MSS Ch 6 Respiratory Disorders: Practice Questions

Question 1

The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client?

1. “Have you had the flu shot in the last two (2) weeks?”
2. “Are there any small children in the home?”
3. “Are you taking over-the-counter medicine for these symptoms?”
4. “Do you have any cold sores associated with your sneezing?”

Answer 1

1. Influenza is a viral illness that might cause these symptoms; however, an immunization should not give the client the illness.
2. Coming into contact with small children increases the risk of contracting colds and the flu, but the client has a problem—not just a potential one.
3. A client diagnosed with hypertension should not take many of the over-the- counter medications because they work by causing vasoconstriction, which will increase the hypertension.
4. Cold sores are actually an infection by the herpes simplex virus. Colds and cold-like symptoms are caused by the rhinovirus or influenza virus. The term “cold sore” is a common term that still persists in the populace.

Question 2

The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss?

1. Instruct the children to always keep a tissue or handkerchief with them.
2. Explain that children current with immunizations will not get a cold.
3. Tell the children they should go to the doctor if they get a cold.
4. Demonstrate to the students how to wash hands correctly.

Answer 2

1. It is not feasible for a child to always have a tissue or handkerchief available.
2. There is no immunization for the common cold. Colds are actually caused by at least 200 separate viruses and the viruses mutate frequently.
3. Colds are caused by a virus and antibiotics do not treat a virus; therefore, there is no need to go to a health-care provider.
4. Hand washing is the single most useful technique for prevention of disease.

Question 3

Which information should the nurse teach the client diagnosed with acute sinusitis?

1. Instruct the client to complete all the ordered antibiotics.
2. Teach the client how to irrigate the nasal passages.
3. Have the client demonstrate how to blow the nose.
4. Give the client samples of a narcotic analgesic for the headache.

Answer 3

1. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic- resistant bacteria. Sinus infections are difficult to treat and may become chronic, and will then require several weeks of therapy or possibly surgery to control.
2. If the sinuses are irrigated, it is done under anesthesia by a health-care provider.
3. Blowing the nose will increase pressure in the sinus cavities and will cause the client increased pain.
4. The nurse is not licensed to prescribe medications, so this is not in the nurse’s scope of practice. Also, narcotic analgesic medications are controlled substances and require written documentation of being prescribed by the health-care provider; samples are not generally available.

Question 4

The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication?

1. Muscle weakness.
2. Purulent sputum.
3. Nuchal rigidity.
4. Intermittent loss of muscle control.

Answer 4

1. Muscle weakness is a sign/symptom of myalgia, but it is not a life-threatening complication of sinusitis.
2. Purulent sputum would be a sign/symptom of a lung infection, but it is not a life-threatening complication of sinusitis.

3. Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges.

4. Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis.

Question 5

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery?

1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
2. The client has an oral temperature of 100.2 ̊F and a dry cough.
3. There are one (1) to two (2) white blood cells in the urinalysis.
4. The client’s current international normalized ratio (INR) is 1.0.

Answer 5

1. The hemoglobin and hematocrit given are within normal range. This would not warrant notifying the health-care provider.
2. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed.
3. One (1) to two (2) WBCs in a urinalysis is not uncommon because of the normal flora in the bladder.
4. The INR indicates that the client’s bleeding time is within normal range.

Question 6

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine?

1. Elderly and chronically ill clients.
2. Child-care workers and children
3. Hospital chaplains and health-care workers.
4. Schoolteachers and students living in a dormitory.

Answer 6

1. The elderly and chronically ill are at greatest risk for developing serious complications if they contract the influenza virus.
2. It is recommended people in contact with children receive the flu vaccine whenever possible, but these clients should be able to withstand a bout with the flu if their immune systems are functioning normally.
3. It is probable these clients will be exposed to the virus, but they are not as likely to develop severe complications with intact functioning immune systems.
4. During flu season, the more people the individual comes into contact with, the greater the risk the client will be exposed to the influenza virus, but this group of people would not receive the vaccine before the elderly and chronically ill.

Question 7

The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?

1. Administer the narcotic analgesic IVP.
2. Perform gentle oral hygiene.
3. Place the client in semi-Fowler’s position.
4. Assess the client’s pain.

Answer 7

1. The client has complained of pain, and the nurse, after determining the severity of the pain and barring any complications in the client, will administer pain medica- tion after completion of the assessment.
2. Oral hygiene helps to prevent the development of infections and promotes comfort, but it will not relieve the pain.
3. Placing the client in the semi-Fowler’s position will reduce edema of inflamed sinus tissue, but it will not immediately affect the client’s perception of pain.
4. Prior to intervening, the nurse must assess to determine the amount of pain and possible complications occurring that could be masked if narcotic medication is administered.

Question 8

The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?

1. The 36-year-old client who has undergone an antral irrigation for sinusitisyesterday and has moderate pain.
2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
3. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
4. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.

Answer 8

1. This client is one (1) day postoperative and has moderate pain, which is to be expected after surgery. A less experienced nurse can care for this client.
2. A child about to go to surgery involving the throat area can be expected to have painful swallowing. This does not require the most experienced nurse.
3. The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client’s condition.
4. Any nurse who is capable of administering IVPB medications can care for this client.

Question 9

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription?

1. “These pills will make me feel better fast and I can return to work.”
2. “The antibiotics will help prevent me from developing a bacterial pneumonia.”
3. “If I had gotten this prescription sooner, I could have prevented this illness.”
4. “I need to take these pills until I feel better; then I can stop taking the rest.”

Answer 9

1. A person with a viral infection should not return to work until the virus has run its course because the antibiotics help prevent complications of the virus, but they do not make the client feel better faster.
2. Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection.
3. Antibiotics will not prevent the flu. Only the flu vaccine will prevent the flu.
4. When people take portions of the antibiotic prescription and stop taking the remainder, an antibiotic-resistant strain of bacteria may develop, and the client may experience a return of symptoms—but this time, the antibiotics will not be effective.

Question 10

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem “altered communication.” Which intervention should the nurse implement?

1. Instruct the client to drink a mixture of brandy and honey several times a day.
2. Encourage the client to whisper instead of trying to speak at a normal level.
3. Provide the client with a blank note pad for writing any communication.
4. Explain that the client’s aphonia may become a permanent condition.

Answer 10

1. The client with laryngitis is instructed to avoid all alcohol. Alcohol causes increased irritation of the throat.
2. Whispering places added strain on the larynx.
3. Voice rest is encouraged for the client experiencing laryngitis.
4. Aphonia, or inability to speak, is a tempo- rary condition associated with laryngitis.

Question 11

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids.
2. Encourage the client diagnosed with a cold to drink a glass of orange juice.
3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis.
4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.

Answer 11

1. Tonsillectomies cause throat edema and difficulty swallowing; the nurse must observe the client’s ability to swallow before this task can be delegated.

2. Clients with colds are encouraged to drink 2,000 mL of liquids a day. The UAP could do this.

3. Throat swabs for culture must be done correctly or false-negative results can occur. The nurse should obtain the swab.
4. Clients with laryngitis are instructed not to smoke. Smoking is discouraged in all health- care facilities. Sending nursing personnel outside encourages an unhealthy practice, which is not the best use of the personnel.

Question 12

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?

1. Vitamin C, 2,000 mg daily.
2. Strict bedrest.
3. Humidification of the air.
4. Decongestant therapy.

Answer 12

1. Alternative therapies are therapies not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system’s functions.
2. Bedrest is accepted standard advice for a client with a cold.
3. Humidifying the air helps to relieve congestion and is a standard practice.
4. Decongestant therapy is standard therapy for a cold.

Question 13

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client?

1. Confusion and lethargy.
2. High fever and chills.
3. Frothy sputum and edema.
4. Bradypnea and jugular vein distention.

Answer 13

1. The elderly client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia.
2. Fever and chills are classic symptoms of pneumonia, but they are usually absent in the elderly client.
3. Frothy sputum and edema are signs and symptoms of heart failure, not pneumonia.
4. The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure.

Question 14

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of “impaired gas exchange.” Which is an expected outcome for this problem?

1. Performs chest physiotherapy three (3) times a day.
2. Able to complete activities of daily living.
3. Ambulates in the hall several times during each shift.
4. Alert and oriented to person, place, time, and events.

Answer 14

1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal.
2. This would be a goal for self-care deficit but not for impaired gas exchange.
3. This would be a goal for the problem of activity intolerance.
4. Impaired gas exchange results in hypoxia, the earliest sign/symptom of which is a change in the level of consciousness.

Question 15

The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Which intervention should the nurse include in the plan of care?

1. Inspect the insertion line at the naris prior to instilling formula.
2. Elevate the head of the bed after feeding the client.
3. Place the client in the Sims position following each feeding.
4. Change the dressing on the feeding tube every three (3) days.

Answer 15

1. A gastrostomy tube is placed directly into the stomach through the abdominal wall; the naris is the opening of the nostril.
2. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration.
3. The Sims position is the left lateral side-lying flat position. This position is used for administering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach.
4. Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily.

Question 16

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?

1. Administer the ordered oral antibiotic STAT.
2. Order the meal tray to be delivered as soon as possible.
3. Obtain a sputum specimen for culture and sensitivity.
4. Have the unlicensed assistive personnel weigh the client.

Answer 16

1. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client’s infection. Clients are placed on oral medications only after several days of IVPB therapy.
2. Meal trays are not priority over cultures.

3. To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibi- otics prior to cultures may make it impossible to determine the actual agent causing the pneumonia.

4. Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection.

Question 17

The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions?

1. “I will take my medication for the full three (3) weeks prescribed.”
2. “I must stay on the medication for months if I am to get well.”
3. “I can be around my friends because I have started taking antibiotics.”
4. “I should get a Tb skin test every three (3) months to determine if I am well.”

Answer 17

1. Clients diagnosed with Tb will need to take the medications for six (6) months to a year.
2. Compliance with treatment plans for Tb includes multidrug therapy for six (6) months to one (1) year for the client to be free of the Tb bacteria.
3. Clients are no longer contagious when three (3) morning sputum specimens are cultured negative, but this will not occur until after several weeks of therapy.
4. The Tb skin test only determines possible exposure to the bacteria, not active disease.

Question 18

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing?

1. The client’s first skin test indicates a purple flat area at the site of injection.
2. The client’s second skin test indicates a red area measuring four (4) mm.
3. The client’s previous skin test was read as positive.
4. The client has never shown a reaction to the tuberculin medication.

Answer 18

1. A purple flat area indicates that the client became bruised when the intradermal injection was given, but it has no bearing on whether the test is positive.
2. A positive skin test is 10 mm or greater with induration, not redness.
3. If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation.
4. These are negative findings and do not indicate the need to have x-ray determination of disease.

Question 19

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.

1. Place the client on oxygen delivered by nasal cannula.
2. Plan for periods of rest during activities of daily living.
3. Place the client on a fluid restriction of 1,000 mL/day.
4. Restrict the client’s smoking to two (2) to three (3) cigarettes per day.
5. Monitor the client’s pulse oximetry readings every four (4) hours.

Answer 19

1. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client.
2. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities.
3. Clients are encouraged to drink at least 2,000 mL daily to thin secretions.
4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited.
5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery.

Question 20

The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?

1. Suction the client’s nares.
2. Turn the client to the side.
3. Place the client in Trendelenburg position.
4. Notify the health-care provider.

Answer 20

1. The nares are the openings of the nostrils. Suctioning, if done, would be of the posterior pharynx.
2. Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs.
3. Placing the client in the Trendelenburg position increases the risk of aspiration.
4. An immediate action is needed to protect the client.

Question 21

The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first?

1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab.
2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube.
3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%.
4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.

Answer 21

1. The specimen needs to be taken to the laboratory within a reasonable time frame, but a UAP can take specimens to the laboratory.
2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage.
3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%.
4. Arterial oxygenation normal values are 80% to 100%.

Question 22

The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?

1. Standard Precautions.
2. Contact Precautions.
3. Droplet Precautions.
4. Airborne Precautions.

Answer 22

1. Standard Precautions are used to prevent exposure to blood and body secretions on all clients. Tuberculosis is caused by airborne bacteria.
2. Contact Precautions are used for wounds.
3. Droplet Precautions are used for infections spread by sneezing or coughing but not transmitted over distances of more than three (3) to four (4) feet.
4. Tuberculosis bacteria are capable of disseminating over long distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross-contaminate the air in the hallway.

Question 23

The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse’s best response?

1. Close the door and discuss the UAP’s action after coming out of the room.
2. Make the UAP come back outside the room and then reenter, closing the door.
3. Say nothing to the UAP but report the incident to the nursing supervisor.
4. Enter the client’s room and discuss the matter with the UAP immediately.

Answer 23

1. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner.
2. The employee is an adult and as such should be treated with respect and corrected accordingly.
3. Problems should be taken care of at the lowest level possible. The nurse is responsible for any task delegated, including the appropriate handling of isolation.
4. Correcting staff should never be done in the presence of the client. This undermines the UAP and creates doubt of the staff’s competency in the client’s mind.

Question 24

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?

1. Pleuritic chest discomfort and anxiety.
2. Asymmetrical chest expansion and pallor.
3. Leukopenia and CRT
4. Substernal chest pain and diaphoresis.

Answer 24

1. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough.
2. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation.
3. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of <3 seconds is normal.
4. Substernal chest pain and diaphoresis are symptoms of myocardial infarction.

Question 25

The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

Answer 25

1. The number of years of smoking is infor- mation needed to treat the client but not the most important in health promotion. 2. The risk factors for complications are important in planning care. 3. Assessing the ability to deliver medications is an important consideration when teaching the client. 4. **The client’s attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan.**

Question 26

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client’s status.

Answer 26

1. **The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client’s safety.** 2. Oxygen will be applied as soon as possible, but the least amount possible. If levels of oxygen are too high, the client may stop breathing. 3. Vital signs need to be monitored, but this is not the first priority. If the equipment is not in the room, another member of the health-care team should bring it to the nurse. The nurse should stay with the client. 4. The health-care provider needs to be noti- fied, but the client must be treated first. The nurse should get assistance if possible so the nurse can treat this client quickly.a

Question 27

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

Answer 27

1. A large amount of thick sputum is a common symptom of COPD. There is no cause for immediate intervention. 2. **The nurse should decrease the oxygen rate to two (2) to three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated.** 3. It is common for clients with COPD to use accessory muscles when inhaling. These clients tend to lean forward. 4. In clients with COPD, there is a characteristic barrel chest from chronic hyperinflation, and dyspnea is common.

Question 28

The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

Answer 28

1. The expected outcome showing no signs of respiratory distress indicates the plan of care is effective and should be continued. 2. An improved respiratory pattern indicates the plan should be continued. 3. **The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision.** 4. The client should participate in planning the course of care. The client is meeting the expected outcome.

Question 29

The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client’s pulse oximeter reading is 92%. 2. The client’s arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client’s sputum is rusty colored.

Answer 29

1. The client with end-stage COPD has decreased peripheral oxygen levels; therefore, this would not warrant immediate intervention. 2. The client’s ABGs would normally indicate a low oxygen level; therefore, this would not warrant immediate intervention. 3. The client who develops dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves. 4. **Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse.**

Question 30

Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. “I should contact my health-care provider if my sputum changes color or amount.” 2. “I will take my bronchodilator regularly to prevent having bronchospasms.” 3. “This metered-dose inhaler gives a precise amount of medication with each dose.” 4. “I need to return to the HCP to have my blood drawn with my annual physical.”

Answer 30

1. When sputum changes in color, amount, or both, this indicates infection, and the client should report this information to the health-care provider. This statement indi- cates the client understands the teaching. 2. Bronchodilators should be taken routinely to prevent bronchospasms. This statement indicates the client understands the teaching. 3. Clients use metered-dose inhalers because they deliver a precise amount of medication with correct use. This statement indicates the client understands the teaching. 4. **Clients should have blood levels drawn every six (6) months when taking bron- chodilators, not yearly. This indicates the client needs more teaching.**

Question 31

Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

Answer 31

**1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on arterial blood gases.** **2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms.** **3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue.** **4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues.** **5. Clients often lose weight because of the effort expended to breathe.**

Question 32

Which outcome is appropriate for the client problem “ineffective gas exchange” for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

Answer 32

1. **Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange.** 2. This would be an appropriate outcome for a knowledge-deficit problem. 3. This outcome does not ensure the client has an effective airway; increasing fluid does not ensure an effective airway. 4. This is not an appropriate outcome for any client problem because the client should be able to ambulate without dyspnea for 100 feet.

Question 33

The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP since this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP’s action with the charge nurse so appropriate action can be taken.

Answer 33

1. The client diagnosed with COPD needs oxygen at all times, especially when exerting energy such as ambulating to the bathroom. 2. **The client needs the oxygen, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff.** 3. The nurse should not verbally correct a UAP in front of the client; the nurse should correct the behavior and then talk to the UAP in private. 4. The primary nurse should confront the UAP and take care of the situation. Continued unsafe client care would warrant notifying the charge nurse.

Question 34

Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client’s fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.

Answer 34

1. Clubbing of the fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. 2. These clients have frequent respiratory infections. 3. **Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD.** 4. These clients have a productive cough, not a nonproductive cough.

Question 35

Which statement made by the client indicates the nurse’s discharge teaching is effective for the client diagnosed with COPD? 1. “I need to get an influenza vaccine each year, even when there is a shortage.” 2. “I need to get a vaccine for pneumonia each year with my influenza shot.” 3. “If I reduce my cigarettes to six (6) a day, I won’t have difficulty breathing.” 4. “I need to restrict my drinking liquids to keep from having so much phlegm.”

Answer 35

1. **Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority.** 2. The pneumococcal vaccine should be ad- ministered every five (5) to seven (7) years. 3. Reducing the number of cigarettes smoked does not stop the progression of COPD, and the client will continue to experience signs and symptoms such as shortness of breath or dyspnea on exertion. 4. Clients diagnosed with COPD should increase their fluid intake unless contraindicated for another health condition. The increased fluid assists the client in expectorating the thick sputum.

Question 36

Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

Answer 36

1. The Asthma Foundation of America is not appropriate for a client in this stage of COPD. 2. The American Cancer Society is helpful for a client with lung cancer but not for a client with COPD. 3. **The American Lung Association has information helpful for a client with COPD.** 4. Many clients with COPD end up with heart problems, but the American Heart Association does not have information for clients with COPD.

Question 37

The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea.

Answer 37

1. Fever is a sign of infection, and crepitus is air trapped in the layers of the skin. 2. Rales indicate fluid in the lung, and hives are a skin reaction to a stimulus such as occurs with an allergy to a specific substance. 3. **During an asthma attack, the muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces, and dyspnea.** 4. During an attack, the chest will be expanded from air being trapped and not being exhaled. A chest x-ray will reveal a lowered diaphragm and hyperinflated lungs.

Question 38

The nurse is planning the care of a client diagnosed with asthma and has written a problem of “anxiety.” Which nursing intervention should be implemented? 1. Remain with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

Answer 38

1. **Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and the client is not alone.** 2. Because anxiety is an expected occurrence with asthma, it is not necessary to notify the health-care provider. 3. An anxiolytic medication could decrease respiratory drive and increase the respiratory distress. Also, the medication will require a delayed time period to begin to work. 4. Drinking fluids will not treat an asthma attack or anxiety.

Question 39

The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply. 1. Nursing. 2. Pharmacy. 3. Social work. 4. Occupational therapy. 5. Speech therapy.

Answer 39

**1. Nursing is the one discipline remaining with the client around the clock. Therefore, nurses have knowledge of the client that other disciplines might not know.** **2. The pharmacist will be able to discuss the medication regimen the client is receiving and make suggestions regarding other medications or medication interactions.** **3. The social worker may be able to assist with financial information or home care arrangements.** 4. Occupational therapists help clients with activities of daily living and modifications to home environments; nothing in the stem indicates a need for these services. 5. Speech therapists assist clients with speech and swallowing problems; nothing in the stem indicates a need for these services.

Question 40

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a “rescue inhaler.” 3. Use of systemic steroids. 4. Leukotriene agonists.

Answer 40

1. Daily inhaled steroids are used for mild, moderate, or severe persistent asthma, not for intermittent asthma. 2. **Clients with intermittent asthma will have exacerbations treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers.** 3. Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma. 4. Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma.

Question 41

Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications? 1. “I should take two (2) puffs when I begin to have an asthma attack.” 2. “I must taper off the medications and not stop taking them abruptly.” 3. “These drugs will be most effective if taken at bedtime.” 4. “These drugs are not good at the time of an attack.”

Answer 41

1. Mast cell stabilizers require 10 to 14 days to be effective. Some clients diagnosed with exercise-induced asthma derive benefit from taking the drugs immediately before exercising, but these drugs must be in the system for a period of time before effectiveness can be achieved. 2. Tapering of medications is done for systemic steroids because of adrenal functioning. 3. The drugs are taken daily, before exercise, or both. 4. **Mast cell drugs are routine maintenance medications and do not treat an attack.**

Question 42

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

Answer 42

1. A complete blood count determines the oxygen-carrying capacity of the hemoglobin in the body, but it will not identify the immediate problem. 2. **Pulmonary function test are completed to determine the forced vital capacity (FVC), the forced expiratory capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicates respiratory compromise.** 3. Allergy skin testing will be done to determine triggers for allergic asthma, but it is not done during an attack. 4. Drug cortisol levels do not relate to asthma.

Question 43

The nurse and a licensed practical nurse (LPN) are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the LPN? Select all that apply. 1. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1,000 mL. 2. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. 3. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed. 4. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications. 5. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.

Answer 43

1. **A forced vital capacity of 1,000 mL is considered normal for most females; therefore, the LPN could care for this client.** 2. **The client should be encouraged to pace the activities of daily living; this is expected for a client diagnosed with asthma, so the LPN could care for this client.** 3. Confusion could be a sign of decreased oxygen to the brain and requires the RN’s expertise. This client should not be assigned to LPN. 4. The client’s mother requires teaching, which is the nurse’s responsibility and cannot be assigned to a LPN. 5. **A pulse oximetry level of 95% is normal, so this client could be assigned to an LPN.**

Question 44

The charge nurse is making rounds. Which client should the nurse assess first? 1. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude. 2. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities. 3. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL. 4. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.

Answer 44

1. **The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have expected and non–life-threatening situations.** 2. Two (2)+ edema of the lower extremities is expected in a client diagnosed with heart failure. 3. A blood glucose reading of 189 mg/dL is not within normal range, but it is not in a range indicating the client is catabolizing the fats and proteins in the body. No ke- tones will be produced at this blood glucose level, so the ketoacidosis has resolved itself. 4. Most clients diagnosed with COPD are receiving oxygen at a low level.

Question 45

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warm-up exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

Answer 45

1. Rescue inhalers are used to treat attacks, not prevent them, so this should not be administered prior to exercising. 2. Warm-up exercises decrease the risk of developing an asthma attack. 3. **Using a bronchodilator immediately prior to exercising will help reduce bronchospasms.** 4. Monosodium glutamate, a food preservative, has been shown to initiate asthma attacks.

Question 46

The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for 15 seconds before swallowing. 4. Take the medication immediately when an attack starts.

Answer 46

1. This applies to systemically administered steroids, not to inhaled steroids. 2. **The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth (oral candidiasis).** 3. Holding the medication in the mouth increases the risk of an oral yeast infection, and the medication is inhaled, not swallowed. 4. Inhaled steroids are not used first; the beta-adrenergic inhalers are used for acute attack.

Question 47

The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse.

Answer 47

1. A child with asthma can eat a regular diet if the child is not allergic to the components of the diet. 2. **Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack.** 3. The stem did not indicate the child is developmentally delayed. 4. The child does not require a home health nurse solely on the basis of asthma; the school nurse or any child-care provider should be informed of the child’s diagnosis, and the parents must know the individual caring for the child is prepared to inter- vene during an attack.

Question 48

The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions? 1. “I will call 911 if my medications don’t control an attack.” 2. “I should wash my bedding in warm water.” 3. “I can still eat at the Chinese restaurant when I want.” 4. “If I get a headache, I should take a nonsteroidal anti-inflammatory drug.”

Answer 48

1. **The client must be able to recognize a life-threatening situation and initiate the correct procedure.** 2. Bedding is washed in hot water to kill dust mites. 3. Many Chinese dishes are prepared with monosodium glutamate, an ingredient that can initiate an asthma attack. 4. Nonsteroidal anti-inflammatory medica- tions, aspirin, and beta blockers have been known to initiate asthma attacks.

Question 49

The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease? 1. The client worked with asbestos for a short time many years ago. 2. The client has no family history for this type of lung cancer. 3. The client has numerous tattoos covering both upper and lower arms. 4. The client has smoked two (2) packs of cigarettes a day for 20 years.

Answer 49

1. Working with asbestos is significant for mesothelioma of the lung, a cancer with a very poor prognosis, but not for small cell carcinoma. 2. Family history is not the significant risk factor for small cell carcinoma. Smoking is the number-one risk factor. 3. Tattoos may be implicated in the develop- ment of blood-borne pathogen disease (if sterile needles were not used), but they do not have any association with cancer. 4. **Smoking is the number-one risk factor for developing cancer of the lung. More than 85% of lung cancers are attributable to inhalation of chemicals. There are more than 400 chemicals in each puff of cigarette smoke, 17 of which are known to cause cancer.**

Question 50

The nurse writes a problem of “impaired gas exchange” for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply. 1. Apply O2 via nasal cannula. 2. Have the dietitian plan for six (6) small meals per day. 3. Place the client in respiratory isolation. 4. Assess vital signs for fever. 5. Listen to lung sounds every shift.

Answer 50

1. **Respiratory distress is a common finding in clients diagnosed with lung cancer. As the tumor grows and takes up more space or blocks air movement, the client may need to be taught positioning for lung expansion. The administration of oxygen will help the client to use the lung capacity that is available to get oxygen to the tissues.** 2. **Clients with lung cancer frequently be- come fatigued trying to eat. Providing six (6) small meals spaces the amount of food the client eats throughout the day.** 3. Cancer is not communicable, so the client does not need to be in isolation. 4. **Clients with cancer of the lung are at risk for developing an infection from lowered resistance as a result of treatments or from the tumor blocking secretions in the lung. Therefore, monitoring for the presence of fever, a possible indication of infection, is important.** 5. **Assessment of the lungs should be completed on a routine and PRN basis**

Question 51

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Question 52

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse? 1. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup. 2. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table. 3. The client receiving Procrit, a biologic response modifier, has a T 99.2 ̊F, P 68, RR 24, and BP of 198/102. 4. The client receiving prednisone, a steroid, is complaining of an upset stomachafter eating breakfast.

Answer 52

1. This is expected from this client and does not warrant immediate attention. 2. This is called a three (3)-point stance. It is a position many clients with lung disease will assume because it assists in the expansion of the lung. 3. **Biologic response modifiers stimulate the bone marrow and can increase the client’s blood pressure to dangerous levels. This BP is high and warrants immediate attention.** 4. This client can be seen after taking care of the client in “3.” The nurse should intervene, but it is not a life-threatening situation.

Question 53

The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement? 1. Discuss implementing an advance directive. 2. Explain the use of chemotherapy for brain involvement. 3. Teach the client to discontinue driving. 4. Have the significant other make decisions for the client.

Answer 53

1. **This situation indicates a terminal process, and the client should make decisions for the end of life.** 2. Radiation therapy is used for tumors in the brain. Chemotherapy as a whole will not cross the blood–brain barrier. 3. There is no indication the client cannot drive at this point. Clients may develop seizures from the tumors at some point. 4. The client should make decisions for himself or herself as long as possible. However, the client should discuss personal wishes with the person named in an advance directive to make decisions.

Question 54

The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach? 1. Investigational regimens provide a better chance of survival for the client. 2. Investigational treatments have not been proven to be helpful to clients. 3. Clients will be paid to participate in an investigational program. 4. Only clients who are dying qualify for investigational treatments.

Answer 54

1. If the investigational regimen proves to be effective, then this statement is true. However, many investigational treatments have not proved to be efficacious. 2. **Investigational treatments are just that—treatments being investigated to determine if they are effective in the care of clients diagnosed with cancer. There is no guarantee the treatments will help the client.** 3. Clients receive medical care and associated treatments and laboratory tests at no cost, but the client is not paid. Paying the client is unethical. 4. Frequently clients who have failed standard treatments and who have no other hope of a treatment are the clients involved in investigational protocols, but the protocols can be used for any client who volunteers for investigational treatment.

Question 55

The nursing staff on an oncology unit are interviewing applicants for the unit manager position. Which type of organizational structure does this represent? 1. Centralized decision making. 2. Decentralized decision making. 3. Shared governance. 4. Pyramid with filtered-down decisions.

Answer 55

1. A centralized system of organization means decisions are made at the top and given to the staff underneath to accept and implement. 2. A decentralized decision-making pattern means there is a fairly flat accountability chart. The unit manager has more auton- omy in managing the unit, but this does not mean the staff has input into decisions. 3. **Shared governance is a system where the staff is empowered to make decisions such as scheduling and hiring of certain staff. Staff members are encouraged to participate in developing policies and procedures to reach set goals.** 4. A pyramid decision-making tree is an example of a centralized system.

Question 56

The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates more teaching is required? 1. “It doesn’t matter if I smoke now. I already have cancer.” 2. “I should see the oncologist at my scheduled appointment.” 3. “If I begin to run a fever, I should notify the HCP.” 4. “I should plan for periods of rest throughout the day.”

Answer 56

1. **Research indicates smoking will still interfere with the client’s response to treatment, so more teaching is needed.** 2. It is expected for the client to follow up with a specialist regarding subsequent treatment; therefore, the client does not need more teaching. 3. Clients diagnosed with cancer and under- going treatment are at risk for developing infections, so more teaching is not needed. 4. Lung cancers produce fatigue as a result of physiological drains on the body in the areas of lack of adequate oxygen to the tissues, the tumor burden on the body, and the toll taken by the effects of the treat- ments. Cancer-related fatigue syndrome is a very real occurrence, so the client understands the teaching.

Question 57

The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation? 1. The client uses Vicks VapoRub every night before bed. 2. The client has had an appendectomy. 3. The client takes a multiple vitamin pill every day. 4. The client has been coughing up blood in the mornings.

Answer 57

1. This is an individual cultural/familial situation and should be encouraged unless it interferes with the medical treatment plan. The nurse should be nonjudgmental when clients discuss their cultural practices if the nurse expects the clients to be honest about health practices. 2. An appendectomy in the past should be documented, but no further information is required. 3. Many clients take a multivitamin, so this would not warrant intervention. 4. **Coughing up blood is not normal and is cause for investigation. It could indicate lung cancer.**

Question 58

The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse? 1. The client has an intake of 1,500 mL IV and an output of 1,000 mL. 2. The client has 450 mL of bright-red drainage in the chest tube. 3. The client is complaining of pain at a “10” on a 1-to-10 scale. 4. The client has absent lung sounds on the side of the surgery.

Answer 58

1. This is an adequate output. After a major surgery, clients will frequently have an intake greater than the output because of the fluid shift occurring as a result of trauma to the body. 2. **This is about a pint of blood loss and could indicate the client is hemorrhaging.** 3. The nurse should intervene and medicate the client, but pain, although a client comfort issue, is not life threatening. 4. The client will have a chest tube to assist in reinflation of the lung, and absent lung sounds are expected at this point in the client’s recovery.

Question 59

The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach? 1. The test will confirm the results of the MRI. 2. The client can eat and drink immediately after the test. 3. The HCP can do a biopsy of the tumor through the scope. 4. There is no discomfort associated with this procedure.

Answer 59

1. A bronchoscopy is not performed to confirm another test; it is performed to confirm diagnoses, such as cancer, Pneumocystis pneumonia, tuberculosis, fungal infections, and other lung diseases. 2. The client’s throat will be numbed with a local anesthetic to prevent gagging during the procedure. The client will not be able to eat or drink until this medication has worn off. 3. **The HCP can take biopsies and perform a washing of the lung tissue for pathological diagnosis during the procedure.** 4. Most HCPs use an anesthetic procedure called twilight sleep to perform endoscopies, but there is no guarantee the client will not experience some discomfort.

Question 60

The client diagnosed with oat cell carcinoma of the lung tells the nurse, “I am so tired of all this. I might as well just end it all.” Which statement should be the nurse’s first response? 1. Say, “This must be hard for you. Would you like to talk?” 2. Tell the HCP of the client’s statement. 3. Refer the client to a social worker or spiritual advisor. 4. Find out if the client has a plan to carry out suicide.

Answer 60

1. The nurse might enter into a therapeutic conversation, but client safety is the priority. 2. The nurse must first assess the seriousness of the client’s statement and whether he or she has a plan to carry out suicide. Depending on the client’s responses, the nurse will notify the HCP. 3. The client can be referred for assistance in dealing with the disease and its ramifications, but this is not the priority. 4. **The priority action anytime a client makes a statement regarding taking his or her own life is to determine if the client has thought it through enough to have a plan. A plan indicates an emergency situation.**

Question 61

The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach? 1. Demonstrate the proper method of gargling with normal saline. 2. Perform voice exercises for 30 minutes three (3) times a day. 3. Explain that a lighted instrument will be placed in the throat to biopsy the area. 4. Teach the client to self-examine the larynx monthly.

Answer 61

1. Gargling with salt water is good for sore throats, but it does not diagnose cancer of the larynx. 2. Clients thought to have a vocal cord prob- lem are encouraged to practice voice rest. Vocal cord exercises would not assist in the diagnosis of cancer. 3. **A laryngoscopy will be performed to allow for visualization of the vocal cords and to obtain a biopsy for pathological diagnosis.** 4. There is no monthly self-examination of the larynx. To visualize the vocal cords, the HCP must numb the throat and pass a fiberoptic instrument through the throat and into the trachea.

Question 62

The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. Which prophylactic procedure will the nurse prepare the client for? 1. Removal of the client’s teeth and fitting for dentures. 2. Take antiemetic medications every four (4) hours. 3. Wear sunscreen on the area at all times. 4. Placement of a nasogastric feeding tube.

Answer 62

1. **The teeth will be in the area of radiation and the roots of teeth are highly sensitive to radiation, which results in root abscesses. The teeth are removed and the client is fitted for dentures prior to radiation.** 2. An antiemetic on a routine scheduled basis is prophylactic for nausea, and the schedule is 30 minutes before a meal. Radiation to the throat does not encompass nausea- producing areas. 3. Sunscreen is used to prevent the penetration of ultraviolet (UV) rays into the dermis. Radiation is gamma rays. 4. The client may receive a PEG tube for severe esophagitis from irradiation of the esophagus. The client does not have a nasogastric tube.

Question 63

The client is three (3) days post–partial laryngectomy. Which type of nutrition should the nurse offer the client? 1. Total parenteral nutrition. 2. Soft, regular diet. 3. Partial parenteral nutrition. 4. Clear liquid diet.

Answer 63

1. The client is three (3) days postopertive partial removal of the larynx and should be eating by this time. 2. **The client should be eating normal foods by this time. The consistency should be soft to allow for less chewing of the food and easier swallowing because a portion of the throat musculature has been removed. The client should be taught to turn the head toward the affected side when swallowing to help prevent aspiration.** 3. The client should be capable of enteral nutrition at this time. 4. The client should have progressed to a diet with a more normal consistency and amount.

Question 64

The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse’s priority? 1. Take the client to the intensive care unit for a visit. 2. Explain that the client will need to ask for pain medication. 3. Demonstrate the use of an antiembolism hose. 4. Find out if the client can read and write.

Answer 64

1. This is an appropriate preoperative intervention, but it is not priority. 2. The client should be taught about pain medication administration, but this is not the highest priority. 3. The client should be told about an antiembolism hose, but it is not necessary to demonstrate the hose because the nurse will apply and remove the hose initially. 4. **The client is having the vocal cords removed and will be unable to speak. Communication is a high priority for this client. If the client is able to read and write, a Magic Slate or pad of paper should be provided. If the client is illiterate, the nurse and the client should develop a method of communication using pictures.**

Question 65

The client has had a total laryngectomy. Which referral is specific for this surgery? 1. CanSurmount. 2. Dialogue. 3. Lost Chord Club. 4. SmokEnders.

Answer 65

1. CanSurmount is a program of cancer survivors who volunteer to talk to clients about having cancer or what the treatments involve. This group is based on the success of Reach to Recovery for breast cancer, but it is not specific to a particular cancer. 2. Dialogue is a cancer support group that brings together clients diagnosed with cancer to discuss the feelings associated with having cancer. 3. **The Lost Chord Club is an American Cancer Society–sponsored group of survivors of larynx cancer. These clients are able to discuss the feelings and needs of clients who have had laryngectomies because they have all had this particular surgery.** 4. SmokEnders is a group of clients working together to stop smoking. It is a group where anyone who smokes could be referred.

Question 66

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a surgical floor. Which information provided by the UAP requires immediate intervention by the nurse? 1. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection. 2. The client who has had a right upper lobectomy is complaining that the patient-controlled analgesia (PCA) pump is not providing any relief. 3. The client diagnosed with cancer of the lung is complaining of being tired and short of breath. 4. The client admitted with chronic obstructive pulmonary disease is making a whistling sound with every breath.

Answer 66

1. **The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. Continuous bright-red drainage indicates bleeding, and this client should be assessed immediately.** 2. Pain is a priority but not over hemorrhaging. 3. Clients with cancer of the lung have fatigue and are short of breath; these are expected findings. 4. Clients with chronic lung problems are taught pursed-lip breathing to assist in expelling air. This type of breathing often produces a whistling sound.

Question 67

The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with cancer of the lung who has chest tubes. 2. The client diagnosed with laryngeal spasms who has stridor. 3. The client diagnosed with laryngeal cancer who has multiple fistulas. 4. The client who is two (2) hours post–partial laryngectomy.

Answer 67

1. **Chest tubes are part of the nursing education curriculum. The new graduate should be capable of caring for this client or at least knowing when to get assistance.** 2. This client is in respiratory compromise, and an experienced nurse should care for the client. 3. A client with multiple fistulas in the neck area is at high risk for airway compromise and should be assigned to a more experienced nurse. 4. This client is at risk for developing edema of the neck area and should be cared for by a more experienced nurse.

Question 68

The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority? 1. Wound infection. 2. Hemorrhage. 3. Respiratory distress. 4. Knowledge deficit.

Answer 68

1. Wound infection is a concern, but in the list of the answer options it is not the highest priority. A wound infection can be treated, but a client who is not breathing is in a life-threatening situation and the problem must be addressed immediately. 2. Hemorrhage is normally a priority, but bleeding is not priority over not breathing. 3. **Respiratory distress is the highest pri- ority. Hemorrhaging and infection are serious problems, but airway is priority.** 4. Knowledge deficit is the lowest on this priority list. It is a psychosocial problem, and these problems rank lower in priority than physiological ones.

Question 69

The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image? 1. The client requests a consultation by the speech therapist. 2. The client has a towel placed over the mirror. 3. The client is attempting to shave himself. 4. The client practices neck and shoulder exercises.

Answer 69

1. This request indicates the client is accepting the situation and trying to deal with it. 2. **Placing a towel over the mirror indicates the client is having difficulty looking at his reflection, a body-image problem.** 3. In attempting to shave himself, the client is participating in self-care activities and also must look at his neck in the mirror, both good steps toward adjustment. 4. Neck and shoulder exercises are done to strengthen the remaining musculature, but they have nothing to do with body image

Question 70

The HCP has recommended a total laryngectomy for a male client diagnosed with cancer of the larynx but the client refuses. Which intervention by the nurse illustrates the ethical principle of nonmalfeasance? 1. The nurse listens to the client explain why he is refusing surgery. 2. The nurse and significant other insist that the client have the surgery. 3. The nurse refers the client to a counselor for help with the decision. 4. The nurse asks a cancer survivor to come and discuss the surgery with the client.

Answer 70

1. **This is an example of nonmalfeasance, where the nurse “does no harm.” In at- tempting to discuss the client’s refusal, the nurse is not trying to influence the client; the nurse is merely attempting to listen therapeutically.** 2. This is an example of paternalism, telling the client what he should do, and it is also coercion, an unethical action. 3. This is an example of beneficence, “to do good”; it is a positive action and a step up from nonmalfeasance. 4. This is an example of beneficence.

Question 71

The client diagnosed with cancer of the larynx has had four (4) weeks of radiation therapy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain? 1. The cancer has grown to obstruct the esophagus. 2. The treatments are working on the cancer and the throat is edematous. 3. Cancers are painful and this is expected. 4. The treatments are also affecting the esophagus, causing ulcerations.

Answer 71

1. The cancer may have grown, but this would not be indicated by the type of pain described. 2. Painful swallowing is caused by esophageal irritation. 3. Most cancers are not painful unless obstructing an organ or pressing on a nerve. This is not what is being described. 4. **The esophagus is extremely radiosensitive, and esophageal ulcerations are common. The pain can become so severe the client cannot swallow saliva. This is a situation in which the client will be admitted to the hospital for IV narcotic pain medication and possibly total parenteral nutrition.**

Question 72

The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply. 1. The client will be able to speak again after the surgery area has healed. 2. The client should wear a protective covering over the stoma when showering. 3. The client should clean the stoma and then apply a petroleum-based ointment. 4. The client should use a humidifier in the room. 5. The client can get a special telephone for communication.

Answer 72

1. This surgery removed the client’s vocal cords, so he or she will not be able to speak again unless the client learns esophageal speech, uses an electric larynx, or has a surgically created transesophageal puncture. 2. **The client breathes through a stoma in the neck. Care should be taken not to allow water to enter the stoma.** 3. The stoma should be cleaned, but petroleum-based products should not be allowed near the stoma. A petroleum- based product is contraindicated because it is not water-soluble, could contribute to an occlusion, and is flammable. 4. **The client has lost the use of the nasal passages to humidify the inhaled air, and artificial humidification is useful until the client’s body adapts to the change.** 5. **Special equipment is available for clients who cannot hear or speak.**

Question 73

The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? \_\_\_\_\_\_\_\_

Answer 73

**880 units.** If there are 20,000 units of heparin in 500 mL of D5W, there are 40 units in each mL: 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour: 40 × 22 = 880

Question 74

The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging.

Answer 74

1. **The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis.** 2. An ABG evaluates oxygenation level, but it does not diagnose a pulmonary embolus (PE). 3. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 4. An MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus.

Question 75

Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

Answer 75

1. This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a sign of a pulmonary embolism. 2. **The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath.** 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications, but not specifically a pulmonary embolism.

Question 76

The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data warrant immediate intervention from the nurse? 1. The client’s ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client’s telemetry exhibits occasional premature ventricular contractions. 3. The client’s pulse oximeter reading is 90%. 4. The client’s urinary output for the 12-hour shift is 800 mL.

Answer 76

1. The ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contrac- tions are not unusual for any client and would not warrant immediate intervention. 3. **The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60.** 4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/hour and would not warrant immediate intervention by the nurse.

Question 77

The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client’s bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

Answer 77

1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client’s respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. 4. **Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs.**

Question 78

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

Answer 78

1. The client would not be experiencing abnormal bleeding with this INR. 2. This is the antidote for an overdose of anticoagulant and the INR does not indicate this. 3. **A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication.** 4. There is no need to increase the dose; this result is within the therapeutic range.

Question 79

The nurse identified the client problem “decreased cardiac output” for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client’s arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

Answer 79

1. Arterial blood gases would be included in the client problem “impaired gas exchange.” 2. **These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output.** 3. This would be appropriate for the client problem “high risk for bleeding.” 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing.

Question 80

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

Answer 80

1. **Heparin is administered during throm- bolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant.** 2. Firm pressure reduces the risk for bleeding into the tissues. 3. **Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for.** 4. **Invasive procedures increase the risk of tissue trauma and bleeding.** 5. **Stool softeners help prevent constipa- tion and straining, which may precipitate bleeding from hemorrhoids.**

Question 81

Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. “I am going to use a regular-bristle toothbrush.” 2. “I will take antibiotics prior to having my teeth cleaned.” 3. “I can take enteric-coated aspirin for my headache.” 4. “I will wear a Medic Alert band at all times.”

Answer 81

1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding, so the teaching is not effective. 2. This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy, so the teaching is not effective. 3. Aspirin, enteric-coated or not, is an antiplatelet, which may increase bleeding tendencies and should be avoided, so the teaching is not effective. 4. **The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy. The client understands the teaching.**

Question 82

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

Answer 82

1. **Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE.** 2. Pulmonary emboli are not caused by atherosclerosis; this is not an appropriate discharge instruction for a client with a pulmonary embolus. 3. Infection does not cause a PE; this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism.

Question 83

The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

Answer 83

1. An INR of 2 to 3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; therefore, the nurse should administer the insulin. 3. **A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clotting and the medication should be held.** 4. This is a normal blood pressure and the nurse should administer the medication.

Question 84

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler’s position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client’s lung sounds.

Answer 84

1. The client needs oxygen, but the nurse can intervene to help the client before applying oxygen. 2. **Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system.** 3. A pulse oximeter reading is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation.

Question 85

The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

Answer 85

1. The client with pneumothorax has absent breath sounds and tachypnea. 2. **Unequal lung expansion and dyspnea indicate a pneumothorax.** 3. Consolidation occurs when there is no air moving through the alveoli, as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease.

Question 86

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client’s pulse oximeter reading.

Answer 86

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. **The key to the answer is “2 hours.” The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop.** 4. The stem does not state the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment.

Question 87

Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn’t take deep breaths, he could die.

Answer 87

1. **The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis.** 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing.

Question 88

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

Answer 88

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. 2. **The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP.** 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than staying in the bed, so no action would be needed

Question 89

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client’s respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

Answer 89

1. The health-care provider will have to be notified, but this is not the first interven- tion. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. **Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.**

Question 90

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

Answer 90

1. This statement describes a spontaneous pneumothorax. 2. This statement describes an open pneumothorax. 3. **This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.** 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but the statement does not describe a tension pneumothorax.

Question 91

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

Answer 91

1. **Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.** 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water-seal compartment. The chest tube is never stripped, which creates a negative air pressure and could suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.

Question 92

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

Answer 92

1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 2. **At three (3) days postinsertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.** 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded.

Question 93

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler’s position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

Answer 93

1. The client should be in the high Fowler’s position to facilitate lung expansion. 2. **The system must be patent and intact to function properly.** 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. **Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube.** 5. **Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.**

Question 94

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post–bronchoscopy procedure.

Answer 94

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore, the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. 4. **A client two (2) hours post– bronchoscopy procedure could safely be assigned to an LPN.**

Question 95

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

Answer 95

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client’s bedside, but it is not the first intervention. 2. **The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client.** 3. This is a correct position to place the client in for a chest tube insertion, but it is not the first intervention. 4. The health care provider will discuss the procedure with the client, then informed consent must be obtained, and the nurse can do further teaching.

Question 96

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client’s bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client’s chart.

Answer 96

1. **Assessment of the lung sounds could indicate the client’s lung has reexpanded because it has been three (3) days since the chest tube has been inserted.** 2. This should be done to ensure the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention.

Question 97

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

Answer 97

1. **The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.** 2. The bed should be at a comfortable height for the UAP to bathe the client, not in the lowest position. 3. The UAP can bathe a client without assis- tance if the client’s safety can be ensured. 4. The UAP is not ensuring the client’s safety because the opposite side rail is not elevated to prevent the client from falling out of the bed.

Question 98

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client’s arterial blood gas results.

Answer 98

1. Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is appropriate, but it is not the first intervention. 2. Making sure alarms are functioning properly is appropriate, but checking a machine is not priority. 3. **Assessment is the first part of the nurs- ing process and is the first intervention the nurse should implement when caring for a client on a ventilator.** 4. Monitoring laboratory results is an appropriate intervention for the client on a ventilator, but monitoring laboratory data is not the priority intervention.

Question 99

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

Answer 99

1. **The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.** 2. These are early signs of ARDS, but they could also indicate pneumonia, atelectasis, and other pulmonary complications, so they do not confirm the diagnosis of ARDS. 3. Clear breath sounds and the oxygen saturation indicate the client is not experiencing any respiratory difficulty or compromise. 4. These are signs of congestive heart failure; ARDS is noncardiogenic (without signs of cardiac involvement) pulmonary edema.

Question 100

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, “What is happening to me? Why did I get this?” Which statement by the nurse is most appropriate? 1. “Most people who almost drown end up developing ARDS.” 2. “Platelets and fluid enter the alveoli due to permeability instability.” 3. “Your lungs are filling up with fluid, causing breathing problems.” 4. “Smoking has caused your lungs to become weakened, so you got ARDS.”

Answer 100

1. This is an incorrect statement. ARDS has multiple etiologies, such as hemorrhagic shock, septic shock, drug overdose, burns, and near-drowning. Many people with near-drowning do not develop ARDS. 2. The layperson may not know what the term alveoli means, and the near-drowning is the initial insult that caused the ARDS. 3. **This is a basic layperson’s terms explanation of ARDS and explains why the client is having trouble breathing.** 4. Smoking does not increase the risk of developing ARDS. The etiology is unknown, but an initial insult occurs 24 to 48 hours before the development of ARDS.

Question 101

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client’s urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

Answer 101

1. A urine output of 30 mL/hr indicates the kidneys are functioning properly. 2. This indicates the client is being adequately oxygenated. 3. **Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.** 4. An increased heart rate does not indicate a complication; this could result from numerous reasons, not specifically because of the ventilator.

Question 102

The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

Answer 102

1. **These arterial blood gases are within normal limits, and therefore the nurse should not take any action except to continue to monitor the client.** 2. The nurse would recommend deep breaths and coughing if the client’s ABGs revealed respiratory acidosis. 3. Sodium bicarbonate is administered when the client is in metabolic acidosis. 4. This is a normal ABG and the respiratory therapist does not need to be notified.

Question 103

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

Answer 103

1. Alternating the ET tube position will help prevent a pressure ulcer on the client’s tongue and mouth. 2. A CXR is performed immediately after insertion of the ET tube, but not daily. 3. The cuff should be inflated but no more than 25 cm H2O to ensure no air leakage, and must be checked every 4 to 8 hours, not daily. 4. **The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.**

Question 104

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

Answer 104

1. Unless the initial insult is an infection, an aminoglycoside antibiotic would not be a medication the nurse would anticipate being ordered. 2. **Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.** 3. A potassium cation, such as Kayexalate, helps remove potassium from the bloodstream in the gastrointestinal tract and would not be prescribed for a client with ARDS. 4. NSAIDs are under investigation for treating ARDS because they block the inflammatory response, but the nurse should not anticipate this being prescribed by the health-care provider.

Question 105

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client’s lung sounds.

Answer 105

1. The nurse must first address the client’s acute respiratory distress and then notify other members of the multidisciplinary team. 2. **If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved.** 3. The nurse must first address the client’s respiratory distress before requesting any laboratory data. 4. Assessment is not always priority. In this situation, the client is in obvious acute respiratory distress; therefore, the nurse needs to intervene to help the client breathe.

Question 106

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client’s level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler’s position.

Answer 106

1. **Altered level of consciousness is the earliest sign of hypoxemia.** 2. Urine output of less than 30 mL/hr indicates decreased cardiac output, which requires immediate intervention; it should be assessed every one (1) or two (2) hours, not once during a shift. 3. **The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers.** 4. **The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake.** 5. **Fowler’s position facilitates lung expansion and reduces the workload of breathing.**

Question 107

Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate.

Answer 107

1. **Not smoking is vital to prevent further lung damage.** 2. The client should get vaccines to help prevent further episodes of serious respiratory distress. 3. Avoiding alcohol intake is appropriate for many serious illnesses, but it is not the most important when discussing ARDS. 4. It usually takes about six (6) months to recover maximal respiratory function after ARDS.

Question 108

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

Answer 108

1. **When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, “bucking” in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.** 2. The alarm may indicate the client needs suctioning, but the nurse should always do the least invasive procedure when troubleshooting a ventilator alarm. 3. The lip line on the ET tube determines how far the ET tube is in the trachea. It should always stay at the same number, but it would not have anything to do with the ventilator alarms. 4. This may be needed, but the nurse should not sedate the client unless absolutely necessary.