UNIT H-Clients with complex respiratory problems

Question 1

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and
identifies that the client has a 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a. Tell the client that he or she needs to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and marijuana
use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.

Answer 1

ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.

Question 2

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider
immediately.
d. Client’s respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

Answer 2

ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by
decreased or absent breath sounds. The primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. If the
client’s heart rate is 55 beats/min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the
oxygen flow rate.

Question 3

A nurse assesses a client’s respiratory status. Which information is most important for the
nurse to obtain?
a. Average daily fluid intake.
b. Neck circumference.
c. Height and weight.
d. Occupation and hobbies.

Answer 3

ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in
a client’s occupation and hobbies. Although it will be important for the nurse to assess the
client’s fluid intake, height, and weight, these will not be as important as determining his
occupation and hobbies. This is part of the I-PREPARE assessment model for particulate
matter exposure. Determining the client’s neck circumference will not be an important part of
a respiratory assessment.

Question 4

A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral
chest diameter. Which question would the nurse ask the client in response to this finding?
a. “Are you taking any medications or herbal supplements?”
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”

Answer 4

ANS: B
The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral
(side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches
the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem,
such as chronic emphysema. It can also be seen in people who have lived at a high altitude for
many years. Medications, herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client to irritants that can cause
chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first.

Question 5

A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds
are absent. While another nurse calls the Rapid Response Team, what action by the nurse
takes is most important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.

Answer 5

ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication
after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry
reading and perform other respiratory assessments. Temperature is not a priority. The nurse
can ask about other symptoms while conducting the assessment. The nurse would assess the
biopsy site and/or dressings, but this is not the first action.

Question 6

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention
would the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.

Answer 6

ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The
nurse would ensure signed informed consent has been obtained. Verifying that the client
understands complications and explaining the procedure to be performed will be done by the
primary health care provider, not the nurse. Measurement of oxygen saturation before and
after a 12-minute walk is not a procedure unique to a thoracentesis.

Question 7

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate
action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck.

Answer 7

ANS: D
A shift of central thoracic structures toward one side is a sign of a tension pneumothorax,
which is a medical emergency. The other findings are normal or near normal. The nurse
would report this finding immediately or call the Rapid Response Team.

Question 8

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of

water. What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.

Answer 8

ANS: C
The topical anesthetic used during the procedure will have affected the client’s gag reflex.
Before allowing the client anything to eat or drink, the nurse must check for the return of this
reflex.

Question 9

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times
when climbing a flight of stairs. Which intervention would the nurse include in this client’s
plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning

Answer 9

ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs
without pausing has class IV dyspnea. The nurse would provide assistance with activities of
daily living. These clients would be encouraged to participate in activities as tolerated. They
would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only
need oxygen if hypoxia is present.

Question 10

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement
would the nurse include in this client’s teaching?
a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
d. “Stopping this medication suddenly increases your risk for a heart attack.”

Answer 10

ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of
stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The
nurse would encourage the client to make a list of reasons for stopping the habit but would not
phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement
therapy. Stopping suddenly does not increase the risk of heart attack.

Question 11

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
The client presents with continuous cyanosis even with oxygen therapy. What action would
the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.

Answer 11

ANS:B
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an
adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify
the Rapid Response Team to provide advanced care. An albuterol treatment would not address
the client’s oxygenation problem. Assessment of pulses and cultures will not provide data
necessary to treat the client.

Question 12

A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action
would the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.

Answer 12

ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
finding over the trachea and larynx. The nurse would document this finding. There is no need
to implement oxygen therapy, administer albuterol, or change the client’s position because the
finding is normal.

Question 13

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or
symptoms would the nurse identify as adverse effects of this medication? (Select all that
apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Manic behavior
e. Increased thirst
f. Orangish urine

Answer 13

ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and
hallucinations. The nurse would assess for changes in behavior and thought processes,
including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and
orange-colored urine are not adverse effects of this medication. Decreased cravings are a
therapeutic response to this medication.

Question 14

While obtaining a client’s health history, the client states, “I am allergic to avocados, molds,
and grass.” Which responses by the nurse are best? (Select all that apply.)
a. “What happens when you are exposed to those things?
b. “How do you treat these allergies?”
c. “When was the last time you ate foods containing avocados?”
d. “I will document this in your record so all so everyone knows.”
e. “Have you ever been in the hospital after an allergic response?”
f. “How do manage to avoid grass and mold?”

Answer 14

ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response
to treatment. The nurse would also document the allergies in a prominent place in the client’s
medical record. Asking about the last time the client ate avocados does not provide any
pertinent information for the client’s plan of care. Asking how a client manages to avoid
environmental allergies in this fashion also does not provide any pertinent information.

Question 15

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
for a client. Which statements would the nurse include in communications with the respiratory
therapist prior to the tests? (Select all that apply.)
a. “I held the client’s morning bronchodilator medication.”
b. “The client is ready to go down to radiology for this examination.”
c. “Physical therapy states the client can run on a treadmill.”
d. “I advised the client not to smoke for 6 hours prior to the test.”
e. “The client is alert and can follow your commands.”

Answer 15

ANS: A, D, E
To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have
been administered in the past 4 to 6 hours (depending on the suspected cause), the client did
not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands,
including different breathing maneuvers. The respiratory therapist can perform PFTs at the
bedside or the respiratory lab. A treadmill is not used for this test.

Question 16

A nurse teaches a client who is interested in smoking cessation. Which statements would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Find an activity that you enjoy and will keep your hands busy.”
b. “Keep snacks like potato chips on hand to nibble on.”
c. “Identify a consequence for yourself in case you backslide.”
d. “Drink at least eight glasses of water each day.”
e. “Make a list of reasons you want to stop smoking.”
f. “Set a quit date and stick to it.”

Answer 16

ANS:A,D,E,F
The nurse would teach a client who is interested in smoking cessation to find an activity that
keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight
glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit
date and stick to it. The nurse would also encourage the client not to be upset if he or she
backslides and has a cigarette but to try to determine what conditions caused him or her to
smoke.

Question 17

A nurse is assessing a client’s history of particular matter exposure. What questions are
consistent with the I PREPARE tool? (Select all that apply.)
a. Investigate all history of known exposures.
b. Determine if breathing problems are worse at work.
c. Ask the client what type of heating is in the home.
d. Gather details about the geographic location of the client’s home.
e. Have client list all previous jobs and work experiences.
f. Assess what hobbies the client and family enjoy.

Answer 17

ANS: A, B, C, D, E, F
All questions are appropriate for the I PREPARE model of particulate matter exposure. The R
and final E stands for resources/referrals and educate.

Question 18

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings
would alert the nurse to a potential pneumothorax? (Select all that apply.)
a. Bradycardia
b. New-onset cough
c. Purulent sputum
d. Tachypnea
e. Pain with respirations
f. Rapid, shallow respirations

Answer 18

ANS: B, D, E
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough,
and pain that is worse at the end of inhalation and the end of exhalation on the affected side.
Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected
side of the chest that does not move in and out with respirations. Purulent sputum is a
symptom of infection.

Question 19

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy
procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)
a. Provide a clear liquid breakfast.
b. Verify that the informed consent was obtained.
c. Document the client’s allergies.
d. Review laboratory results.
e. Hold the client’s bronchodilator.
f. Monitor the client for at least 24 hours afterwards.

Answer 19

ANS: B, C, D, F
Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep
the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent
aspiration, document allergies, and review laboratory results including complete blood count
and bleeding times. There is no reason to hold the client’s bronchodilator prior to this
procedure. The nurse will monitor the client at least every 4 hours for 24 hours.

Question 20

A nurse caring for a client removes the client’s oxygen as prescribed. The client is now
breathing what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%

Answer 20

ANS: B

Oxygen content of atmospheric or “room air” is about 21%.

Question 21

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is
the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure that informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.

Answer 21

ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be
on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required
but do not take priority.

Question 22

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
a. Assess the client’s oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.

Answer 22

ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the client’s oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

Question 23

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client’s bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.

Answer 23

ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food particles seen in secretions or
by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a
swallow study will not correct this situation.

Question 24

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse is
best?
a. Assess the client’s lung sounds.
b. Assign a different AP to the client.
c. Report the AP to the manager.
d. Request thicker liquids for meals.

Answer 24

ANS: A
The best action is to check the client’s oxygenation because he or she may have aspirated.
Once the client has been assessed, the nurse would notify the primary health care provider of
possible aspiration and would consult with the registered dietitian about appropriately
thickened liquids. The UAP should have reported the incident immediately, but addressing
that issue is not the immediate priority.

Question 25

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

Answer 25

ANS: C To prevent pressure injuries and for client safety, when ties are used that must be knotted, the knot would be placed at the side of the client’s neck, not in back. The other actions are appropriate.

Question 26

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

Answer 26

ANS: A Suction would only be applied while withdrawing the catheter. The other actions are appropriate.

Question 27

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

Answer 27

ANS: B Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with oxygen therapy are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.

Question 28

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client’s pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately.

Answer 28

ANS:D This client may have a tracheoinnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the primary health care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

Question 29

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client’s decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

Answer 29

ANS: B The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for disrupted self-esteem are being met. The other findings are all positive signs but do not relate to this client problem.

Question 30

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed

Answer 30

ANS: A Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen.

Question 31

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client’s oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

Answer 31

ANS:B Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary health care provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the primary health care provider about this issue. The primary health care provider would need to prescribe discontinuing oxygen if the client’s oxygen saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

Question 32

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home. f. No alcohol-based hand sanitizers are present.

Answer 32

ANS: A, B, C Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse would assess if the client allows smoking in the house, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand sanitizers are permitted.

Question 33

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Applying water-soluble lip balm to the client’s lips b. Ensuring that the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy f. Holding the new tracheostomy tube while the RN changes the ties

Answer 33

ANS: A, D The AP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity is adequate and suctioning through the tracheostomy are nursing functions. When needed, a second licensed person assists with holding the tracheostomy tube during tie changes; some hospitals require a second licensed person during the first 72 hours after placement.

Question 34

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don’t go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

Answer 34

ANS:A,D,E The client with a tracheostomy may be shy and hesitant to go out in public. The client needs to have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

Question 35

``` A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion ```

Answer 35

ANS: A, B, D, E, F The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and would be assessed. Upper arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to the ability to perform self-care.

Question 36

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply. ) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity

Answer 36

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal cannulas such as Vapotherm, which both humidifies and warms the oxygen.

Question 37

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client’s lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

Answer 37

ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

Question 38

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

Answer 38

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

Question 39

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? a. “Breathing so rapidly interferes with oxygenation.” b. “Maybe the client has respiratory distress syndrome.” c. “The blood clot interferes with perfusion in the lungs.” d. “The client needs immediate intubation and mechanical ventilation.”

Answer 39

ANS:C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

Question 40

A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.

Answer 40

For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client’s PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

Question 41

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

Answer 41

ANS: B Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

Question 42

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82  109/L) c. Red blood cell count: 4.8/mm3 (4.8  1012/L) d. White blood cell count: 8700/mm3 (8.7  109/L)

Answer 42

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

Question 43

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

Answer 43

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

Question 44

A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client’s oxygen saturation.

Answer 44

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client’s oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.

Question 45

An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure that all connections are patent. c. Listen to the client’s lung sounds. d. Suction the endotracheal tube.

Answer 45

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.

Question 46

A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

Answer 46

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.

Question 47

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

Answer 47

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

Question 48

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client’s hands. d. Sedate the client immediately.

Answer 48

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.

Question 49

A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

Answer 49

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival.

Question 50

A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is needed since the client “only has lung problems.” What response by the nurse is best? a. “It will increase the motility of the gastrointestinal tract.” b. “It will keep the gastrointestinal tract functioning normally.” c. “It will prepare the gastrointestinal tract for enteral feedings.” d. “It will prevent ulcers from the stress of mechanical ventilation.”

Answer 50

ANS: D Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent.

Question 51

``` A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines. ```

Answer 51

ANS: C The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

Question 52

A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client’s 24-hour fluid balance.

Answer 52

ANS: B Research has shown that clients with ARDS may benefit from conservative fluid therapy along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as scheduled. There is no reason to contact the provider or request an increased IV rate. The nurse can calculate the 24-hour fluid balance, but this will not influence the administration of the medication.

Question 53

A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client’s lungs are clear. What explanation does the more senior nurse provide? a. “The client is too dehydrated for moist-sounding lungs.” b. “The client hasn’t started having any bronchospasm yet.” c. “Lung edema is in the interstitial tissues, not the airways.” d. “Clients with ARDS usually have clear lung sounds.”

Answer 53

ANS: C The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can’t be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.

Question 54

A client in the emergency department has several broken ribs and reports severe pain. What care measure will best promote comfort? a. Prepare to assist with intercostal nerve block. b. Humidify the supplemental oxygen. c. Splint the chest with a large ACE wrap. d. Provide warmed blankets and warmed IV fluids.

Answer 54

ANS: A Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.

Question 55

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

Answer 55

ANS: A Alteplase is a “clot-busting” agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

Question 56

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client’s chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client’s lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

Answer 56

ANS: D This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

Question 57

A new nurse asks for an explanation of “refractory hypoxemia.” What answer by the staff development nurse is best? a. “It is chronic hypoxemia that accompanies restrictive airway disease.” b. “It is hypoxemia from lung damage due to mechanical ventilation.” c. “It is hypoxemia that continues even after the client is weaned from oxygen.” d. “It is hypoxemia that persists even with 100% oxygen administration.”

Answer 57

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

Question 58

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis

Answer 58

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

Question 59

``` When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes. ```

Answer 59

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

Question 60

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

Answer 60

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client’s fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client’s anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

Question 61

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

Answer 61

ANS: A, B, C, D, F The “ventilator bundle” is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.

Question 62

A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client’s bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

Answer 62

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client’s skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

Question 63

``` The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia ```

Answer 63

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.

Question 64

A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the following are potentially correct ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures

Answer 64

ANS: A, C, E The client with ARDS who needs mechanical ventilation benefits from “open lung” and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight). Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client.

Question 65

How will the nurse expect a client’s age-related decreased skeletal muscle strength to affect gas exchange? A. Reduced gas exchange as a result of decreased alveolar surface B. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity D.Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

Answer 65

C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

Question 66

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? Difficulty swallowing Dry respiratory tract membranes Development of nasal polyps Frequent episodes of tonsillitis

Answer 66

B. Dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.

Question 67

When performing an assessment on an older client, which finding is most important for the nurse to assess further? Soft speaking voice Slight kyphoscoliosis Inability to state name and date of birth Need to rest after activity

Answer 67

D. Inability to state name and date of birth The nurse would further assess the client who is unable to state name and date of birth. The older client has a higher risk for hypoxemia than a younger client, and often becomes confused during acute respiratory conditions. The other assessment findings are considered normal age-related conditions in an older client and do not warrant additional investigation.

Question 68

How will the nurse document the client’s respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation? Coarse crackles Rhonchi Wheezes Fine crackles

Answer 68

D. Fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.

Question 69

How will the nurse document the pack-year smoking history for a client who reports smoking 3 packs of cigarettes per day for 25 years and then smoking 2 packs per day for the past 20 years? 45–pack-year 90–pack-year 115–pack-year 80–pack-year

Answer 69

C. 115–pack-year Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). 3 packs/day × 25 years = 75–pack-year, plus 2 packs/day × 20 years = 40–pack-year.

Question 70

What is the most relevant technique for the nurse to use when assessing a client for dyspnea? Checking oxygen saturation by pulse oximetry Observing the client’s rate, depth, and ease of inhalation and exhalation Comparing previous respiratory assessment information with current data Asking the client about whether any breathlessness is present

Answer 70

D. Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea. The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.

Question 71

Which precaution to prevent harm is most important for the nurse to teach a client who is newly prescribed nicotine replacement therapy (NRT)? Immediately report any change in thought process or suicide ideation because this drug can alter behavior. Avoid crowds and people who are ill because your immunity is reduced while on this drug. Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. Be sure to remain in an upright position for an hour after taking the drug to avoid esophageal reflux and ulceration.

Answer 71

Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. NRT contains nicotine and cannot be used when smoking or with nicotine use in any other form because this will greatly increase circulating nicotine levels and the risk for stroke or heart attack. NRT does not have psychotropic properties and does not increase feelings of self-harm or suicide ideation. NRT does not induce esophageal irritation or ulcers nor does it reduce immunity.

Question 72

What is the nurse’s interpretation of a 50-year-old client’s respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area? Obstruction of the larger airways Normal physical exam for a 50 year old An area of increased density Subcutaneous emphysema

Answer 72

C. An area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air. Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a “crackling” in the skin and subcutaneous tissues, not within any part of the respiratory tract

Question 73

What is the nurse’s best next question after observing that a 60-year-old client’s anteroposterior (AP) chest diameter is the same as the lateral chest diameter? “What are your hobbies?” No questions are needed regarding this normal finding. “Do you have any chronic breathing problems?” “How often do you perform aerobic exercise?

Answer 73

“Do you have any chronic breathing problems?” The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a “barrel” chest. Most commonly, a barrel chest occurs as a result of a long-term chronic airflow limitation problem such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at high altitudes for many years.

Question 74

What is the nurse’s best first action on finding the client’s oxygen saturation by pulse oximetry on the finger is 84%? Apply supplemental oxygen by mask or nasal cannula. Notify the Rapid Response Team immediately. Assess the client’s cognitive function. Recheck the value on the forehead

Answer 74

Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

Question 75

Which teaching point is most important for the nurse to emphasize for a client who is scheduled to undergo pulmonary function testing (PFT)? Avoid strenuous physical activity for 24 hours before the procedure. Use your bronchodilating inhaler right before arriving for the procedure. Do not smoke for 6 hours before the test. Eat only clear liquids for 12 hours before the procedure.

Answer 75

Do not smoke for 6 hours before the test. The essential teaching point for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results. Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.

Question 76

The nurse has just received report on a group of clients. Which client is the nurse’s first priority? A 40 year old admitted 3 hours ago for a scheduled thoracentesis in 30 minutes. A 55 year old with bronchogenic lung cancer who returned from bronchoscopy 4 hours ago. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. A 68 year old with pleural effusion who has decreased breath sounds at the right base.

Answer 76

30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation. The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion

Question 77

Which sign or symptom will the nurse report immediately to the pulmonary health care provider to prevent harm for a client who had a percutaneous lung biopsy 2 hours ago? Bruising at the puncture site Lateral displacement of the trachea Oxygen saturation of 97% Pink-tinged sputum

Answer 77

Lateral displacement of the trachea The trachea should always be midline. Lateral displacement after a percutaneous lung biopsy is associated with complications, especially pneumothorax, which requires immediate intervention

Question 78

Which action will the nurse safely assign to an experienced assistive personnel (AP) to perform with a client who returned an hour ago to the medical-surgical unit after a bronchoscopy? Offering clear liquids when gag reflex returns Determining level of consciousness Assessing breath sounds Monitoring blood pressure and pulse

Answer 78

Determining level of consciousness The best nursing action for the nurse to assign to the experienced AP is monitoring blood pressure and pulse. An experienced AP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia. Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.

Question 79

Which client conditions will the nurse recognize as most likely to cause a “right shift” of the oxyhemoglobin dissociation curve? (Select all that apply.) Select all that apply. Reduced blood and tissue levels of oxygen Alkalosis Increased metabolic demands Reduced blood and tissue levels of diphosphoglycerate (DPG) Increased body temperature Reduced blood and tissue pH

Answer 79

Increased metabolic demands The oxyhemoglobin dissociation curve is shifted to the right when conditions are present that increase overall oxygen needs. This right shift makes it easier for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with higher metabolism and oxygen need. These include increased body temperature, increased metabolic demand, hypoxia, and acidosis (low pH with higher concentration of hydrogen ions. Reduced DPG and alkalosis (fewer hydrogen ions) are associated with increased oxygen need and a left shift in the oxyhemoglobin dissociation curve. Increased body temperature The oxyhemoglobin dissociation curve is shifted to the right when conditions are present that increase overall oxygen needs. This right shift makes it easier for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with higher metabolism and oxygen need. These include increased body temperature, increased metabolic demand, hypoxia, and acidosis (low pH with higher concentration of hydrogen ions. Reduced DPG and alkalosis (fewer hydrogen ions) are associated with increased oxygen need and a left shift in the oxyhemoglobin dissociation curve. Reduced blood and tissue pH The oxyhemoglobin dissociation curve is shifted to the right when conditions are present that increase overall oxygen needs. This right shift makes it easier for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with higher metabolism and oxygen need. These include increased body temperature, increased metabolic demand, hypoxia, and acidosis (low pH with higher concentration of hydrogen ions. Reduced DPG and alkalosis (fewer hydrogen ions) are associated with increased oxygen need and a left shift in the oxyhemoglobin dissociation curve

Question 80

For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) Select all that apply. ``` Slowing heart rate Sensation of air hunger Pain at the insertion site Cyanosis of oral mucous membranes Wheezing on inhalation and exhalation Tracheal deviation ```

Answer 80

Sensation of air hunger Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of “nagging” cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax. Cyanosis of oral mucous membranes Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of “nagging” cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax Tracheal deviation Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of “nagging” cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax

Question 81

Which blood gas value indicates to the nurse that a client is experiencing hypercarbia? Bicarbonate = 20 mEq/L The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia. pH = 7.33 The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia. PaO2 = 80 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia. PaCO2 = 60 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.

Answer 81

PaCO2 = 60 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.

Question 82

Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask? Keeping a small cylinder of oxygen at client’s bedside stand for emergency use in case the central oxygen delivery system fails The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes. Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bed des for this potential emergency. Changing to a nasal cannula during meals The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes. Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency. Sealing the edges of the mask to the client’s skin with a water-soluble lubricant. The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency. Ensuring that the flaps are closed over the exhalation ports The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes. Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency

Answer 82

Changing to a nasal cannula during meals The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes. Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency.

Question 83

What is the nurse’s best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused? Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange Documenting the observation as the only action Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange. Notifying the primary health care provider immediately Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange. Repositioning the client from a high-Fowler to a low-Fowler position Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange

Answer 83

Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange

Question 84

Which oxygen delivery device will the nurse consider best to meet the needs to apply for a newly admitted client who requires high-flow oxygen therapy after suffering facial burns and smoke inhalation? Nonrebreather mask The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device. Nasal cannula The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device Venturi mask The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device. Nonrebreather mask The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

Answer 84

Nonrebreather mask The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

Question 85

Which changes in a client receiving oxygen therapy at 60% for more than 24 hours alert the nurse to the possibility of oxygen toxicity? Decreased PaCO2 Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity. Client report of increased dyspnea Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity. Production of thick, white, frothy sputum Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity. Client demand to remove the mask Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity.

Answer 85

Client report of increased dyspnea Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity.

Question 86

The nurse has just received report on a group of clients. Which client is the nurse’s first priority? A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula. A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula. A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula. A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask

Answer 86

A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently. The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

Question 87

``` Which problem does the nurse suspect when a client who has been receiving 50% oxygen by Venturi mask for 2 days now has crackles and decreased breath sounds on auscultation? New-onset asthma Absorptive atelectasis Bronchiolar infection Stasis pneumonia ```

Answer 87

Absorptive atelectasis Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density

Question 88

What is the nurse’s best response to a client who smokes and is being discharged home on oxygen states, “My lungs are already damaged, so I’m not going to quit smoking? “Tell me more about why you think quitting wont’s help you.” For safety, lower your oxygen flow rate when you smoke.” “The progression to damage to your lungs can be slowed if you stop smoking now.” “For now, let’s discuss why smoking around oxygen is dangerous.”

Answer 88

“For now, let’s discuss why smoking around oxygen is dangerous.” The nurse’s best response is to ask the client to discuss why smoking around oxygen is dangerous. The nurse would use this opportunity to educate the client about the dangers of smoking in the presence of oxygen. Although knowing the benefits of quitting smoking could be helpful for this client, safety is the most important issue at this time. Decreasing the oxygen flow rate while smoking still poses a safety risk.