon until no leakage around the cuff is auscultated.
d. Check the pilot balloon after inflation to ensure that it is firm.
ANS: A
Cuff inflation pressure should not exceed 20 mm Hg or 25 cm H2O because higher pressures may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis.
41
A patient is discharged from the hospital with a tracheostomy tube for long-term airway management. Which of the following responses by the patient helps the nurse determine that teaching related to care of the tracheostomy has been effective?
a. “I must use sterile gloves and catheters to suction my tracheostomy.”
b. “I should maintain a liquid diet as long as I have the tracheostomy tube in place.”
c. “I will be changing my tracheostomy tube at home about once a month.”
d. “If I have thick mucus, I can instill about a teaspoon of tap water into my tracheostomy tube.”
ANS: C
It takes several months for the formation of a fully healed tract, so the patient is taught that after the initial tube change the tracheostomy is to be changed once a month. Clean technique is used to suction a tracheostomy in the home environment, not sterile technique. A liquid diet is not required when a patient has a tracheostomy; many people live with a permanent tracheostomy and consume a normal diet. Tap water should not be inserted into a tracheostomy tube; if secretions are thick provide humidification and hydration.
42
A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?
a. “I will need to buy a water bottle to carry with me.”
b. “Until the radiation is complete, I may have diarrhea.”
c. “Alcohol-based mouthwashes will help clean oral ulcers.”
d. “I can use lotions to moisturize the skin on my throat.”
ANS: A
| Xerostomia can be partially alleviated by drinking fluids at frequent intervals.
43
When obtaining a health history from a patient with hoarseness and tightness in his throat, the nurse should specifically ask the patient about which of the following information?
a. Alcohol and tobacco use
b. The presence of dentures
c. A history of allergic rhinitis
d. A history of streptococcal pharyngitis
ANS: A
Prolonged alcohol use is associated with the development of laryngeal cancer, which the patient’s symptoms and history suggest.
44
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse how the surgery will affect his throat. What is the best response?
a. “You will breathe through a permanent opening in your neck, and you will not be able to speak.”
b. “You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”
c. “You won’t be able to speak as you used to, but a lot of artificial voice devices are available that will give you the ability to speak normally.”
d. “You will have a tube into your trachea through which you will breathe, but you will be able to speak when the stoma heals and the tube is removed.”
ANS: B
Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication.
45
A patient returns from surgery with a cuffed, single-cannula tracheostomy tube after a total laryngectomy and radical neck dissection. In planning tracheostomy care for the patient during the first 24 hours after surgery, what is the priority nursing intervention?
a. The tracheostomy ties should not be changed.
b. The tracheostomy dressings should not be changed.
c. The patient should be encouraged to assist in the procedure.
d. Assess the airway and breath sounds.
ANS: D
The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the airway and breath sounds is the priority action.
46
On entering the room of the patient who has just returned from surgery for a total laryngectomy and radical neck dissection, the nurse recognizes a need for intervention upon making which one of the following observations?
a. The gastrostomy tube is clamped.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The patient is positioned in a lateral position with the head of the bed flat.
d. There are 200 mL of serosanguineous drainage in the patient’s portable drainage device.
ANS: C
| The nurse should elevate the head of the bed to maximize lung expansion and enable an effective cough.
47
In which position should the nurse position the patient before commencing tracheostomy care?
a. Prone position
b. Supine position
c. Semi-Fowler’s position
d. High-Fowler’s position
ANS: C
| Patients should be positioned in a semi-Fowler’s position before commencing tracheostomy care.
48
After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient makes which of the following responses?
a. “I must keep the stoma covered with a dressing at all times.”
b. “I can participate in most of my prior fitness activities except swimming.”
c. “I need to eat nutritious meals even though I can’t smell or taste very well.”
d. “I should wear a MedicAlert bracelet that identifies me as a neck breather.”
ANS: A
| The stoma may be covered with clothing or a loose dressing, but this is not essential.
49
Following assessment of a patient with pneumonia, the nurse documents a nursing diagnosis of ineffective airway clearance. On which of the following data would the nurse base this nursing diagnosis?
a. SpO2 of 85%
b. Respiratory rate of 28 breaths/min
c. Presence of greenish sputum
d. Weak, nonproductive cough
ANS: D
| The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively.
50
A 56-year-old normally healthy patient at the clinic is diagnosed with community-acquired pneumonia. The nurse anticipates that empirical treatment of the patient could include the administration of which of the following medications?
a. Ciprofloxacin (Cipro)
b. Azithromycin (Zithromax)
c. Trimethoprim–sulfamethoxazole (Bactrim)
d. A second- or third-generation cephalosporin
ANS: B
Early initiation of appropriate antibiotic therapy has been demonstrated to reduce mortality. The treatment of choice is a macrolide (erythromycin, azithromycin, or clarithromycin).
51
During assessment of the chest in a patient with pneumococcal pneumonia, what would the nurse expect to find?
a. Hyperresonance on percussion
b. Increased tactile fremitus on palpation
c. Fine crackles in all lobes on auscultation
d. Asymmetrical chest expansion on inspection
ANS: B
Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased tactile fremitus over the affected area of the lungs. The area would be dull to percussion.
52
To promote airway clearance in a patient with pleurisy, what should the nurse instruct the patient to do?
a. Splint the chest when coughing.
b. Maintain a semi-Fowler’s position.
c. Wear the nasal oxygen cannula at all times.
d. Use relaxation techniques to reduce anxiety.
ANS: A
| Coughing is less painful and more likely to be effective when the patient splints the chest during coughing.
53
Four days after admission, a patient with chronic obstructive lung disease is diagnosed with hospital-acquired pneumonia (HAP). Which of the following organisms does the nurse recognize is a common cause of this type of pneumonia?
a. Pneumocystis carinii
b. Haemophilus influenzae
c. Pseudomonas aeruginosa
d. Mycoplasma pneumoniae
ANS: C
Bacteria are responsible for the majority of HAP infections, including Pseudomonas, Enterobacter, Staphylococcus aureus, methicillin-resistant S. aureus, and S. pneumoniae.
54
The nurse is preparing a patient with a diagnosis of bronchiectasis for chest physiotherapy with postural drainage. Which one of the following will the nurse implement?
a. Position the patient supine.
b. Elevate the head of the bed by 20 cm.
c. Elevate the foot of the bed by 10 to 15 cm.
d. Ensure the patient is in the left lateral position for the first part of the chest physiotherapy.
ANS: C
Chest physiotherapy with postural drainage should be done on affected parts of the lung; elevate the foot of the bed 10 to 15 cm, to facilitate drainage.
55
During assessment of the patient with pneumonia, what does the nurse understand about the disease?
a. All patients with pneumonia will have a productive cough.
b. Manifestations of pneumonia vary, depending on the causative organism.
c. The typical pneumonia symptoms are usually caused by M. pneumoniae.
d. The pathophysiology of the disease is the same, regardless of the causative microorganism.
ANS: B
| Manifestations of pneumonia vary according to their causative agent.
56
Following discharge teaching, the nurse evaluates that the patient with pneumonia understands measures to prevent a relapse of the pneumonia when the patient gives which of the following responses?
a. “I will increase my food intake to 2400 calories a day.”
b. “I must use home oxygen therapy for 3 months.”
c. “I will seek medical treatment for any upper respiratory infections.”
d. “I should continue to do deep breathing and coughing exercises for at least 6 weeks.”
ANS: D
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.
57
To protect susceptible patients in the hospital from aspiration pneumonia, what must the nurse do?
a. Turn and reposition immobile patients every 2 hours.
b. Position patients with altered consciousness in a lateral position.
c. Monitor for respiratory symptoms in those patients who are immunosuppressed.
d. Plan room assignments to prevent infected patients from placement with surgical patients.
ANS: B
The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position.
58
Which of the following is a general term used for lung diseases caused by the inhalation and retention of dust particles?
a. Berylliosis
b. Byssinosis
c. Paraneoplastic syndrome
d. Pneumoconiosis
ANS: D
| Pneumoconiosis is a general term for lung diseases caused by the inhalation and retention of dust particles.
59
What should the nurse teach patients at risk for pneumonia to obtain?
a. Staphylococcal vaccine
b. Measles, mumps, rubella (MMR) vaccine
c. Pneumococcal vaccine
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: C
Individuals at risk for pneumonia (e.g., the chronically ill, older adults) should be encouraged to obtain both influenza and pneumococcal vaccines. This is particularly important because the rate of drug-resistant S. pneumoniae infections is increasing. Pneumococcal vaccine can be given simultaneously with other vaccines, such as the flu vaccine, but each should be administered in a separate site.
60
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 physician
c. Right after the patient gets up in the morning
d. After the skin test is administered
ANS: C
If the patient has a productive cough, an early-morning sputum specimen will be required for an acid-fast bacilli (AFB) smear, to detect the presence of mycobacteria.
61
A patient has just been started on chemotherapy for TB. What should the nurse tell the patient regarding how long the disease can be transmitted to others?
a. Until the night sweats have subsided
b. Until three AFB smears are negative
c. Until the medications have been taken for 6 months
d. Until sputum cultures on 3 consecutive days are negative
ANS: B
| The patient is considered infectious until three sputum smears are negative for AFB.
62
The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB carries out which of the following actions?
a. Wears a mask when in contact with others
b. Reports daily to the public health department
c. Boils dishes and personal items between uses
d. Covers the mouth and nose when coughing or sneezing
ANS: D
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.
63
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.”
ANS: A
| Peripheral neurotoxicity associated with this drug can be prevented by taking vitamin B6 when being treated with INH.
64
A patient diagnosed with TB is started on initial drug therapy. Which of the following medications should the nurse plan to teach the patient about the uses and effects of?
a. INH, rifampin, and ethambutol
b. INH, pyrazinamide, and streptomycin
c. INH, rifampin, pyrazinamide, streptomycin, and ethambutol
d. Para-aminosalicylic acid, ethambutol, rifampin, and pyrazinamide
ANS: C
| The five primary drugs used are INH, rifampin, pyrazinamide, streptomycin, and ethambutol.
65
A homeless patient with alcoholism is diagnosed with active TB. Which nursing intervention will be most effective in ensuring adherence to 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 centre and giving the medication then
d. Educating the patient about the long-term impact of TB on health
ANS: C
Directly observed therapy (DOT) is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication.
66
A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. A sputum specimen is taken for culture and to determine whether the microorganism is sensitive to the medications. What knowledge does the nurse use to question the patient regarding the treatment regimen?
a. DOT will be necessary if the patient has been noncompliant.
b. A combination product of INH, rifampin, and pyrazinamide is indicated if the patient skips doses.
c. Treatment protocols involving twice-weekly administration of the drugs are not as effective as daily administration.
d. If the drugs are causing side effects, a regimen including the administration of only INH can be substituted.
ANS: A
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.
67
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 which of the following?
a. Use and side effects of INH
b. Standard four-medication therapy for TB
c. Need for annual repeat TB skin testing
d. Recommendation guidelines for BCG vaccine
ANS: A
| The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months.
68
During intravenous (IV) administration of amphotericin B ordered for treatment of coccidioidomycosis, how can the nurse increase the patient’s tolerance of the drug?
a. Cooling the solution to 26.7°C 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 distilled water before administering
d. Administering diphenhydramine (Benadryl) 1 hour before the infusion
ANS: D
Many of the side effects of an infusion can be avoided by premedicating with an anti-inflammatory or diphenhydramine 1 hour before the infusion.
69
The nurse is performing TB screening in a clinic that has many patients who have immigrated to Canada. 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 Canada?”
b. “Do you have a family history of TB?”
c. “Have you received the BCG vaccine for TB?”
d. “Do you take any over-the-counter medications?”
ANS: C
Patients who have received the BCG vaccine will have a positive purified protein derivative test. Another method for screening (such as a chest X-ray) will be used in determining whether the patient has a TB infection.
70
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 does which of the following?
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
ANS: B
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.
71
The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for which of the following?
a. Shortness of breath
b. Stabbing chest pain
c. Elevated temperature
d. Barrel chest
ANS: A
Occupational asthma refers to the development of symptoms of shortness of breath, wheezing, cough, and chest tightness as a result of exposure to fumes or dust that trigger an allergic response.
72
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 which of the following?
a. Reasons for annual sputum cytology testing
b. Computed tomography screening for lung cancer
c. Erlotinib (Tarceva) therapy to prevent tumour risk
d. Options for smoking cessation
ANS: D
Because smoking is the major cause of lung cancer, the most important role for the nurse to educate patients about the benefits of and means of smoking cessation.
73
A lobectomy is scheduled for a patient with squamous cell carcinoma of the lung. The patient tells the nurse, “I would rather have radiation than surgery.” What is the most appropriate response?
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?”
ANS: B
More assessment of the patient’s concerns about surgery is indicated. An open-ended response will elicit the most information from the patient.
74
A 52-year-old patient has a 40-pack-year history of smoking and has been diagnosed with cancer of the lung. He tells the nurse that he did not know that anything was wrong until he had a routine chest X-ray. The nurse explains that symptoms of lung cancer occur late in the disease. What is the first thing people usually notice?
a. Fatigue
b. Chest pain
c. A persistent cough
d. Shortness of breath
ANS: C
| The first thing usually noticed with lung cancer is a persistent cough.
75
In relation to lung cancer and gender, which of the following statements is true?
a. More women than men are diagnosed with lung cancer.
b. Men are more likely to develop small-cell carcinoma than women.
c. Women develop lung cancer after fewer years of smoking than men do.
d. Lung cancer incidence and deaths are increasing in men.
ANS: C
The accurate fact related to gender and lung cancer is that women develop lung cancer after fewer years of smoking than men do.
76
A young man is admitted to the emergency department with a stab wound to the right chest. He has moderate bleeding from the site, and his vital signs show symptoms of shock. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, what should the nurse do?
a. Position the patient on his injured side.
b. Administer high-flow oxygen using a nonrebreathing mask.
c. Cover the sucking chest wound with a petrolatum gauze dressing.
d. Apply a nonporous dressing taped on three sides to the chest wound.
ANS: D
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.
77
The physician 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 concerned about which of the following?
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
ANS: B
| The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.
78
A patient experiences a flail chest as a result of an automobile accident. During the respiratory assessment, what would the nurse expect to find?
a. Bloody sputum
b. Laryngeal stridor
c. Deep, irregular respirations
d. Paradoxical chest movement
ANS: D
Paradoxical chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia.
79
The nurse establishes the presence of a tension pneumothorax when assessment findings reveal which of the following results?
a. Decreased breath sounds on the affected side
b. Inability to auscultate tracheal breath sounds
c. A sucking sound with each patient breath
d. A shift of the point of maximal impulse to the left, with bounding pulses
ANS: A
Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side.
80
The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and expiratory wheezing after having a pneumonectomy. To promote airway clearance, what is the nurse’s initial action?
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.
ANS: B
A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing), so it is important that patients be appropriately medicated so that they are able to breathe deeply and cough.
81
A patient has a chest tube following a thoracotomy. Continuous bubbling in the suction-control chamber of the collection device would alert the nurse to which of the following facts?
a. An air leak may be present.
b. The lung has fully expanded.
c. The unit is functioning normally.
d. A tension pneumothorax is developing.
ANS: C
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction.
82
When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that postoperatively he can expect which of the following interventions?
a. To be positioned on the unaffected side
b. Chest tubes to water-seal chest drainage
c. Endotracheal intubation with mechanical ventilation
d. Frequent use of an incentive spirometer
ANS: D
| Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis.
83
A 68-year-old man has a long history of chronic obstructive pulmonary disease and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is would indicate that the patient with a diagnosis of cor pulmonale also has heart failure?
a. Audible crackles at both lung bases
b. Peripheral edema
c. Loud murmur at the mitral area
d. High systemic blood pressure
ANS: B
Clinical manifestations of cor pulmonale include dyspnea, chronic productive cough, wheezing respirations, retrosternal or substernal pain, and fatigue. If heart failure accompanies cor pulmonale, additional manifestations will also be found, including peripheral edema; weight gain; distended neck veins; full, bounding pulse; and enlarged liver.
84
Which of the following is an extrapulmonary cause of restrictive lung disease?
a. Kyphoscoliosis
b. Atelectasis
c. Interstitial lung disease
d. Tuberculosis
ANS: A
Kyphoscoliosis is an extrapulmonary cause of restrictive lung disease. The other answer choices are all intrapulmonary causes of restrictive lung disease.
85
A patient with primary pulmonary hypertension (PPH) is on diuretic therapy. The nurse will evaluate that the treatment is effective in which of the following situations?
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/min.
d. The patient’s chest X-ray indicates clear lung fields.
ANS: A
Given that a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective.
86
A patient is scheduled for a thoracentesis to obtain pleural fluid for diagnosis of a large pleural effusion. Before the procedure, the nurse will anticipate which of the following?
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 IV 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.
ANS: A
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can be located and removed more easily. The lung will expand after the effusion is removed.
87
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 which of the following?
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/min.”
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.”
ANS: D
| After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results.
88
A patient who was admitted the previous day with pneumonia complains of a sharp pain whenever he takes 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.
ANS: A
The patient’s statement indicates that pleurisy or a pleural effusion may have developed, so the nurse will need to listen for a pleural friction rub, decreased breath sounds, or both.
89
A patient with a chronic productive cough and weight loss is receiving a TB 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 TB infection.”
b. “The skin test will indicate whether you have active TB.”
c. “The skin test is used to decide which antibiotic therapy will work best.”
d. “The skin test is done before notification of the public health department.”
ANS: A
| A positive skin test will indicate whether the patient has been infected with TB.
90
The nurse obtains the following information when caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment information is most important to communicate to the physician?
a. The patient has many abdominal bruises.
b. The patient’s blood pressure is 90/46 mm Hg.
c. The activated partial thromboplastin time is two times the patient baseline.
d. The patient’s stool is dark green and liquid.
ANS: B
The low blood pressure may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy.
91
The nurse is preparing a patient for discharge after treatment for a pulmonary embolism. The patient asks the nurse how long he will have to be on anticoagulant therapy. The nurse’s response is based on knowledge that the patient will be on this therapy for which period of time?
a. 10 days post discharge
b. 2 to 4 weeks
c. 3 to 6 months
d. 6 to 8 months
ANS: C
| Anticoagulant therapy continues for at least 3 to 6 months for patients after having a pulmonary embolism.
92
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 physician?
a. Blood pressure is 150/90 mm Hg.
b. Pain level is 5 on a 10-point scale with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory rate is 24 breaths/min when lying flat.
ANS: C
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring.
93
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 ciprofloxacin (Cipro) 400 mg IV.
c. Send patient to have a chest radiograph.
d. Administer an aspirin suppository.
ANS: A
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration.
94
The nurse has received a change-of-shift report about these four patients. Which one will the nurse plan to assess first?
a. A 23-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 38.5°C
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
ANS: C
| Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse.
95
A patient with a deep-vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respiration of 42 breaths/min. The nurse’s first action should be to do which of the following?
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.
ANS: A
The patient has symptoms consistent with a pulmonary embolism, so elevating the head of the bed will improve ventilation and gas exchange.
96
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 physician immediately on finding which of the following assessment data?
a. An SpO2 of 90%
b. A peak expiratory flow rate of 240 mL/min
c. Decreased breath sounds and decreased audible wheezing
d. Arterial blood gas (ABG) results of pH 7.4, PaCO2 50 mm Hg, and PaO2 74 mm Hg
ANS: C
Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated.
97
The nurse recognizes that intubation and mechanical ventilation are indicated for a patient experiencing a severe asthma attach when which one of the following changes occurs?
a. Ventricular dysrhythmias occur.
b. The thorax becomes hyperinflated.
c. Pulsus paradoxus is greater than 40 mm Hg.
d. Fatigue leads to increased hypercapnia and hypoxemia.
ANS: D
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.
98
An Advair Diskus DPI (combined fluticasone and salmeterol) dry powder inhaler is prescribed for a patient diagnosed with mild, persistent asthma. The patient asks the nurse why she must use two different drugs. What should the nurse explain about this treatment?
a. Both drugs are bronchodilators, but the exact mechanism of action of fluticasone is not known.
b. Both the salmeterol and the fluticasone are bronchodilators but act in different ways to decrease bronchospasm.
c. The salmeterol is used to decrease the bronchospasm, and the fluticasone helps control the inflammatory response.
d. The salmeterol stimulates the bronchodilator effect of 2 receptors, and the fluticasone blocks the bronchoconstrictor effect of the parasympathetic nervous system.
ANS: C
Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks.
99
The physician has prescribed a budesonide metered-dose inhaler (MDI) two puffs every 8 hours and ciclesonide MDI one puff twice daily (BID). In teaching the patient about the use of the inhalers, what is the best instruction?
a. “Use the budesonide inhaler first, wait a few minutes, then use the ciclesonide 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 medications, inhale quickly when using the inhalers.”
ANS: B
| More medication reaches the bronchioles when a spacer is used along with an MDI.
100
Clinically significant airway obstruction develops in what percentage of smokers?
a. 5% to 10%
b. 15% to 20%
c. 25% to 30%
d. 40% to 50%
ANS: B
| Clinically significant airway obstruction develops in 15% to 20% of smokers.
101
The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. Which common etiological factor would the nurse document for this nursing diagnosis in patients with asthma?
a. Work of breathing
b. Fear of suffocation
c. Anxiety and restlessness
d. Side effects of medications
ANS: A
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.
102
The nurse evaluates the effectiveness of therapy for a patient with an acute asthma exacerbation. Which of the following findings indicates to the nurse that the patient’s respiratory function is beginning to improve?
a. Wheezing becomes louder.
b. The cough remains unproductive.
c. Vesicular breath sounds decrease.
d. Aerosol bronchodilators stimulate coughing.
ANS: A
| Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working.
103
A 25-year-old patient has had moderate asthma for 10 years. She uses an salbutamol (Apo-Salvent) inhaler when she develops chest tightness and wheezing but does not use her salmeterol (Serevent) as prescribed. To increase the patient’s management and control of her asthma, what should the nurse teach the patient?
a. She should use the salmeterol when the albuterol does not relieve her symptoms.
b. Using the salmeterol helps prevent the early-phase response of bronchospasm and thus further inflammatory changes.
c. Salmeterol should be used when she uses the -agonist inhaler to decrease the late-phase inflammatory reaction of asthma.
d. Asthma attacks can be prevented if she uses both the albuterol and the salmeterol as prescribed and not just when symptoms develop.
ANS: B
Salmeterol is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms.
104
During assessment of a patient with asthma, the nurse notes wheezing and dyspnea, recognizing that these symptoms are related to which of the following pathophysiological features?
a. Laryngospasm
b. Pulmonary edema
c. Airway narrowing
d. Overdistension of the alveoli
ANS: C
| The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading to airway narrowing.
105
A patient with an acute attack of asthma comes to the emergency department, where blood is drawn for ABGs. The nurse determines the patient is in the early phase of the attack, based on which of the following ABG results?
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
ANS: B
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.
106
While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse instructs the patient to implement which of the following actions?
a. Take and record peak flow readings when having asthma symptoms or an attack.
b. Increase the doses of long-term control medications if the peak flow numbers decrease.
c. Use the flow meter each morning after taking medications to evaluate the effectiveness of the medications.
d. Empty the lungs, and then inhale as rapidly as possible through the mouthpiece to measure how fast air can be inhaled.
ANS: A
It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline.
107
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 which of the following?
a. 1-Antitrypsin testing
b. Use of the nicotine patch
c. Continuous pulse oximetry
d. Effects of leukotriene modifiers
ANS: A
When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in 1-antitrypsin should be suspected.
108
A patient with chronic obstructive pulmonary disease (COPD) asks the nurse how his smoking caused his lung disease. The nurse explains that long-term exposure to tobacco smoke leads to which of the following?
a. Weakening of the smooth muscle lining the airways
b. Decrease in the area available for oxygen absorption
c. A reduction in the number of red blood cells available for oxygen delivery
d. Decreased production of protective respiratory secretions
ANS: B
Carbon monoxide is a component of tobacco smoke. Carbon monoxide has a high affinity for hemoglobin and combines with it more readily than does oxygen, thereby reducing the smoker’s oxygen-carrying capacity. Smokers inhale a lower percentage of oxygen than normal; as a result, less oxygen is available at the alveolar level.
109
The nurse knows that the interventions carried out to promote airway clearance in the patient with COPD are successful based on which of the following findings?
a. The patient has no dyspnea.
b. The patient’s mental status is improved.
c. The patient has effective and productive coughing.
d. The PaO2 is within the normal range for the patient.
ANS: C
The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively.
110
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%. What does the nurse recognize these values as evidence of?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Normal acid–base balance with hypoxemia
d. Normal acid–base balance with hypercapnia
ANS: A
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.
111
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements for a patient with COPD. What is an appropriate intervention for this problem?
a. Order fruits and fruit juices to be offered between meals.
b. Order a high-calorie, high-protein diet with six small meals a day.
c. Teach the patient to use frozen meals that can be microwaved at home.
d. Provide a high-calorie, high-carbohydrate, nonirritating, frequent-feeding diet.
ANS: B
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.
112
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 all winter for the past 2 years.
ANS: D
A diagnosis of chronic bronchitis is based on a history of having a productive cough for at least 3 months for at least 2 consecutive years.
113
The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by which of the following methods?
a. Loosening secretions so that they may be coughed up more easily
b. Promoting maximal inhalation for better oxygenation of the lungs
c. Preventing bronchial collapse and air trapping in the lungs during expiration
d. Slowing the respiratory rate and giving the patient control of respiratory patterns
ANS: C
Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents collapse of the airways, allowing for more complete exhalation.
114
The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress based on which of the following assessment findings?
a. An SpO2 of 86%
b. Dyspnea and a respiratory rate of 32 breaths/min
c. Use of the accessory muscles of respiration
d. The presence of crackles and coarse rales in the lungs
ANS: A
| The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry.
115
When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. The nurse will monitor which of the following to assess for cor pulmonale?
a. Elevated temperature
b. Complaints of chest pain
c. Jugular vein distension
d. Clubbing of the fingers
ANS: C
| Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension.
116
What is the best nursing action when a patient with COPD is receiving oxygen?
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.
ANS: D
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 an adequate blood oxygen level without the danger of suppressing the respiratory drive.
117
A patient has been receiving oxygen per nasal cannula during her hospitalization for emphysema. She asks the nurse whether she will have to use oxygen at home. What should the nurse tell the patient about long-term home oxygen therapy?
a. It can improve the patient’s prognosis and quality of life.
b. It is contraindicated in patients with COPD to prevent oxygen dependency.
c. It is used only for patients who have severe end-stage respiratory disease.
d. It should never be used at night because the patient cannot monitor its effect.
ANS: A
| Research supports the use of home oxygen to improve quality of life and prognosis.
118
A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, what is it most important for the nurse to do?
a. Keep the air entrainment ports clean and unobstructed.
b. Apply an adaptor to increase humidification of the oxygen.
c. Drain moisture condensation from the oxygen tubing every hour.
d. Keep the flow rate high enough to keep the bag from collapsing during inspiration.
ANS: A
| The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed.
119
What grade of dyspnea would the nurse document when a patient with COPD walks slower than his peers of the same age and needs to stop for breath when walking at his own pace on a flat surface?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
ANS: C
A patient with grade 3 dyspnea walks slower than people of the same age on the level or stops for breath while walking at his or her own pace on the level.
120
A 70-year-old patient is recovering from an acute episode of COPD. In planning with the patient to increase his activity tolerance at home, which of the following activities does the nurse understand is an appropriate exercise goal for the patient?
a. Increase his activity any amount over his current level.
b. Walk for 20 minutes a day with his pulse rate less than 150 beats/min.
c. Limit his exercise to activities of daily living to conserve his energy.
d. Swim for 10 minutes a day, gradually increasing to 30 minutes a day.
ANS: B
The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily, with the pulse rate not to exceed 150 beats/min.
121
A patient with severe COPD tells the nurse he wishes he would die because he is so disabled with his disease that he just cannot do anything for himself. Based on this information, the nurse identifies which of the following nursing diagnoses?
a. Hopelessness related to long-term stress
b. Anticipatory grieving related to expectation of death
c. Ineffective coping related to unknown outcome of illness
d. Depression related to physical and psychological dependence
ANS: D
The patient’s statement about not being able to do anything for himself 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.
122
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
ANS: A
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.
123
When evaluating a patient’s oral intake, the nurse knows that which fluid intake would be considered adequate for the patient with COPD?
a. 1200 mL
b. 2000 mL
c. 2500 mL
d. 3000 mL
ANS: D
| Collaborative care for the patient with COPD includes hydration of 3 L/day.
124
The nurse has completed teaching a patient about MDI use. Which statement by the patient indicates to the nurse that further patient teaching is needed?
a. “I will shake the MDI to check for fullness each time before using.”
b. “I will take a slow, deep breath in after pushing down on the MDI.”
c. “I will check the MDI counter.”
d. “I will attach a spacer to the MDI to make it easier for me to use.”
ANS: A
Shaking the container is no longer recommended as a means of determining whether the medication needs replacement because the patient may be hearing only the propellant move in the canister when the MDI is nearly empty.
125
To promote healthy coping in the patient with COPD, what should the nurse do?
a. Assist the patient to identify strengths and ignore limitations.
b. Teach the patient relaxation techniques and other alternative therapies.
c. Encourage family members to include the patient in family and social activities.
d. Refer the patient to a support group at the local chapter of the Lung Association.
ANS: B
Relaxation techniques may provide benefit in terms of relief of dyspnea for some patients, but the evidence for this is unclear. Relaxation techniques include progressive muscular relaxation; positive thinking and visualization; and use of music, yoga, massage, and humour.
126
In planning care for the patient with cystic fibrosis (CF), the nurse understands that which of the following interventions is the most important therapeutic approach to promote pulmonary function in the patient?
a. Regular administration of bronchodilators
b. Administration of continuous low-flow oxygen
c. Maintenance of prophylactic doses of antibiotics
d. Chest physiotherapy every 4 hours to mobilize secretions
ANS: D
| Routine scheduling of airway clearance techniques is an essential intervention for patients with CF.
127
When teaching a patient about the various methods of oxygen administration, the nurse tells the patient that, with high flow rates, pain may develop in the frontal sinuses as a result of which of the following methods?
a. Simple face mask
b. Nasal cannula
c. Partial rebreathing mask
d. Transtracheal catheter
ANS: B
| When using nasal prongs, high-flow rates often cause dry nasal membranes and pain in the frontal sinuses.
128
A 19-year-old male with CF and his wife are considering having a child. In counselling the patient and his wife, the nurse determines their knowledge of the situation by asking them for which following information?
a. Whether they have considered that the patient is probably sterile
b. Whether they have thought about the patient’s ability to care for a child
c. Whether they have considered adoption as a solution to their desire to have a family
d. Whether they know that any children produced by them will have CF
ANS: A
| Most men with CF are sterile.
129
When caring for a patient with CF, the nurse recognizes that the manifestations of the disease are caused by which of the following pathophysiological processes?
a. Inflammation and fibrosis of lung tissue
b. Failure of the bronchial goblet cells to produce mucus
c. Altered function of exocrine glands, with abnormally thick, viscous secretions
d. Thickening and fibrosis of the pleural linings of the lungs, causing thoracic wall changes
ANS: C
| CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs, pancreas, and sweat glands
130
All of the following orders are received for a patient having an acute asthma attack. Which one will the nurse administer first?
a. Intravenous methylprednisolone (Solu-Medrol) 60 mg
b. Triamcinolone (Azmacort) two puffs per MDI
c. Salmeterol 50 mcg per dry-powder inhaler (DPI)
d. Albuterol (Ventolin) 2.5 mg per nebulizer
ANS: D
Albuterol (Ventolin) 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.
131
Which following statement by the patient with COPD indicates that the nurse’s teaching about nutrition has been effective?
a. “I will drink a lot 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 too much meat or dairy products.”
ANS: B
High-calorie foods such as 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.
132
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.”
ANS: B
| Use of a bronchodilator before exercise improves airflow for some patients and is recommended.
133
When teaching a patient about continuous home oxygen use, the nurse tells the patient that evaporation of the oxygen accelerates during which season, and they should take extra care to ensure that they do not run out of oxygen?
a. Spring
b. Summer
c. Fall
d. Winter
ANS: B
During the summer, with liquid oxygen, evaporation is accelerated and may decrease reservoir duration to less than 1 week.
134
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 (Ventolin) and salmeterol.
c. The patient uses hydrocortisone (Solu-Cortef) before any aerobic exercise.
d. The patient’s heart rate increases after using the albuterol (Ventolin) inhaler.
ANS: B
Long-acting 2-adrenergic 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.
135
When taking an admission history of a patient with COPD 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.
ANS: B
| -Adrenergic blockers such as propranolol can cause bronchospasm in some patients.
136
A patient who is experiencing an acute asthma attack is admitted to the emergency department. What is the priority nursing action?
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.
ANS: C
Assessment of the patient’s breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary.
137
After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states which of the following?
a. “I will use my corticosteroid inhaler as soon as I start to get short of breath.”
b. “I will turn the home oxygen level up only 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.”
ANS: D
| Peak flows of 80% or greater indicate that the asthma is well controlled.
