Question 1

The nurse is planning care for a child with respiratory syncytial virus (RSV)bronchiolitis with the nursing diagnosis of Impaired Gas Exchange.Which interventions should be included in the child's plan of care? Select all that apply.
A) Weigh daily.
B) Monitor vital signs and pulse oximetry.
C) Administer oxygen as prescribed.
D) Weigh diapers.
E) Provide frequent rest periods.

Accepted Answer

A) Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.
B) Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.
C) Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.
D) Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.
E) Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.

Question 2

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV).The nurse is aware that which action is the best way to prevent RSV?
A) Hand washing
B) Monitoring temperature
C) Administering antibiotics
D) Limiting fluid intake

Accepted Answer

A) According to the Center for Disease Control and Prevention (CDC), the best way to prevent RSV is through good hand hygiene and infection-control measures. This can be accomplished through frequent washing of hands with soap and water and avoiding sharing items such as food, cups, or utensils with infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when infection is suspected. There is no indication of the need to limit fluids, which could potentially produce other complications.
B) According to the Center for Disease Control and Prevention (CDC), the best way to prevent RSV is through good hand hygiene and infection-control measures. This can be accomplished through frequent washing of hands with soap and water and avoiding sharing items such as food, cups, or utensils with infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when infection is suspected. There is no indication of the need to limit fluids, which could potentially produce other complications.
C) According to the Center for Disease Control and Prevention (CDC), the best way to prevent RSV is through good hand hygiene and infection-control measures. This can be accomplished through frequent washing of hands with soap and water and avoiding sharing items such as food, cups, or utensils with infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when infection is suspected. There is no indication of the need to limit fluids, which could potentially produce other complications.
D) According to the Center for Disease Control and Prevention (CDC), the best way to prevent RSV is through good hand hygiene and infection-control measures. This can be accomplished through frequent washing of hands with soap and water and avoiding sharing items such as food, cups, or utensils with infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when infection is suspected. There is no indication of the need to limit fluids, which could potentially produce other complications.

Question 3

An infant with respiratory syncytial virus (RSV)bronchiolitis is prescribed intubation to maintain an adequate airway.Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? Select all that apply.
A) An advanced practice nurse
B) A dietitian
C) The primary healthcare provider
D) A respiratory therapist
E) A play therapist

Accepted Answer

A) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.
B) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.
C) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.
D) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.
E) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. In addition, the nurse will collaborate with the dietitian for nutritional support once the endotracheal tube is in place. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.

Question 4

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD).Which observation would indicate that care provided to this client has been effective?
A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.
B) Client needs assistance with morning care and meals due to shortness of breath.
C) Client states family members are discussing admission to a nursing home for continuing care.
D) Client leaves hospital unit to smoke outside 4 times a day.

Accepted Answer

A) Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client's leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.
B) Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client's leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.
C) Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client's leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.
D) Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client's leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.

Question 5

The nurse on the medical unit is admitting a client with chronic obstructive pulmonary disease (COPD).Which prescription does the nurse anticipate to decrease this client's risk for developing a respiratory infection?
A) A broad-spectrum antibiotic
B) A bronchodilator
C) A corticosteroid
D) An influenza vaccine

Accepted Answer

A) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when asthma is a major component of COPD. It improves symptoms and exercise tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an infection.
B) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when asthma is a major component of COPD. It improves symptoms and exercise tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an infection.
C) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when asthma is a major component of COPD. It improves symptoms and exercise tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an infection.
D) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when asthma is a major component of COPD. It improves symptoms and exercise tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an infection.

Question 6

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD).The client's family ask how their loved on got this disease.Which risk factors for COPD will the nurse include in the teaching session?
A) Asthma and bronchitis
B) Asthma and emphysema
C) Bronchitis and emphysema
D) Emphysema and atelectasis

Accepted Answer

A) Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Although the COPD complex can also include asthma, small airways disease, and narrowing of small bronchioles, it is more commonly known to include bronchitis and emphysema.
B) Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Although the COPD complex can also include asthma, small airways disease, and narrowing of small bronchioles, it is more commonly known to include bronchitis and emphysema.
C) Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Although the COPD complex can also include asthma, small airways disease, and narrowing of small bronchioles, it is more commonly known to include bronchitis and emphysema.
D) Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Although the COPD complex can also include asthma, small airways disease, and narrowing of small bronchioles, it is more commonly known to include bronchitis and emphysema.

Question 7

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD).When planning care for this client,which interventions are appropriate to enhance the client's breathing pattern? Select all that apply.
A) Provide adequate rest periods.
B) Assist with ADLs.
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer a cough suppressant.

Accepted Answer

A) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.
B) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.
C) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.
D) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.
E) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.

Question 8

A client diagnosed with chronic obstructive pulmonary disease (COPD)has a pulse oximetry reading of 93%,increased red blood and white blood cell count,temperature of 101°F,pulse 100 bpm,respirations 35 bpm,and a chest x-ray that showed a flattened diaphragm with infiltrates.Based on this data,which prescription does the nurse question for this client?
A) Antibiotic therapy
B) Nonsteroidal anti-inflammatory agents
C) Oxygen by nasal cannula at 3-4 liters/minute
D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

Accepted Answer

A) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a client with COPD because the client's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute, with close assessments of the client's breathing status. The order for antibiotic therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this client.
B) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a client with COPD because the client's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute, with close assessments of the client's breathing status. The order for antibiotic therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this client.
C) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a client with COPD because the client's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute, with close assessments of the client's breathing status. The order for antibiotic therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this client.

Question 9

Which interventions would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV)bronchiolitis? Select all that apply.
A) Do not smoke, and avoid all secondhand smoke around the child.
B) Practice frequent hand washing.
C) Encourage physical activity and play.
D) Consider alternatives to sending the child to daycare.
E) Ensure an adequate nutritional intake.

Accepted Answer

A) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.
B) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.
C) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.
D) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.
E) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke is a known risk factor for the development of the illness. The nurse should discuss with the parents the need for smoking cessation and not permitting the child to be exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the development of the disorder. The nurse should ask the parents to consider alternatives to sending the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this client and parents at this time. Nutritional intake and physical activity are also important but not of the highest priority to the child and parents at this time.

Question 10

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV).Which nursing diagnosis would be most appropriate for the infant?
A) Acute Pain
B) Ineffective Tissue Perfusion
C) Activity Intolerance
D) Decreased Cardiac Output

Accepted Answer

A) Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.
B) Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.
C) Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.
D) Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.

Question 11

The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD.Which interventions are appropriate in order to control the client's breathing pattern? Select all that apply.
A) Instruct in pursed-lip breathing.
B) Teach visualization and meditation.
C) Deep breathing and coughing every hour.
D) Instruct in abdominal breathing.
E) Provide oxygen 2 liters nasal cannula.

Accepted Answer

A) Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.
B) Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.
C) Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.
D) Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.
E) Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.

Question 12

The nurse observes a toddler-age client,admitted with possible respiratory syncytial virus (RSV)bronchiolitis,grunting with expiration.Which action by the nurse is appropriate?
A) Assist the child to clear the nasal passages.
B) Limit fluids.
C) Suction the airway to relieve the obstruction.
D) Lay the child on his back.

Accepted Answer

A) Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.
B) Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.
C) Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.
D) Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.

Question 13

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD)who has a breathing rate of 32 per minutes,elevated blood pressure,and fatigue.Which nursing diagnosis is the priority for this client?
A) Ineffective Coping
B) Ineffective Airway Clearance
C) Anxiety
D) Ineffective Breathing Pattern

Accepted Answer

A) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
B) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
C) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
D) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.

Question 14

The mother of a 5-month-old baby,who attends daycare,is concerned because the child has developed a runny nose,cough,and low-grade fever over the last few days.Based on this data,which diagnosis does the nurse anticipate?
A) Meningitis
B) Respiratory syncytial virus (RSV) bronchiolitis
C) Bronchitis
D) The common cold

Accepted Answer

A) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.
B) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.
C) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.
D) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.

Question 15

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD).The client speaks very little English and is a smoker.Which action would be the most beneficial for this client?
A) Have the adult child of the client translate during the assessment process
B) Encourage aerobic activity
C) Encourage the client to write down questions prior to seeing the healthcare provider
D) Obtain educational materials about smoking cessation written in Spanish.

Accepted Answer

A) A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish. Relatives should not be used as a medical interpreter due to the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English speaking client but will not be appropriate for a Spanish speaking client being treated in an English speaking healthcare environment.
B) A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish. Relatives should not be used as a medical interpreter due to the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English speaking client but will not be appropriate for a Spanish speaking client being treated in an English speaking healthcare environment.
C) A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish. Relatives should not be used as a medical interpreter due to the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English speaking client but will not be appropriate for a Spanish speaking client being treated in an English speaking healthcare environment.
D) A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish. Relatives should not be used as a medical interpreter due to the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English speaking client but will not be appropriate for a Spanish speaking client being treated in an English speaking healthcare environment.

Question 16

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD)is educating the client on effective coughing techniques.Which statement made by the client indicates a need for further teaching?
A) "I should inhale by sniffing."
B) "I should avoid aerosol sprays."
C) "I should limit my fluid intake to 1-1.5 quarts daily."
D) "I should get a flu vaccine every year."

Accepted Answer

A) Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.
B) Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.
C) Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.
D) Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.

Question 17

The nurse is providing care to a client with respiratory syncytial virus (RSV).The client's condition is not severe and there is no history of immune compromise.Which pharmacologic therapies does the nurse anticipate based on this data? Select all that apply.
A) Nebulized epinephrine
B) Ribavirin
C) Systemic corticosteroids
D) Antibiotics
E) Antipyretics

Accepted Answer

A) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.
B) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.
C) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.
D) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.
E) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to result in some reduction in RSV hospitalizations. Antipyretics may be used to treat the fever associated with RSV. Unless the client also has a bacterial infection, antibiotics will not be prescribed. The use of Ribavirin remains controversial because it has only marginal benefit. Its use is reserved for cases of severe disease, such as infants with complicated congenital heart disease or who are immunocompromised.

Question 18

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV.Which response by the nurse is appropriate?
A) "There is a higher risk in children who are being breastfed."
B) "There is no way to avoid the illness."
C) "There is a higher risk in children who are exposed to secondary cigarette smoke."
D) "It is seen more frequently in children who do not attend daycare."

Accepted Answer

A) Risk for RSV is higher when the parent or caregiver smokes. Tobacco smoke increases mucus production and reduces the action of cilia within the airway passages. Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.
B) Risk for RSV is higher when the parent or caregiver smokes. Tobacco smoke increases mucus production and reduces the action of cilia within the airway passages. Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.
C) Risk for RSV is higher when the parent or caregiver smokes. Tobacco smoke increases mucus production and reduces the action of cilia within the airway passages. Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.
D) Risk for RSV is higher when the parent or caregiver smokes. Tobacco smoke increases mucus production and reduces the action of cilia within the airway passages. Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.

Question 19

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the client's history support the current diagnosis? Select all that apply.
A) Working in an industrial environment
B) Working in an office setting with air conditioning
C) History of asthma
D) Current cigarette smoking
E) Playing golf several times a week

Accepted Answer

A) Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.
B) Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.
C) Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.
D) Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.
E) Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.

Question 20

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV)bronchiolitis.Which assessment finding indicate that treatment has been effective?
A) Client ingesting small amounts of clear fluids when encouraged
B) Client resting in bed with limited interest in play or activities
C) Client respiratory rate within normal limits for age
D) Client coughing copious amounts of green sputum and requires occasional suctioning.

Accepted Answer

A) Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.
B) Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.
C) Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.
D) Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.

Quiz 15: Oxygenation

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis with the nursing diagnosis of Impaired Gas Exchange.Which interventions should be included in the child's plan of care? Select all that apply.

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV) .The nurse is aware that which action is the best way to prevent RSV?

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway.Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? Select all that apply.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) .Which observation would indicate that care provided to this client has been effective?

The nurse on the medical unit is admitting a client with chronic obstructive pulmonary disease (COPD) .Which prescription does the nurse anticipate to decrease this client's risk for developing a respiratory infection?

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD) .The client's family ask how their loved on got this disease.Which risk factors for COPD will the nurse include in the teaching session?

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) .When planning care for this client,which interventions are appropriate to enhance the client's breathing pattern? Select all that apply.

Which interventions would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis? Select all that apply.

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV) .Which nursing diagnosis would be most appropriate for the infant?

The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD.Which interventions are appropriate in order to control the client's breathing pattern? Select all that apply.

The nurse observes a toddler-age client,admitted with possible respiratory syncytial virus (RSV) bronchiolitis,grunting with expiration.Which action by the nurse is appropriate?

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minutes,elevated blood pressure,and fatigue.Which nursing diagnosis is the priority for this client?

The mother of a 5-month-old baby,who attends daycare,is concerned because the child has developed a runny nose,cough,and low-grade fever over the last few days.Based on this data,which diagnosis does the nurse anticipate?

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD) .The client speaks very little English and is a smoker.Which action would be the most beneficial for this client?

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) is educating the client on effective coughing techniques.Which statement made by the client indicates a need for further teaching?

The nurse is providing care to a client with respiratory syncytial virus (RSV) .The client's condition is not severe and there is no history of immune compromise.Which pharmacologic therapies does the nurse anticipate based on this data? Select all that apply.

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV) /bronchiolitis wants to know which factors contribute to the risk of contracting RSV.Which response by the nurse is appropriate?

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) ? Which factors in the client's history support the current diagnosis? Select all that apply.

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis.Which assessment finding indicate that treatment has been effective?