Interventions
Which of the following is the MOST important action by the nurse after a client has a chest tube inserted for pneumothorax?
A) Ensure client's PO intake is at least 3,000 ml of fluid per 24 hours
B) Provide client with adequate medication for pain relief
C) Maintain integrity of the client's chest tube
D) Reposition the client every 2 hours
Answer: C
Rationale:
A tension pneumothorax (medical emergency) may result is the chest tube ingregirty becomes compromised. The other interventions are important to implement, however, following the ABC's airway management, takes priority
A Cromolyn sodium (Intal) inhaler is prescribed to a client with asthma. A nurse provides instructions regarding the side effects of this medication. The nurse tells the client that which undesirable effect is associated with this medication?
A) Wheezing
B) Insomnia
C) Hypotension
D) Constipation
Answer: A
Rationale:
Cromolyn Sodium (Intal) is used to prevent asthma attacks in people with bronchial asthma. Undesirable side effects associated with the use of inhaler is wheezing. cough. nasal congestion. bronchospasm and throat irritation.Options B. C. and D. are not related to the medication.
The nurse is assessing a client admitted to the hospital with an asthma exacerbation. Which of the following findings is most indicative of an asthma attack?
A) Wheezing
B) Cough
C) Shortness of breath
D) Increased respiratory rate
Correct Answer: A
Rationale:
Wheezing is a high-pitched, whistling sound that occurs when air passes through narrowed airways. It is the most common/specific symptom of an asthma exacerbation. Cough, shortness of breath, and increased respiratory rate are also common symptoms of an asthma exacerbation and can be caused by a variety of conditions, including asthma, bronchitis, and pneumonia.
The nurse caring for a client with emphysema walks into the client’s hospital room and finds the client sitting on the side of the bed while leaning on the overbed table. Which statement is accurate?
A) “Please call the staff before leaning over the table as it is unsafe.”
B) “Next time sit upright instead of leaning over the table.”
C) “You need to recline in the bed-side chair to relax the diaphragm.”
D) “You are demonstrating the correct position to enhance breathing.”
Answer: D
Rationale:
The best breathing position for patients with emphysema is the tripod position. It's lessons strain on the diaphragm and allows for full lung expansion.
The nurse suspects that a 9-month-old child has respiratory syncytial virus (RSV). Which symptom led the nurse to this conclusion?
A) Cool skin
B) Wheezing
C) Bruising
D) Diarrhea
Answer: B
Rationale:
A clinical manifestations of bronchiolitis include: wheezing, crackles, rhinorrhea, atelectasis, hypoxia, and apnea. Bruising, diarrhea, and cool skin are not clinical manifestations of bronchiolitis.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to?
A) Promote oxygen intake
B) Strengthen the diaphragm
C) Strengthen the intercostal muscles
D) Promote carbon dioxide elimination
Answer: D
Rationale:
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing
The provider prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause?
A) Nasal Congestion
B) Nervousness
C) Lethargy
D) Hyperkalemia
Answer: B
Rationale:
Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat. not nasal congestion; insomnia. not lethargy; and hypokalemia (with high doses). not hyperkalemia. Other adverse effects of albuterol include tremor. dizziness. headache. tachycardia. palpitations. hypertension. heartburn. nausea. vomiting and muscle cramps.
When providing discharge teaching to a patient who is newly diagnosed with asthma, which of these points should the healthcare provider emphasize?
A) “Keep a symptom diary to identify asthma triggers, so you can avoid them.”
B) “Measure and record your peak flow meter readings every month.”
C) “Take a nonsteroidal anti-inflammatory agent daily as part of your treatment.”
D) “When you feel an attack is imminent, use your inhaled corticosteroid.”
Answer: A
Rationale:
The best way to reduce asthma complications and attacks is to avoid known triggers, so keeping a dairy is instrumental in helping clients identify triggers they should be avoiding. Clients should be using peak flow meters and recording readings daily. NSAIDS trigger asthma attacks. Inhaled corticosteroids help manage asthma, but are not used as rescue inhalers. Rescue inhalers are short-acting bronchodilators.
The nurse is caring for a client admitted for a COPD exacerbation. Which of the following would be an appropriate discharge outcome for this client?
A) The client promises to do purse-lip breathing at home
B) The client states actions to reduce pain
C) The client states that he will use oxygen via nasal cannula at 5 L/min
D) The client states they will call the physician for worsening SOB
Correct Answer: D
Rationale:
Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.
The parents of an infant patient with respiratory syncytial virus (RSV) ask the nurse why their child is being suctioned with the bulb syringe before feeding. Which response by the nurse is appropriate?
A) "We do this routinely every hour."
B) "Suctioning the nose will help your child breathe better during feeding."
C) "If you prefer, we can have you do this."
D) "If we put this in the plan of care, we can be sure it is done regularly."
Answer: B
Rationale:
The caregiver needs to be alert for the first several months of life, as infants are obligate nose breathers. This means that the infant's nose is the preferential route for air exchange. Suctioning prior to feeding will ensure comfort while the infant is sucking. Providing suctioning prior to feeding is done to ensure it is done regularly. While some infants may require suctioning every hour, it should be done as necessary. Suctioning should be performed anytime the infant appears to be having difficulty breathing. Telling the parent that they can do this if they prefer is not answering their question and can be interpreted as a defensive response.
A nursing student is caring for a very short of breath client requiring oxygen therapy. Which of the following interventions performed by the student, would the primary RN question? Select all that apply.
A) Attaching a flow meter to the wall outlet
B) Providing oral hygiene when necessary
C) Using a petroleum based lubricant to treat dry nares
D) Removing the oxygen while the client is eating
E) Placing a new continuous pulse ox the client's finger
Answer: C, D
Rationale:
The client is very short of breath. Activity like eating can increase the client's oxygen demand, so it's important to keep the oxygen on to prevent respiratory complications. Oxygen is also very combustible. Petroleum-based substances increase the risk of fire, when in the presence of oxygen. It's recommended a water-based lubricant be used for patients receiving oxygen to prevent fire.
What statement made by the client prescribed salmeterol will the registered nurse (RN) identify as the need for further education?
A) “I understand that this drug will help to improve my breathing while treating my asthma.”
B) “It will be necessary to take this drug with other drugs prescribed to treat my asthma.”
C) “This is the drug that I will take first whenever I feel an asthma attack beginning.”
D) “It will be necessary for me to take this drug as a long term treatment for my asthma.”
Answer: C
Rationale:
Salmeterol is a slow-acting beta-2 agonist and is not considered a rescue drug. Salmeterol is used with steroids as a long-term control of medium to severe asthma.
A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first?
A) Take a full medication history
B) Give a bronchodilator by nebulizer
C) Apply a cardiac monitor to the client
D) Provide emotional support to the client
Answer: B
The client is having an acute asthma attack and needs to increase oxygen delivery to the lungs and body. This is done by delivering oxygen therapy and administering a short-acting bronchodilator that opens the airways.
A client arrives at the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD) with SpO2 of 78%, hypercapnia, and a respiratory rate of 32 breaths per minute. Which action by the nurse is considered priority?
A) Apply a partial rebreather mask with FIO2 of 60-80% and call for a blood gas sample
B) Apply a Venturi mask at 24% oxygen setting or nasal cannula at 2 L/M pending health care provider (HCP) determination
C) Begin an aminophylline drip then prepare a tracheotomy tray and alert the health care provider (HCP)
D) Educate on activity tolerance to minimize further episodes.
Answer: B
Rationale:
In the COPD patient, low-flow oxygen supplement is preferred to avoid affecting the client’s hypoxemic drive to breathe. Of all answer choices, the venturi mask offers the lowest flow of oxygen. Non-rebreathers are contraindicated in COPD as patients can rebreathe unwanted carbon dioxide. An aminophylline drip may be indicated for the COPD patient at some point during admission, but we must stabilize the airway first. It's also inappropriate to provide education to the patient at this time since they are unstable.
The nurse explains to parents the importance of maintaining fluid balance in their 9-month-old diagnosed with respiratory syncytial virus (RSV). Which statement by the parent demonstrates understanding of how this can be accomplished?
A) "I should count my child's diapers."
B) "I should restrict my child's dietary intake."
C) "I should suction my child's nose and write down a description of what I get out."
D) "I should offer large feedings spread apart."
Answer: A
Rationale:
Interventions related to the child's risk for fluid volume deficit include counting the child's diapers and encouraging oral intake. Suctioning of the nose is important, but it is not related to fluid balance. Offering small, frequent meals, not large meals spaced out, is helpful.
The nurse is instructing a client on using a metered-dose inhaler and will include which instruction(s)? Select all that apply.
A) After exhalation, hold the metered-dose inhaler 1-2 inches from mouth
B) After inhalation, close the mouth and hold the breath for 5-10 seconds
C) Take short quick breaths with each inhalation
D) Exhale deeply after inhalation of medication
E) Hold breath for 20 seconds before inhaling the medication then exhaling
Answer: B
Rationale:
It's important for clients to absorb all medication with a metered-dose inhaler. Nurses can help clients achieve this by instructing them to carry out the following steps....
- Exhale and place the mouth over the metered-dose inhaler before taking the medication. DO NOT place the mouthpiece away from the mouth.
- Inhale deeply, and hold breath for 5-10 seconds.
- Remove mouthpiece & exhale slowly.
Which instruction will the registered nurse (RN) provide the client who is prescribed theophylline for the treatment of asthma? Select all that apply.
A) “It is recommended to take this drug at the end of the day.”
B) “It is recommended to take this drug at the beginning of the day.”
C) “This drug needs to be taken every day as prescribed for your asthma.”
D) “This drug needs to be taken whenever you feel an asthma attack occurring.”
E) “It is beneficial to avoid all forms of caffeine while taking this drug.”
Answer: B, C, E
Rationale:
Theophylline causes tachycardia and a feeling of stimulation. Therefore, it's important to avoid caffeine as it will increase these manifestations. It's also important to take this drug in the morning so it's effects are diminished at night to allow better sleep for the client. Theophylline is a maintenance drug, so it's necessary for the drug to be taken daily. It should not be taken at the onset of an asthma attack because it's not a rescue drug.
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to?
A) Avoid eating or drinking for 4 hours before testing
B) Take oral corticosteroids at least 2 hours before the examination
C) Withhold bronchodilators for 6 to 12 hours before the examination.
D) Use rescue medications immediately before testing
Answer: C
Rationale:
Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
The nurse begins the hospital shift by assessing a client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD). The nurse expects to document which findings? Select all that apply.
A) Hypercapnia
B) Increased vital capacity on pulmonary function studies
C) Oxygen desaturation when ambulating with physical therapy
D) Hematuria
E) Pursed-lip breathing
Answer: A, C, E
Rationale:
Hypercapnia is a clinical manifestation associated with COPD. Due to inelastic alveoli, CO2 will not be exhaled as readily and will accumulate leading to hypercapnia. Activity of any kind will lead to hypoxemia in clients with COPD. Pursed-lip breathing is a method used by many COPD patients to increase pressure within the alveoli, therefore opening the airways during exhalation to improve ventilation. Hematuria or blood in the urine is not associated with a diagnosis of COPD. COPD clients exhibit decreased vital capacity on pulmonary function tests.
An infant patient with respiratory syncytial virus (RSV) is ordered delivery of nutrition via an intravenous (IV) line. The infant's parent asks why IV nutrition is being ordered. Which response by the nurse is correct?
A) "Rapid breathing indicates the need for IV nutrition."
B) "Your child is vomiting and cannot tolerate oral feedings."
C) "Fluid in the lungs indicates the need for IV nutrition."
D) "IV nutrition is typical protocol for this type of infection."
Answer: A
Rationale:
IV nutrition is not the standard protocol for respiratory syncytial virus (RSV) infection and is only indicated if the infant presents with rapid breathing. Very rapid breathing rates increase the risk for aspiration, and the child may tire very quickly while eating. Vomiting would not be expected in a child with RSV, and fluid in the lungs is not an indication for IV nutrition. A nutritionist collaborates with the healthcare team to ensure caloric intake meets the needs of the infant with RSV.
A nurse is caring for a client who is having difficulty breathing. The client is sitting up in bed and is already receiving oxygen therapy 2 liters via nasal cannula, with a pulse ox of 85%. Which of the following interventions should the nurse implement first?
A) Increase oxygen flow to 5 L nasal cannula and re-assess the pulse ox reading
B) Call the respiratory therapist to obtain an arterial blood gas
C) Administer 40 mg IV furosemide stat
D.) Send client down for stat chest x-ray
Answer: A
Rationale:
Following least invasive to most invasive priority setting framework, increasing oxygen flow is the least invasive intervention presented from the answer choices.
Recognizing that the client prescribed theophylline for the treatment of bronchitis is at risk for toxicity, which clinical manifestation will alert the registered nurse (RN) to this occurrence? Select all that apply.
A) Loss of appetite
B) Drowsiness
C) Restlessness
D) Onset of seizures
E) Insomnia
Answer: A, C, D, E
Rationale:
Theophylline has a narrow therapeutic range of 10 to 20 mcg/mL, of which any value greater than 20 mcg/mL is considered toxic. Early indicators of toxicity include the occurrence of anorexia, nausea/vomiting, insomnia, and/or restlessness. A critical sign of toxicity is the occurrence of tonic clonic seizures.
During the nursing care of a client with asthma, the client experiences an acute asthma attack. As the nurse provides immediate interventions, which observation by the nurse is most concerning?
A) Decreased wheezing and a silent chest
B) The use of accessory muscles to breathe
C) Coarse breath sounds and wheezing
D) Restlessness and diaphoresis
Answer: A
Rationale:
B, C, D are all concerning findings that a nurse can expect during an asthma attack. These findings indicate the lungs are still trying to function and participate in gas exchange. However, decreased wheezing and a silent chest indicates the patient has stopped breathing entirely.
The nurse receives the shift report on four clients who are diagnosed with chronic obstructive pulmonary disease (COPD). Which client should the nurse see first?
A) A client with an oxygen saturation of 88%.
B) A client who just had an albuterol treatment with a heart rate of 108 beats/min.
C) A client with a serum theophylline level of 29 mcg/mL.
D) A client with a white blood cell (WBC) count of 11,000 who was admitted for pneumonia.
Answer: C
Rationale:
C is CORRECT. This client serum theophylline level is toxic (normal range is 10 to 20 mcg/ml); therefore, the nurse should see this client first. Symptoms of elevated serum theophylline levels include nausea, vomiting, diarrhea, insomnia and restlessness while symptoms of toxicity include cardiac dysrhythmia, seizure activity, and death.
A is INCORRECT. Low oxygen saturation is expected for a patient with COPD. A theophylline level that is approaching the toxic range is more concerning because it can kill the patient faster.
B is INCORRECT. Albuterol is a bronchodilator that causes tachycardia and tremors after administration. A heart rate of 108 beats/min is expected based on the current data.
D is INCORRECT. This client’s WBC count is within the normal range; therefore, priority assessment is not required in the provision of care for this client who is diagnosed with both COPD and pneumonia.
During a home visit, the nurse assesses a 2-year-old client. Which factor should the nurse identify as putting the child at risk for contracting respiratory syncytial virus (RSV)? Select all that apply.
A) Both parents are unemployed
B) Both parents smoke cigarettes
C) The toddler shares a drinking cup with their siblings
D) There's an abscence of soap at the kitchen and bathroom sink
E) The toddler wears clean, but wrinkled pants and shirt
Answer: A, B, C, D
Rationale: Risk factors for the contraction of RSV include living in socioeconomically disadvantaged circumstances, exposure to secondhand smoke, poor hand hygiene, and sharing drinking/eating utensils. Wearing clean but rumpled clothing is not a risk factor for the contraction of RSV.