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Flashcards in MS2 - Respiratory - Questions Deck (42):
1

The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem?
1. Humidify the patient's oxygen.
2. Use a simple face mask instead of a nasal cannula.
3. Provide the patient with an extra pillow.
4. Have the patient sit up in a chair at the bedside.

1. Humidify the patient's oxygen.

Rationale:
When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

2

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?\
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions

Rationale:
When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

3

You are supervising an RN who floated from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.)
1. Position the patient supine and turned on his side.
2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cool compresses to the nose.
5. Instruct the patient not to blow the nose for several hours.

2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cool compresses to the nose.
5. Instruct the patient not to blow the nose for several hours.

Rationale:
The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed.

4

You are acting as preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? (Select all that apply.)
1. 38-year-old with moderate persistent asthma awaiting discharge
2. 63-year-old with a tracheostomy needing tracheostomy care every shift
3. 56-year-old with lung cancer who has just undergone left lower lobectomy
4. 49-year-old just admitted with a new diagnosis of esophageal cancer
5. 76-year-old newly diagnosed with type 2 diabetes

1. 38-year-old with moderate persistent asthma awaiting discharge
2. 63-year-old with a tracheostomy needing tracheostomy care every shift

Rationale:
The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly-diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with him or her in providing care for these patients with more complex needs. The newly-diagnosed diabetic patient will need much teaching as well as careful monitoring.

5

You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply.)
1. Avoid potential environmental asthma triggers such as smoke.
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
3. Wash all bedding in cold water to reduce and destroy dust mites.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG).

1. Avoid potential environmental asthma triggers such as smoke.
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG).

Rationale:
Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

6

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN/LVN under your supervision?
1. Observing how well the patient performs pursed-lip breathing
2. Planning a nursing care regimen that gradually increases activity tolerance
3. Assisting the patient with basic activities of daily living (ADLs)
4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing

Rationale:
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

7

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
1. Chest tube drainage of 10 to 15 mL/hr
2. Continuous bubbling in the water-seal chamber
3. Reports of pain at the chest tube site
4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber

Rationale:
Continuous bubbling indicates an air leak that must be identified. With the physician's order, you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

8

After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
1. 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory
2. 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
3. 72-year-old with pneumonia who needs to be started on IV antibiotics
4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

Rationale:
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In COPD patients, pulse oximetry oxygen saturations of more than 90% are acceptable.

9

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit?
1. 58-year-old on airborne precautions for tuberculosis (TB)
2. 65-year-old who just returned from bronchoscopy and biopsy
3. 72-year-old who needs teaching about the use of incentive spirometry
4. 69-year-old with COPD who is ventilator dependent

3. 72-year-old who needs teaching about the use of incentive spirometry

Rationale:
Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

10

When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching?
1. "Everyone in my family needs to go and see the doctor for TB testing."
2. "I will continue to take my isoniazid until I am feeling completely well."
3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.
4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

2. "I will continue to take my isoniazid until I am feeling completely well."

Rationale:
Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing tissues in plastic bags, help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

11

You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
1. The patient was recently in a motor vehicle accident.
2. The patient participated in an aerobic exercise program for 6 months.
3. The patient gave birth to her youngest child 1 year ago.
4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle accident.

Rationale:
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for deep vein thrombosis and pulmonary embolus, but this period of bed rest was very short.

12

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs? (Select all that apply.)
1. Use a lift sheet when moving and positioning the patient in bed.
2. Use an electric razor when shaving the patient each day.
3. Use a soft-bristled toothbrush or tooth sponge for oral care.
4. Use a rectal thermometer to obtain a more accurate body temperature.
5. Be sure the patient's footwear has a firm sole when the patient ambulates.

1. Use a lift sheet when moving and positioning the patient in bed.
2. Use an electric razor when shaving the patient each day.
3. Use a soft-bristled toothbrush or tooth sponge for oral care.
5. Be sure the patient's footwear has a firm sole when the patient ambulates.

Rationale:
While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.

13

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
1. Perform endotracheal intubation and initiate mechanical ventilation.
2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth.
3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT).
4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

Rationale:
A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

14

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
1. Assessing for bilateral breath sounds and symmetrical chest movement
2. Auscultating over the stomach to rule out esophageal intubation
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering a chest radiograph to verify that tube placement is correct

3. Marking the tube 1 cm from where it touches the incisor tooth or nares

Rationale:
The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed.

15

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately?
1. Heart rate of 98 beats/min
2. Respiratory rate of 24 breaths/min
3. Blood pressure of 168/90 mm Hg
4. Tympanic temperature of 101.4° F (38.6° C)

4. Tympanic temperature of 101.4° F (38.6° C)

Rationale:
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system.

16

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?
A. Tidaling of water in water seal chamber
B. Bilateral muffled breath sounds at bases
C. Temperature of 101° F
D. Absence of chest tube drainage for 2 days

A. Tidaling of water in water seal chamber

Rationale:
Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed (A) to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. (B) may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. (C) usually indicates an infection, which may not be related to the chest tube. (D) is an expected finding.

17

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?
A. Leukocytosis and febrile
B. Polycythemia and crackles
C. Pharyngitis and sputum production
D. Confusion and tachycardia

D. Confusion and tachycardia

Rationale:
The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia.

18

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A. Immediately after feeding
B. Just prior to tube feeding
C. Continuous inflation is required
D. Inflation is not required

B. Just prior to tube feeding

Rationale:
The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.

19

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?
A. A young adult with bacterial meningitis with recent seizures
B. An older adult client with pneumonia and viral meningitis
C. A female client in isolation with meningococcal meningitis
D. A male client 1 day postoperative after drainage of a brain abscess

B. An older adult client with pneumonia and viral meningitis

Rationale:
The most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

20

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing.

D. Assess for kinks or dependent loops in the tubing.

Rationale:
The least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

21

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine?
A. The vaccine is given annually before the flu season to those older than 50 years.
B. The immunization is administered once to older adults or those at risk for illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

B. The immunization is administered once to older adults or those at risk for illness.

Rationale:
It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime (B). Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year, not Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

22

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD?
A. The client's father was diagnosed with COPD in his 50s.
B. A close family member contracted tuberculosis last year.
C. The client smokes one to two packs of cigarettes per day.
D. The client has been 40 pounds overweight for 15 years.

C. The client smokes one to two packs of cigarettes per day.

Rationale:
Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD (C). The exact mechanism of genetic and hereditary implications (A) for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling second-hand smoke) may increase the likelihood of COPD incidence among family members. (B and D) do not exceed the risks associated with cigarette smoking in the development of COPD.

23

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching?
A. Recommend that the client carry suction equipment at all times.
B. Instruct the client to have writing materials with him at all times.
C. Tell the client to carry a medical alert card that explains his condition.
D. Caution the client not to travel outside the United States alone.

C. Tell the client to carry a medical alert card that explains his condition.

Rationale:
Neck breathers carry a medical alert card (C) that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages (B) is probably the least effective.

24

Which nursing action is necessary for the client with a flail chest?
A. Withhold prescribed analgesic medications.
B. Percuss the fractured rib area with light taps.
C. Avoid implementing pulmonary suctioning.
D. Encourage coughing and deep breathing.

D. Encourage coughing and deep breathing.

Rationale:
Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph.

25

You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
1. Fine bibasilar crackles
2. Respiratory rate of 8 breaths/min
3. The patient sitting up and leaning over the nightstand
4. A large barrel chest

2. Respiratory rate of 8 breaths/min

Rationale:
For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema.

26

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions

Rationale:
When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

27

You are acting as preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? (Select all that apply.)
1. 38-year-old with moderate persistent asthma awaiting discharge
2. 63-year-old with a tracheostomy needing tracheostomy care every shift
3. 56-year-old with lung cancer who has just undergone left lower lobectomy
4. 49-year-old just admitted with a new diagnosis of esophageal cancer
5. 76-year-old newly diagnosed with type 2 diabetes

1. 38-year-old with moderate persistent asthma awaiting discharge
2. 63-year-old with a tracheostomy needing tracheostomy care every shift

Rationale:
The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly-diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with him or her in providing care for these patients with more complex needs. The newly-diagnosed diabetic patient will need much teaching as well as careful monitoring.

28

You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply.)
1. Avoid potential environmental asthma triggers such as smoke.
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
3. Wash all bedding in cold water to reduce and destroy dust mites.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG).

1. Avoid potential environmental asthma triggers such as smoke.
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG).

Rationale:
Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

29

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN/LVN under your supervision?
1. Observing how well the patient performs pursed-lip breathing
2. Planning a nursing care regimen that gradually increases activity tolerance
3. Assisting the patient with basic activities of daily living (ADLs)
4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing

Rationale:
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

30

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
1. Chest tube drainage of 10 to 15 mL/hr
2. Continuous bubbling in the water-seal chamber
3. Reports of pain at the chest tube site
4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber

Rationale:
Continuous bubbling indicates an air leak that must be identified. With the physician's order, you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

31

After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
1. 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory
2. 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
3. 72-year-old with pneumonia who needs to be started on IV antibiotics
4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

Rationale:
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In COPD patients, pulse oximetry oxygen saturations of more than 90% are acceptable.

32

You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP?
1. Teaching the patient about the importance of adequate fluid intake and hydration
2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession

3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake

Rationale:
UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN.

33

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit?
1. 58-year-old on airborne precautions for tuberculosis (TB)
2. 65-year-old who just returned from bronchoscopy and biopsy
3. 72-year-old who needs teaching about the use of incentive spirometry
4. 69-year-old with COPD who is ventilator dependent

3. 72-year-old who needs teaching about the use of incentive spirometry

Rationale:
Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

34

You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
1. The patient was recently in a motor vehicle accident.
2. The patient participated in an aerobic exercise program for 6 months.
3. The patient gave birth to her youngest child 1 year ago.
4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle accident.

Rationale:
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for deep vein thrombosis and pulmonary embolus, but this period of bed rest was very short.

35

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN/LVN on your patient care team?
1. Evaluating the patient's reports of chest pain
2. Monitoring laboratory values for changes in oxygenation
3. Assessing for symptoms of respiratory failure
4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles

Rationale:
An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation, under supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

36

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
1. Perform endotracheal intubation and initiate mechanical ventilation.
2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth.
3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT).
4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

Rationale:
A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

37

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
1. Assessing for bilateral breath sounds and symmetrical chest movement
2. Auscultating over the stomach to rule out esophageal intubation
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering a chest radiograph to verify that tube placement is correct

3. Marking the tube 1 cm from where it touches the incisor tooth or nares

Rationale:
The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed.

38

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately?
1. Heart rate of 98 beats/min
2. Respiratory rate of 24 breaths/min
3. Blood pressure of 168/90 mm Hg
4. Tympanic temperature of 101.4° F (38.6° C)

4. Tympanic temperature of 101.4° F (38.6° C)

Rationale:
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system.

39

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
1. Reassure the patient that the ventilator will do the work of breathing for him.
2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
3. Increase the fraction of inspired oxygen (FiO2) on the ventilator to 100% in preparation for endotracheal suctioning.
4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

Rationale:
Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.

40

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
4. Switch the patient to a nonrebreather mask at 95% to 100% FiO2 and call the physician to discuss the patient's status.

4. Switch the patient to a nonrebreather mask at 95% to 100% FiO2 and call the physician to discuss the patient's status.

Rationale:
The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an FiO2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

41

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
1. The patient starts crying and says she can't go on with treatment much longer.
2. The patient reports sharp, stabbing chest pain with every deep breath.
3. The blood pressure is 100/48 mm Hg and the heart rate is 102 beats/min.
4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

3. The blood pressure is 100/48 mm Hg and the heart rate is 102 beats/min.

Rationale:
Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure.

42

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
1. Administer ordered antibiotics as scheduled.
2. Hyperoxygenate the patient before suctioning.
3. Maintain the head of bed at a 30- to 45-degree angle.
4. Suction the airway when coarse crackles are audible.

3. Maintain the head of bed at a 30- to 45-degree angle.

Rationale:
Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.