Unit K-Adult Respiratory

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

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

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 is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency ```

Answer 37

ANS: D A patent airway is the priority. The nurse first would make sure that the airway is patent and then would determine whether the client is in pain and whether bone displacement or blood loss has occurred.

Question 38

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

Answer 38

ANS: A The client with nasal drainage after facial trauma could have a skull fracture resulting in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the patient’s risk for infection.

Question 39

A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing

Answer 39

ANS:B The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech language pathologist teaches the client the supraglottic method of swallowing. This includes placing a small amount of food in the mouth, performing the Valsalva maneuver, then swallowing twice. The client sits upright. The client holds the breath while swallowing twice. Keeping the head still and straight will not decrease the risk of aspiration.

Question 40

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant. b. A 42-year-old man with gastroesophageal reflux disease. c. A 55-year-old woman who is 50 lb (23 kg) overweight. d. A 73-year-old man with type 2 diabetes mellitus.

Answer 40

ANS: C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. Clients with sleep apnea may develop gastroesophageal reflux

Question 41

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography

Answer 41

ANS: A Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA). The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a problem, the nurse would consult the primary health care provider for further testing. An at-home sleep-study is often done prior to a polysomnography. Excessive weight can contribute to OSA so exercising is always encouraged, but this is not specific to assessing for OSA.

Question 42

A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? a. Ask the client to gargle with mouthwash containing lidocaine b. Administer IV fluid boluses every 2 hours. c. Explain that xerostomia may be a permanent side effect. d. Assess the client’s neck for redness and swelling.

Answer 42

ANS: C Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the salivary glands were in the radiation zone. Unfortunately, this may be long term or even permanent. Gargling with lidocaine would not help. Increasing fluids is somewhat helpful, but the client would be encouraged to drink. The client’s neck may have redness and swelling, but this finding is not related to the reported dry mouth.

Question 43

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? a. “I will consult the speech therapist to ensure you are swallowing properly.” b. “This is normal after surgery. What types of food do you like to eat?” c. “I will ask the dietitian to change the consistency of the food in your diet.” d. “Replacement of protein, calories, and water is very important after surgery.”

Answer 43

ANS: B Many clients experience changes in taste after surgery. The nurse would identify foods that the client wants to eat to ensure that the client maintains necessary nutrition. Although the nurse would collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the patient’s concerns.

Question 44

nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

Answer 44

ANS: C The client will not be able to speak after surgery. The nurse would assist the client to choose a communication method that he or she would like to use after surgery. Assessing the patient’s airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this patient’s gait would not be impacted by a total laryngectomy and therefore is not a priority.

Question 45

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? a. Contact the primary health care provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler position. d. Ask the client to perform deep-breathing exercises.

Answer 45

ANS: A Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, would be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler position and asking the client to perform breathing exercises may temporarily improve the patient’s comfort, these actions will not decrease the underlying problem or improve airway patency

Question 46

A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. Assess the client’s pain level. b. Keep the client’s head elevated. c. Teach the client about the causes of nasal bleeding. d. Assess the client’s airway.

Answer 46

ANS: D If the packing slips out of place, it may obstruct the client’s airway. The other options are good interventions, but ensuring that the airway is patent in the priority objective.

Question 47

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient’s teaching? a. “Add peppermint oil to the humidifier to relax the airway.” b. “Make sure you clean the humidifier to prevent infection.” c. “Keep the humidifier filled with water at all times.” d. “Use the humidifier when you sleep, even during daytime naps.”

Answer 47

ANS: B Priority teaching related to the use of a room humidifier focuses on infection control. Clients would be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil would not be added to a humidifier. The humidifier would be refilled with water as needed and would be used while awake and asleep.

Question 48

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Client’s vital signs are within normal parameters.

Answer 48

ANS: C The priority after a modUPPP is maintaining a patent airway. The client who has a patent airway can swallow his or her own secretions without drooling. Controlled pain is important, but not the priority. Foul breath odor and beefy red mucus membranes indicate possible infection, which probably would not occur this soon after surgery, but preventing infection does not take priority over airway. Vital signs “within normal parameters” are vague.

Question 49

nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

Answer 49

ANS: A, B, C, D The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse would assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse would also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which would be changed by the surgeon the first time.

Question 50

The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first.

Answer 50

ANS: B, C, E, F A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an increased risk for fungal infections. Patients may have anxiety about using the equipment and worry about it being disruptive; most clients have a period of adjustment when first starting to use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours a day. The mask or pillows should be cleaned daily.

Question 51

``` A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin ```

Answer 51

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called “battle sign” and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

Question 52

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient’s teaching? (Select all that apply.) a. “You will need to cut the wires if you start vomiting.” b. “Eat six soft or liquid meals each day while recovering.” c. “Use a Waterpik for dental hygiene until you can brush again. d. “Sleep in a semi-Fowler position after the surgery.” e. “Gargle with mouthwash that contains hydrogen peroxide once a day.”

Answer 52

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a recommendation.

Question 53

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24 year old with a traumatic brain injury b. A 36 year old who fractured his left femur c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic

Answer 53

ANS: A, C, D, E Thickly crusted, dry secretions that potentially can cause asphyxiation and airway obstruction (inspissated secretions or mucoid impaction) are seen most often in clients who have an altered mental status and level of consciousness (brain injury), are dehydrated, are unable to communicate (aphasic), are unable to cough effectively (quadriplegic), or are at risk for aspiration. The clients with the femur fracture and receiving radiation therapy are not as high of a risk. The location of the radiation is not known.

Question 54

A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.) a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice c. Persistent weight gain over the past 2 months d. Oral lesions that are over 2 weeks old e. Changes in the patient’s voice quality

Answer 54

ANS: A, B, D, E Symptoms of head and neck cancer include color changes in the mouth or tongue to gray or dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or changes in voice quality.

Question 55

A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.) a. “I will vigorously blow my nose multiple times each day.” b. “Nasal saline sprays will help to prevent rebleeding.” c. “I will wait at least 1 month before resuming weight lifting.” d. “Ibuprofen will decrease nasal swelling and pain.” e. “I will apply a small amount of petroleum jelly to my nares.”

Answer 55

ANS: B, C, E A nurse would teach a client to avoid vigorous nose blowing, the use of aspirin or other NSAIDs, and strenuous activities such as heavy lifting for at least 1 month. The nurse would also teach the client to apply petroleum jelly sparingly to the nares for lubrication and comfort, and to use nasal saline sprays and humidification to prevent rebleeding.

Question 56

``` A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease ```

Answer 56

ANS: A, B, C, D, E, F The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease

Question 57

A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min

Answer 57

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment

Question 58

A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? a. Review the client’s pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases. ANS:

Answer 58

ANS: B Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client’s history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

Question 59

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client’s understanding. Which statement indicates that the client comprehends the teaching? a. “I will carry this medication with me at all times in case I need it.” b. “I will take this medication when I start to experience an asthma attack.” c. “I will take this medication every morning to help prevent an acute attack.” d. “I will be weaned off this medication when I no longer need it.”

Answer 59

ANS: C Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications

Question 60

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client’s understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head.

Answer 60

ANS: B To perform diaphragmatic breathing correctly, the client would place his or her hands on the abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

Question 61

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole-wheat bread d. Pasta salad, custard, orange juice

Answer 61

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients would be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

Question 62

After teaching a client who is prescribed salmeterol, the nurse assesses the client’s understanding. Which statement by the client indicates a need for additional teaching? a. “I will be certain to shake the inhaler well before I use it.” b. “It may take a while before I notice a change in my asthma.” c. “I will use the drug when I have an asthma attack.” d. “I will be careful not to let the drug escape out of my nose and mouth.”

Answer 62

ANS: C Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client’s part allows the drug to escape through the nose and mouth.

Question 63

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? a. “There are a variety of support groups for people who have COPD.” b. “I will ask your primary health care provider to prescribe an antianxiety agent.” c. “I’d like to hear about thoughts and feelings causing you to limit social activities.” d. “Friends can be a good support system for clients with chronic disorders.”

Answer 63

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. While friends can be good sources of support, the client specifically is discussing going out of the home.

Question 64

A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client’s teaching? a. “Take an antibiotic each day.” b. “You should get genetic screening.” c. “Eat a well-balanced, nutritious diet.” d. “Plan to exercise for 30 minutes every day.”

Answer 64

ANS: C Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening might be an option; however, the nurse would not just tell the client to do something like that

Question 65

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the primary health care provider. d. Reinsert the tube using sterile technique.

Answer 65

ANS: B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The nurse does not need to assess the site at this moment. The primary health care provider would be called to reinsert the chest tube or prescribe other treatment options.

Question 66

A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

Answer 66

ANS: A The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse would document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is not necessary to care for this client

Question 67

A nurse cares for a client who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client separated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

Answer 67

ANS:C B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients. Strict isolation measures will not be necessary. Although the client would wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with B. cepacia infection.

Question 68

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client’s anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

Answer 68

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client’s discomfort and need to take deep breaths to prevent complications.

Question 69

The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information about gene therapy. What response by the nurse is best? a. “Unfortunately, gene therapy is only provided to children upon diagnosis.” b. “Do you know that you will have to have genetic testing?” c. “There is a good treatment for the most common genetic defect in CF.” d. “Gene therapy will only help improve your pulmonary symptoms.

Answer 69

ANS: C The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the F508del (also known as the Phe508del) mutation, the most common mutation involved in CF, even in patients who are homozygous for the mutation with both alleles being affected. The nurse would provide that information as the best response. Asking if the client understands he or she will have to undergo genetic testing is a correct statement, but is a yes/no question which is not therapeutic and might sound paternalistic. It also does not provide any information on the therapy itself. The drug is not limited to children and helps move chloride closer to the membrane surfaces so it would have an effect on any organ compromised by CF.

Question 70

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client’s history and clinical signs and symptoms? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

Answer 70

ANS: A Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left-heart failure and is not directly caused by a 40-year smoking history.

Question 71

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a. “Do you have a strong support system?” b. “What do you understand about your disease?” c. “Do you experience shortness of breath with basic activities?” d. “What medications are you prescribed to take each day?”

Answer 71

ANS: C Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client’s support systems, current knowledge, and medications, these questions do not address the client’s appearance.

Question 72

A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information? a. “I still will use my rapid-acting inhaler for an asthma attack.” b. “I will always use the spacer with my dry powder inhaler.” c. “If I am stable for 3 months, I might be able to reduce my drugs.” d. “My inhaled corticosteroid must be taken regularly to work well.”

Answer 72

ANS: B | Dry powder inhalers are not used with a spacer. The other statements are accurate.

Question 73

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first? a. A 46 year old with a 30–pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingers d. A 74 year old with a chronic cough and thick, tenacious secretions

Answer 73

ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress. DIF: Applying

Question 74

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

Answer 74

ANS: D Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device’s manufacturer, not the primary health care provider

Question 75

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, “What does this mean?” How would the nurse respond? a. “Your children will be at high risk for chronic obstructive pulmonary disease.” b. “I will contact a genetic counselor to discuss your condition.” c. “Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.” d. “This is a recessive gene and would have no impact on your health.”

Answer 75

ANS:C Alpha1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the client smokes or there is sufficient exposure to other inhalants. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner’s AAT levels. Contacting a genetic counselor may be helpful but does not address the client’s current question.

Question 76

nurse cares for a client who has a family history of cystic fibrosis. The client asks, “Will my children have cystic fibrosis?” How would the nurse respond? a. “Since many of your family members are carriers, your children will also be carriers of the gene.” b. “Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.” c. “Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.” d. “Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.”

Answer 76

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse would encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

Question 77

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.

Answer 77

ANS: B Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators

Question 78

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.) a. Administer prescribed salmeterol inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen and place client on an oximeter. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol inhaler. f. Assess the client’s lung sounds after administering the inhaler

Answer 78

ANS: C, E, F Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is becoming unstable, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would reassess the lung sounds after the rescue inhaler. The nurse would not do a peak flow reading at this time, nor would a code be called. The nurse could assess for tracheal deviation after administering oxygen and albuterol.

Question 79

``` A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse’s immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site ```

Answer 79

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum and pain at the insertion site are not signs/symptoms that would require immediate intervention.

Question 80

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client’s teaching? (Select all that apply.) a. “Avoid drinking fluids just before and during meals.” b. “Rest before meals if you have dyspnea.” c. “Have about six small meals a day.” d. “Eat high-fiber foods to promote gastric emptying.” e. “Use pursed-lip breathing during meals.” f. “Choose soft, high-calorie, high-protein foods.”

Answer 80

ANS: A, B, C, E, F Clients with COPD often are malnourished for several reasons. The nurse would teach the client not to drink fluids before and with meals to avoid early satiety. The client needs to rest before eating, and eat smaller frequent meals: 4 to 6 a day. Pursed-lip breathing will help control dyspnea. Food that is easy to eat will be less tiring and the client should choose high-calorie, high-protein foods.

Question 81

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client’s activity tolerance? (Select all that apply.) a. “What color is your sputum?” b. “Do you have any difficulty sleeping?” c. “How long does it take to perform your morning routine?” d. “Do you walk upstairs every day?” e. “Have you lost any weight lately?” f. “How does your activity compare to this time last year?”

Answer 81

ANS: B, C, E, F Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client’s sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously. The nurse would ask the client to compare his or her current level of activity with that of a month or even a year ago.

Question 82

A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.) a. The need to avoid large crowds and people who are ill b. Safety measures to take if home oxygen is needed c. Information about appropriate use of the drug nintedanib d. Genetic therapy to stop the progression of the disease e. Measures to avoid fatigue during the day f. The possibility of receiving a lung transplant if infection-free for a year

Answer 82

ANS: A, B, C, E Pulmonary fibrosis is a progressive disorder with no cure. Therapy focuses on slowing progression and managing dyspnea. Clients need to avoid contracting infections so should be taught to stay away from large crowds and sick people. Home oxygen is needed and the nurse would teach safety measures related to oxygen. The drug nintedanib has shown to improve cellular regulation and slow progression of the disease. Gene therapy is not available. Energy conservation measures are also an important topic. Lung transplantation is an unlikely option due to selection criteria

Question 83

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.) a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating chest physiotherapy device. e. Encourage diaphragmatic breathing. f. Administer the ordered mucolytic agent.

Answer 83

ANS:A,B,D,F Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating chest physiotherapy device can also help clients remove thick secretions but is usually used in clients with cystic fibrosis. Mucolytic agents help thin secretions, making them easier to bring up. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client’s ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

Question 84

A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client’s safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

Answer 84

ANS: A, C, E Intravenous prostacyclin agents would be administered to a client with pulmonary artery hypertension through a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted even briefly; therefore, a backup drug cassette would also be available. The nurse would use strict aseptic technique when using the drug delivery system. The nurse would teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

Question 85

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client’s evaluation? (Select all that apply.) a. Examination of mucous membranes and nail beds b. Measurement of rate, depth, and rhythm of respirations c. Auscultation of bowel sounds for abnormal sounds d. Check peripheral veins for distention while at rest e. Determine the client’s need and use of oxygen f. Ability to perform activities of daily living

Answer 85

ANS:A,B,E,F A home health nurse would assess the client’s respiratory status and adequacy of ventilation including an examination of mucous membranes and nail beds for evidence of hypoxia, measurement of rate, depth and rhythm of respirations, auscultation of lung fields for abnormal breath sounds, checking neck veins for distention with the client in a sitting position, and determining the client’s needs and use of supplemental oxygen. The home health nurse would also determine the client’s ability to perform his or her own ADLs. Auscultation of bowel sounds and assessment of peripheral veins are not part of a focused assessment for a client with COPD.

Question 86

A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) a. “Open your mouth and breathe deeply.” b. “Use your abdominal muscles to squeeze air out of your lungs.” c. “Breath out slowly without puffing your cheeks.” d. “Focus on inhaling and holding your breath as long as you can.” e. “Exhale at least twice the amount of time it took to breathe in.” f. “Lie on your back with your knees bent.”

Answer 86

ANS: B, C, E A nurse would teach a client to close his or her mouth and breathe in through his or her nose, purse his or her lips and breathe out slowly without puffing his or her cheeks, and use his or her abdominal muscles to squeeze out every bit of air. The nurse would also remind the client to use pursed-lip breathing during any physical activity, to focus on exhaling, and to never hold his or her breath. Lying on the back with bent knees is the preferred position for diaphragmatic breathing.

Question 87

nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.) a. Gynecomastia in male patients b. Frequent shaking and sweating relieved by eating c. Positive Chvostek and Trousseau signs d. “Moon” face and “buffalo” hump e. Expectorating purulent sputum f. General edema

Answer 87

ANS: A, B, D, F Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be caused by antidiuretic hormone.

Question 88

``` The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.) a. Over 10–pack-year history of smoking b. Persistent coughing c. Rusty or blood-tinged sputum d. Dyspnea e. Hoarseness f. Fatigue ```

Answer 88

ANS: B, C, D, E Some common signs of lung cancer include persistent cough, rusty or blood-tinged sputum, dyspnea, and hoarseness. Fatigue is common to many conditions. Smoking history is a risk factor for lung cancer.