Miscellaneous
An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she developed a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?
Nurse Lei, caring for a client with a pneumothorax and who has had a chest tube inserted, intermittent gentle bubbling is seen in the suction control chamber. What action is appropriate?
A nurse is assessing a client with chronic airflow limitation and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitation?
A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?
A client is prescribed with guaifenesin (Mucinex). The nurse determines that the client understands the proper administration of this medication if the client states that he or she will:
A. Limit oral fluid intake
B. Take the medication with meals only
C. Take an additional dose once fever and cough persist
D. Drink extra fluids while taking this medication
D. Drink extra fluids while taking this medication
Encouraging fluids will increase the liquidity of the mucus enabling the patient to be able to easy cough it up.
A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
B. Continue to monitor the client.
A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client?
A. Altered nutrition: Less than body requirements related to fatigue.
A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
D. Impaired gas exchange related to airflow obstruction.
A nurse is caring for a patient with COPD exacerbation. The provider the following orders:
- Albuterol neb x 1
- Ventolin inhaler
- Prednisone injection x 1
- Oxygen 3 LPM
The nurse recognizes that which order is the priority intervention?
D. Albuterol
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
B. 2 L/min
The ULP caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
B. Place the tube in a bottle of sterile water.
When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following?
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
A nurse is about to administer naloxone hydrochloride (Narcan) to a client with a known opioid overdose. Which of the following equipment should be readily available at the bedside?
A. Suction machine
B. Nasogastric tube
C. Resuscitative equipment
D. Dressing tray
C. Resuscitative equipment
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client:
D. Agrees to call the physician if dyspnea on exertion increases.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
B. Develop an alternative communication method.
A 25 year old man with chronic bronchitis is receiving theophylline intravenously. After several dosages, the client started to become restless and complains of palpitations. The nurse determines that the client is experiencing theophylline toxicity in which of the following?
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?
A new nurse caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD?
A. Increased anteroposterior chest diameter.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
A pediatric client with asthma has just received omalizumab (Xolair). The nurse determines that the client might be suffering a life-threatening effect in which of the following?
A. Headache and dizziness
B. Nausea and vomiting
C. Swelling of the tongue
D. Joint pain
C. Swelling of the tongue