Chapter 19: Lower Respiratory Tract Disorders
The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client?
A. Safe technique for self-suctioning of secretions
B. Technique for performing postural drainage
C. Correct and safe use of oxygen therapy equipment
D. How to provide safe and effective tracheostomy care
ANS: C
Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the client and family in their correct and safe use. The scenario does not indicate the client needs suctioning, postural drainage, or tracheostomy care.
A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?
A. Prepare the client for opening or bivalving of the cast.
B. Obtain a prescription for a different analgesic.
C. Encourage the client to wiggle and move the fingers.
D. Petal the edges of the client's cast.
ANS: A
Rationale: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Prescribing different analgesics does not address the underlying problem. Encouraging the client to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?
A. Hydrochlorothiazide
B. Furosemide
C. Mannitol
D. Spironlactone
ANS: C
Rationale: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?
A. Risk for impaired skin integrity related to immobility and sensory loss
B. Impaired physical mobility related to loss of motor function
C. Ineffective breathing patterns related to weakness of the intercostal muscles
D. Urinary retention related to inability to void spontaneously
ANS: C
Rationale: A nursing diagnosis related to breathing pattern would be the priority for this client. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.
A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
A. Arrange for the client to receive a low residue diet.
B. Position the client upright during feeding.
C. Suction the client following each meal.
D. Withhold liquids until the client has finished eating.
ANS: B
Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration.
While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often?
A. Every 2 hours when the client is awake
B. When adventitious breath sounds are auscultated
C. When there is a need to prevent the client from coughing
D. When the nurse needs to stimulate the cough reflex
ANS: B
Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team?
A. Maximize the efficiency of care.
B. Ensure that the client's health care is holistic.
C. Facilitate the client's adjustment to a new body image.
D. Promote the client's highest possible level of function.
ANS: D
Rationale: The multidisciplinary rehabilitation team helps the client achieve the highest possible level of function and participation in life activities. The team is not primarily motivated by efficiency, the need for holistic care, or the need to foster the client's body image, despite the fact that each of these are valid goals.
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
A. Maintaining accurate records of intake and output
B. Maintaining a patent airway
C. Inserting a nasogastric (NG) tube as prescribed
D. Providing appropriate pain control
ANS: B
Rationale: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.
The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
A. Position the client in a high-Fowler position when in bed.
B. Support the knees with a pillow when the client is in bed.
C. Perform passive ROM exercises as prescribed.
D. Administer NSAIDs as prescribed.
ANS: C
Rationale: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the client's risk of muscle spasticity.
A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment?
A. Reduction in the appearance of new lesions on the MRI
B. Decreased muscle spasms in the lower extremities
C. Increased muscle strength in the upper extremities
D. Decreased severity and duration of exacerbations
ANS: B
Rationale: Baclofen, a -aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities.
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?
A. The system is functioning normally.
B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
ANS: C
Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside?
A. A tourniquet
B. A syringe preloaded with vitamin K
C. A unit of packed red blood cells, placed on ice
D. A dose of protamine sulfate
ANS: A
Rationale: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the client's bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not given to treat active postsurgical bleeding.
A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?
A. As soon as the client's pain becomes unbearable
B. As soon as the client senses the onset of symptoms
C. Twenty to 30 minutes after the onset of symptoms
D. When the client senses his or her symptoms peaking
ANS: B
Rationale: A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.
A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?
A. Urinary catheter use often leads to urinary tract infections (UTIs).
B. Urinary function is permanently lost following an SCI.
C. Urinary catheters should not remain in place for more than 7 days.
D. Overuse of urinary catheters can exacerbate nerve damage.
ANS: A
Rationale: Catheter use does not cause nerve damage, although it is a major risk factor for UTIs. Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury.
The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client?
A. Using the incentive spirometer as prescribed
B. Maintaining the client on bed rest
C. Providing aids to compensate for loss of vision
D. Assessing frequently for loss of cognitive function
ANS: A
Rationale: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision.
The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess?
A. Fluid intake for the last 24 hours
B. Arterial blood gas (ABG) levels
C. Prior outcomes of weaning
D. Electrocardiogram (ECG) results
ANS: B
Rationale: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.
A. Systemic infection
B. Complex regional pain syndrome
C. Deep vein thrombosis
D. Compartment syndrome
E. Fat embolism
ANS: C, D, E
Rationale: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?
A. Place the client in a side-lying position.
B. Pad the client's bed rails.
C. Administer antianxiety medications as prescribed.
D. Reassure the client and family members.
ANS: A
Rationale: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.
Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints?
A. At the client's request
B. Each morning and evening
C. Every 2 hours
D. One hour prior to mobility exercises
ANS: C
Rationale: The feet are prone to foot drop; therefore, various types of splints are used to prevent foot drop. When used, the splints are removed and reapplied every 2 hours.
The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client?
A. Maintaining the client's functional independence
B. Providing health education
C. Monitoring neurologic status closely
D. Promoting mobility
ANS: C
Rationale: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.
A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply.
A. Coping
B. Level of consciousness
C. Oral intake
D. Arterial blood gases
E. Vital signs
ANS: B, D, E
Rationale: Trauma clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment but would become more important later during recovery.
A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.
A. Massage
B. Applying ice
C. Compression dressings
D. Resting the affected extremity
E. Corticosteroids
F. Elevating the injured limb
ANS: B, C, D, F
Rationale: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.
An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply.
A. "Are you exposed to any toxins or chemicals at work?"
B. "How would you describe your ability to cope with stress?"
C. "What medications are you currently taking?"
D. "When was the last time you were hospitalized?"
E. "Does anyone else in your family struggle with headaches?"
ANS: A, B, C, E
Rationale: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.
A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply.
A. Orthostatic hypotension
B. Autonomic dysreflexia
C. DVT
D. Salt-wasting syndrome
E. Increased ICP
ANS: A, B, C
Rationale: For a spinal cord-injured client, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome and increased ICP are not typical complications following the immediate recovery period.
The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply.
A. Possible nursing home placement
B. Pain associated with physical therapy
C. Increasing disability
D. Becoming a burden on the family
E. Loss of appetite
ANS: A, C, D
Rationale: Older adult clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.