Medicines
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
A) Orange-colored sputum
B) Yellow-tinged sclera
C) Blood tinged sputum
D) Difficulty hearing high-pitched voices
B) Yellow-tinged sclera
Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. Blood tinged sputum is an expected finding with a diagnosis of TB.
A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first?
A) Document changes in respiratory status.
B) Administer IV methylprednisolone (Solu-Medrol).
C) Encourage the patient to cough and deep breathe.
D) Notify the health care provider.
Notify health care provider
The patient’s assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
A) Ask the patient to lie down to complete a full physical assessment.
B) Complete the admission database to check for allergies before treatment.
C) Briefly ask specific questions about this episode of respiratory distress.
D) Delay the physical assessment to first complete pulmonary function tests.
C) Briefly ask specific questions about this episode of respiratory distress.
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
A) “I use my long acting inhaler 2 times a day, like my health care provider ordered.”
B) “I’ve been taking Tylenol 650 mg every 6 hours for chest wall pain.”
C) “I know if I lose weight, I will not have to use my rescue inhaler as often.”
D) “I’ve been using my albuterol inhaler more frequently over the last 4 days.”
D) “I’ve been using my albuterol inhaler more frequently over the last 4 days.”
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
The nurse is preparing a patient for thoracentesis. Which information is a priority to communicate to the health care provider?
A) Pain level is 5 (on 0 to 10 scale) with a deep inspiration.
B) Blood pressure is 100/70 mm Hg.
C) The patient reached 450 mm on the incentive spirometer.
D) International Normalized Ratio (INR) result of 3.
D) International Normalized Ratio (INR) result of 3.INR results of 3
Normal INR is less than . The other assessment data also indicate a need for ongoing assessment or intervention.. 450 mm reading on an incentive spirometer is of no consequence without knowing the baseline and trend.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
A) codeine
B) Piperacillin/tazobactam (Zosyn)
C) 2 puffs of their short acting beta agonsist (SABA)
D) Acetaminophen (Tylenol)
B) Piperacillin/tazobactam (zosyn)
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?
A) pH 7.29, PaCO2 30 mm Hg, and PaO2 65 mm Hg
B) pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
C) pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
D) pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
B) pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.
The nurse observes a student who is listening to a patient’s lungs. Which action by the student indicates a good demonstration of respiratory assessment skills?
A) The student instructs the patient to breathe slowly and deeply through the nose
B) The student listens complete respiratory cycle for each lung field auscultated, then moves the stethoscope.
C) The student asks the patient to hold their breath and bear down for each lung field auscultated.
D) The student asks the patient to pursed lip breath for each lung field auscultated.
B) The student listens complete respiratory cycle for each lung field auscultated, then moves the stethoscope.
the student asks the patient to pursed lip breath for each lung field auscultated. Listening during full respiratory cycle for each lung field is proper technique. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. The choices are not correct assessment techniques.
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response?
A) A PFT measures how much air moves in and out of your lungs when you breathe.
B) A PFT measures how much energy you get from the oxygen you breathe.
C) A PFT measures how elastic your lungs are.
D) A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
A) A PFT measures how much air moves in and out of your lungs when you breathe.
PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?
A) Encourage the patient to sit up at the bedside in a chair and lean forward.
B) Increase the oxygen to 6L and place the patient on Non-Rebreather (NRB) Mask.
C) Ask the patient to rest in bed in a high-Fowler's position with pillows behind the head.
D) Call the respiratory rapid response team, for assessment and support.
A) Encourage the patient to sit up at the bedside in a chair and lean forward
Patients with COPD improve the mechanics of breathing by sitting up in the “tripod” position. Resting in bed with the head elevated in a semi-Fowler’s position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The respiratory rapid response team should not be notified at this juncture, nursing interventions should be implemented prior to calling. Non-Rebreather Mask with 6L of oxygen is not an appropriate intervention for the COPD patient at this time, nursing interventions should be implemented prior.
A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
A) metabolic alkalosis
B) metabolic acidosis
C) respiratory acidosis
D) respiratory alkalosis
A) Metabolic alkalosis
Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?
A) A patient manifesting jugular venous distention and dependent peripheral edema while sitting up.
B) A patient with a respiratory rate of 38 breaths/min
C) A patient with loud expiratory wheezes
D) Oxygen saturation of 88% on room air.
B) A patient with a respiratory rate of 38 breaths/min
A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client’s compensation mechanism?
A) Increased thirst and hunger
B) Increased urinary output
C) Increased rate and depth of respirations
D) Increased release of acids from the kidneys
C) Increased rate and depth of respirations
This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?
A) The patient puffs up the cheeks while exhaling.
B) The patient’s ratio of inhalation to exhalation is 1:3
C) The patient states, "this method will help me control my shortness of breath.:"
D) The patient inhales slowly through the nose.
A) The patient puffs up the cheeks while exhaling.
The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
A) Position the patient sitting up on the side of the bed.
B) Give the patient the scheduled dose of morning medications:
Lasix (furosimide)
Correg (carvedilol)
Warfarin (coumadin)
Albuterol (albuterol sulfate) inhaler 2 puffs
C) Obtain a collection device to hold 3 liters of pleural fluid.
D) Remind the patient not to eat or drink anything for 6 hours.
A) Position the patient sitting up on the side of the bed.
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema. Anticoagulants should not be administered prior to this procedure.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
A) Encourage chlorhexidine rinse TID
B) Obtain an oral specimen for culture and sensitivity.
C) Start the client on a broad-spectrum antibiotic.
D) Encourage oral rinsing after fluticasone administration.
D) Encourage oral rinsing after fluticasone administration
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, chlorhexidine, and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the findings, 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 will not provide information necessary to care for this client.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
A) Pain medication for chest discomfort
B) Ciprofloxacin (Cipro) 400 mg IV
C) Chest x-ray via stretcher
D) Blood cultures from two sites
D) Blood cultures from two sites
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
A) Abnormal lung sounds in the apices of both lungs
B) Expiratory wheezes in both lungs
C) Pleural friction rub in the right and left lower lobes
D) Inspiratory crackles at the bases
D) Inspiratory crackles at the bases
crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not the apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client’s teaching? (Select all that apply.)
A) “Increase carbohydrate intake for energy.”
B) “Avoid drinking fluids just before and during meals.”
C) “Eat high-fiber foods to promote gastric emptying.”
D) “Rest before meals if you have dyspnea.”
E) “Have about six small meals a day.”
B) “Avoid drinking fluids just before and during meals”
D) “Rest before meals if you have dyspnea”
E) “Have about six small meals a day”
Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client’s risk of for acidosis.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?
A) Minimize O2 use to avoid O2 dependency.
B) Avoid administration of O2 at a rate of more than 2 L/min.
C) Administer O2 according to the patient’s level of dyspnea.
D) Maintain the pulse oximetry level at 90% or greater.
D) Maintain the pulse oximetry level at 90% or greater.
The best way to determine the appropriate O2 flow rate is by monitoring the patient’s oxygenation either by arterial blood gases ABGs or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flow rate of 2 L/min may not be adequate.
Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient’s perceived dyspnea level may be affected by other factors e.g., anxiety besides blood O2 level.
After teaching a client who is prescribed a long-acting beta-agonist medication for Asthma, a nurse assesses the client’s understanding. Which statement indicates the client comprehends the teaching?
A)“I will take this medication when I start to experience an asthma attack.”
B) “I will take this medication every morning to help prevent an acute attack.”
C) “I will be weaned off this medication when I no longer need it.”
D)“If I use my inhaler as ordered, it will will cure my asthma.”
B) “I will take this medication every morning to help prevent an acute attack.”
Long-acting beta-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.
The nurse analyzes the laboratory results of a patient. Which finding would require immediate action?
A) The serum sodium of 135 mEq/L
B) The serum calcium is 8 mg/dL
C) The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg
D) The bicarbonate level (HCO3-) is 31 mEq/L
C) The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation. Electrolyte levels are not the priority at this time because they are close to normal. They should continue to be monitored for trends.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
A) Respiratory rate of 26 breaths/min
B) Pulse oximetry reading of 91%
C) Use of accessory muscles in breathing
D) Peak expiratory flow rate of 240 L/min
C) Use of accessory muscles in breathing
Use of accessory muscle indicates that the patient is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.
Which information will the nurse include in the asthma teaching plan for a patient being discharged?
A) Hold your breath for 5 seconds after using the bronchodilator inhaler.
B) Monitor their Peek Expiratory Flow Rate (PEFR) monthly.
C) Tremors are an expected side effect of rapidly acting bronchodilators.
D) Inhale slowly and deeply when using the dry powder inhaler (DPI).
C) Tremors are an expected side effect of rapidly acting bronchodilators.
Tremors are a common side effect of short-acting b2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold their breath for 10 seconds after using inhalers. Monitor their Peek Expiratory Flow Rate (PEFR) daily
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client’s room. The nurse asks the client when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take?
A) Add a small amount of normal saline to moisten the specimen.
B) Refrigerate the sputum specimen and submit it once it is chilled.
C) Discard the specimen and assist the client in obtaining another specimen
D) Immediately take the sputum specimen to the laboratory.
C) Discard the specimen and assist the client in obtaining another specimen.
Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.