Question 1

The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action?

Accepted Answer

Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. (Option A) Morphine is effective in relieving anxiety and decreasing the work of breathing by slowing respirations. It can cause hypoventilation and decrease gas exchange in the lungs and is not the priority action, especially as the client's respirations are shallow. (Option B) The cause of the wheezing could be from lung tumor or true bronchoconstriction. Paging the respiratory therapist to administer a bronchodilator nebulizer treatment to relieve wheezing is an appropriate intervention, but it is not the priority action. (Option D) Encouraging the client to talk about the diagnosis and upcoming surgery is an appropriate intervention to help alleviate anxiety and address self-actualization needs, but is not the priority action. Educational objective: Elevating the head and chest in the Fowler's, high Fowler's, orthopneic, and tripod positions allows for maximum lung expansion and promotes oxygenation, especially in clients with dyspnea.

Question 2

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately?

Accepted Answer

11ecbb05_ca65_0001_b433_09875613dfbc_MD0009_00 An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes, prevent laryngospasm, and facilitate passage of the scope. The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed. Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax (rare), and adverse effects from medications used before and during the procedure. (Option A) Absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic. (Option C) Headache is not a complication of bronchoscopy. (Option D) Respirations of 10/min and saturation of 92% are expected after mild sedation before and/or or during the procedure. Educational objective: Immediately post bronchoscopy, the nurse monitors for associated potential complications, including hemoptysis, hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax, and adverse effects from medications used before and during the procedure.

Question 3

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply.

Accepted Answer

Clients should be taught to understand that symptoms of pneumonia (eg, cough, sputum production, shortness of breath, fatigue, and activity intolerance) remain after discharge even though the bacteria are no longer present and will dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching includes the following instructions: Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis. Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions. Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation, oxygenation, and airway clearance. Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and alcohol as they can dry mucus membranes due to diuretic effects. Notify the HCP of any increase in symptoms (eg, shortness of breath, cough, sputum production, chest pain, fever, confusion). Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and oxygenation. Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain resistance to infection. (Option B) After a client has IV antibiotic therapy, completing a full course of oral antibiotic therapy is necessary to prevent reoccurrence of disease and antibiotic resistance. (Option C) Contracting pneumonia does not provide lifelong immunity to the disease. Yearly influenza vaccination and pneumonia vaccination as directed by the HCP are recommended. Educational objective: Discharge instructions for a client recovering from pneumonia focus on proper medication regimen, lung expansion and coughing techniques, activity level, hydration, nutrition, avoidance of tobacco products, reportable manifestations (eg, respiratory distress, chest pain, fever, cough, change in mucus), follow-up care, influenza and pneumonia vaccinations, and respiratory and hand hygiene.

Question 4

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply.

Accepted Answer

Strategies to prevent postoperative pneumonia include the following: Adequate pain control is a priority so that the client can move, deep breathe, and cough more effectively and comfortably. Opioids are effective for relieving postoperative pain, but because they depress respirations and the cough reflex, assessing the client's response to the medication and level of sedation is important. Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and lung expansion. Usually, it can be initiated within 4-8 hours after surgery. Coughing with splinting every hour. Splinting of the incision and adequate pain management are useful for promoting an effective cough (huff, cascade) that clears the airway of secretions. Coughing with splinting Deep breathing and use of the incentive spirometer every hour. Deep breathing in conjunction with the use of the incentive spirometer promotes ventilation and oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to move into collapsed alveoli, and it helps to prevent/decrease atelectasis and hypoventilation caused by the effects of anesthesia, analgesia, and pain. Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours. Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-associated and postoperative pneumonia. Use hand hygiene (all personnel) to decrease transmission of microorganisms. (Option A) Adequate pain control is a priority. The decision to hold opioids is usually based on sedation level. Giving pain medicine only for severe pain is not appropriate. If the client is awake and complains of pain, adequate analgesia should be provided (oral or IV). (Option E) Use of pneumatic compression devices promotes venous return and helps to prevent venous thrombosis, not pneumonia. Educational objective: Strategies to prevent postoperative pneumonia include adequate pain management, positioning, coughing and deep breathing, mobilization and early ambulation, twice daily chlorhexidine mouth care, and precautions for limiting the transmission of microorganisms.

Question 5

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply.

Accepted Answer

11ecbb05_ca66_fbd3_b433_71c86b042a05_MD0009_00 Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option B) Dyspnea and hypoxemia (Options C and D) Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option E) Tachycardia Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option A) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option F) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung. Educational objective: Pulmonary embolism is a potentially life-threatening medical emergency occurring when a pulmonary artery is obstructed. Common clinical manifestations include pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral leg swelling.

Question 6

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

Accepted Answer

HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm³). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. ³ The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). (Option A) The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is not the best indicator of treatment effectiveness. (Option B) Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best indicators of treatment effectiveness. (Option C) Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease, peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness. Educational objective: Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production).

Question 7

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action?

Accepted Answer

The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/minin order to reverse this displacement of oxygen. (Option A) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option C) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option D) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO₂) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective: The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO.

Question 8

A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply.

Accepted Answer

Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy. Clinical manifestations indicating impending respiratory failure include: PaCO₂ ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO₂ rises and respiratory acidosis develops (Option B). PaO₂ ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand (Option C) Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles (Option D) Paradoxical breathing Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia (Option E) Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath (Option A) Normal arterial pH is 7.35-7.45. A pH of 7.50 indicates alkalosis, which could be respiratory or metabolic. Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO₂). Educational objective: Clinical manifestations indicating impending respiratory failure in clients with asthma include hypercapnia, hypoxemia, paradoxical breathing, and mental status changes.

Question 9

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply.

Accepted Answer

11ecbb05_ca64_8ad0_b433_17ec3b0ff3c2_MD0009_00 A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Thoracentesis Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options A and C). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option B). (Option D) Fluid outside the lung interrupts the transmission of sound, resulting in decreased fremitus and dullness with percussion in pleural effusion. Percussion is hyperresonant in clients with pneumothorax. (Option E) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion. Educational objective: A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.

Question 10

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?

Accepted Answer

11ecbb05_ca68_d095_b433_b92e14e6f6b6_MD0009_00 Pneumonia is an inflammatory process in the alveoli and interstitium of the lung usually caused by an infectious or noninfectious agent. Any condition, such as advanced age (>65), that compromises the respiratory system's protective mechanical or immune mechanisms to maintain the sterility of the lower airway can increase the risk for pneumonia. (Options B, C, and D) Working in the garden and being exposed to environmental factors (eg, pollen), eating a vegetarian diet, and obesity do not pose the greatest risks for development of pneumonia. Educational objective: Any condition that compromises the respiratory system's protective mechanical or immune mechanisms, which maintain the sterility of the lower airway, can increase the risk for pneumonia.

Question 11

The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN).  They are caring for a client who has a chest tube connected to wall suction for a pneumothorax.  The client is being transferred from the ED to the telemetry unit.  Which action by the new RN would cause the charge nurse to intervene?

Accepted Answer

Clamping the chest tube during transport is contraindicated. Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition. A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls. (Option B) The wall suction needs to be temporarily disconnected during transport. It should be reconnected promptly at the destination. (Option C) The chest tube collection unit should be hung below the level of the chest to promote drainage and keep fluids from re-entering the chest cavity. (Option D) All connections should be secured with tape to prevent accidental disconnection or air to enter the system. Educational objective: Chest tubes should not be clamped during transport of a client. A clamped chest tube may cause a tension pneumothorax, a potentially life-threatening event.

Question 12

A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority?

Accepted Answer

11ecbb05_ca67_bf24_b433_efea9dd9ba73_MD0009_00 Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO₂ <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need-oxygen. Clients will not survive without adequate oxygenation. (Options A, B, and C) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival. Educational objective: Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival.

Question 13

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply.

Accepted Answer

Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option A) Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options C and D) Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) (Option B) Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax). pneumothorax (Option E) A trachea deviating from midline is not a symptom of pneumonia but instead indicates a tension pneumothorax where the trachea deviates away from the tension. Educational objective: Physical examination of a client with pneumonia can reveal crackles, increased vocal/tactile fremitus, unequal chest expansion, and bronchial breath sounds in peripheral areas. Clients often report fever, chills, productive cough, dyspnea, and pleuritic chest pain.

Question 14

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?

Accepted Answer

11ecbb05_ca63_c77f_b433_e196aba19113_MD0009_00 A thoracentesis involves the insertion of a large-bore needle through an intercostal space to remove excess fluid. The procedure has the following advantages: Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testingTherapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection. After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any abnormalities are noted, a post-procedure chest x-ray is obtained. Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should be reported immediately. pneumothorax (Option B) Hypotension, pulmonary edema, and tachycardia can occur as the result of removal of large amounts of pleural fluid (>1.5 L). This client's blood pressure is adequate (mean arterial pressure 77 mm Hg), and the nurse should continue to monitor. However, this blood pressure does not need to be reported immediately. (Option C) Mild to moderate pain is common after the procedure. It does not need to be reported immediately. (Option D) Difficulty breathing, tachypnea, and hypoxemia are pulmonary complications that can occur after thoracentesis. Saturation (94%) and respiratory rate (24/min) are adequate and do not need to be reported immediately. Educational objective: Complications of thoracentesis include iatrogenic pneumothorax, hemothorax, and infection. Post-procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds.

Question 15

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education?

Accepted Answer

Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). (Option A) Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote comfort in clients receiving MV. (Option C) Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. (Option D) It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency. Educational objective: To minimize removal of oxygen and mucosal trauma, suction should be applied only when removing the catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg, hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, preoxygenating with 100% oxygen, and limiting suction time to 10-15 seconds.

Question 16

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

Accepted Answer

11ecbb05_ca65_ea62_b433_e3792b92debf_MD0009_00 The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option A) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option C) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option D) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy. Educational objective: The immediate postoperative priority goal for a client with a newly placed tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway.

Question 17

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply.

Accepted Answer

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option A) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option C) and repositioning the client (Option E). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option B) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H₂O is not indicated. (Option D) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space. Educational objective: The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.

Question 18

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask?

Accepted Answer

11ecbb05_ca61_cbae_b433_012f44c13e89_MD0009_00 Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space (Option C) (Options A, B, and D) It is important to reconcile the client's vaccinations, obtain a nutritional history, and explore the nature of the client's symptoms, but it is essential to rule out the possibility of CO toxicity given the circumstances of this client's illness. Educational objective: Carbon monoxide (CO) toxicity can occur when fuel-burning (eg, wood, coal) stoves or appliances are used in poorly ventilated settings. Clients with CO toxicity may have vague symptoms (eg, headache, dizziness, nausea), so it is important to assess for possible CO exposure to prevent delay of appropriate emergency care.

Question 19

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction?

Accepted Answer

Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace. (Option A) Smoking cessation is the best way to prevent lung cancer. Nicotine replacement therapy (eg, patches, gum, inhalers, lozenges) is effective in helping smokers quit by reducing cravings. Although users receive a low dose of nicotine, they do not receive the other toxins that cigarettes include. (Option C) The best way to reduce the risk of lung cancer is to avoid both firsthand and secondhand smoke. Smoke from someone else's burning cigarette contains the same carcinogens as those found in mainstream smoke and creates a health risk to those inhaling it. (Option D) Exposure to high levels of radon can cause lung cancer. Radon levels must be tested before a home can be sold. Educational objective: Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace.

Question 20

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP?

Accepted Answer

VAP is the second most common health care-associated infection (HAI) in the United States and is associated with increased mortality, hospital cost, and length of stay. Because it is a nosocomial infection, signs and symptoms associated with VAP usually present within ≥2-3 days after initiation of mechanical ventilation (MV). Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (12,000 mm³), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray. ³ (Option A) Blood-tinged sputum may occur but is not the best indicator of VAP. (Option B) Positive blood cultures may identify the microorganism causing the infection but are not the best indicator of VAP. Positive blood cultures could be from another source of infection. (Option D) Rhonchi and crackles are adventitious lung sounds associated with pneumonia but can be present in pulmonary edema or just from increased mucous secretions. They are not the best indicator of VAP. Educational objective: VAP is an HAI that usually occurs within ≥2-3 days after the initiation of mechanical ventilation. Characteristic manifestations of VAP include purulent secretions, positive sputum culture, leukocytosis, elevated temperature, and new or progressive pulmonary infiltrates on chest x-ray.

Exam 1: Adult Health

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately?

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply.

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply.

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply.

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action?

A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply.

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply.

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply.

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV) . Which action by the new RN indicates the need for further education?

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask?

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction?