Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems Nursing School Test Banks

Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92% at rest
c. A 35-year-old client who has a longer expiratory phase than inspiratory phase
d. A 27-year-old client with a heart rate of 120 beats/min
ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

DIF: Applying/Application REF: 552
KEY: Respiratory distress/failure| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

2. A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
a. Review the clients pulmonary function test results.
b. Ask about medications the client is currently taking.
c. Assess how frequently the client uses a bronchodilator.
d. Consult the provider and request arterial blood gases.
ANS: B
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the clients history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

DIF: Applying/Application REF: 553
KEY: Respiratory distress/failure| medication
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching?
a. I will carry this medication with me at all times in case I need it.
b. I will take this medication when I start to experience an asthma attack.
c. I will take this medication every morning to help prevent an acute attack.
d. I will be weaned off this medication when I no longer need it.
ANS: C
Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

DIF: Applying/Application REF: 554
KEY: Medication| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?
a. The client lays on his or her side with his or her knees bent.
b. The client places his or her hands on his or her abdomen.
c. The client lays in a prone position with his or her legs straight.
d. The client places his or her hands above his or her head.
ANS: B
To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

DIF: Applying/Application REF: 562
KEY: Respiratory distress/failure| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?
a. Spaghetti with meat sauce, ice cream
b. Chicken soup, grilled cheese sandwich
c. Omelet, soft whole wheat bread
d. Pasta salad, custard, orange juice
ANS: C
Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

DIF: Applying/Application REF: 576 KEY: Cancer| nutrition
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond?
a. I will ask the provider to change your medication to a drug that is less potent.
b. Would you like me to use music therapy to distract you from your pain?
c. It is unlikely you will become addicted when taking medicine for pain.
d. Would you like me to give you acetaminophen (Tylenol) instead?
ANS: C
Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication.

DIF: Applying/Application REF: 576
KEY: Cancer| pain| pharmacologic pain management
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
a. I will be certain to shake the inhaler well before I use it.
b. It may take a while before I notice a change in my asthma.
c. I will use the drug when I have an asthma attack.
d. I will be careful not to let the drug escape out of my nose and mouth.
ANS: C
Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the clients part allows the drug to escape through the nose and mouth.

DIF: Applying/Application REF: 554
KEY: Medication| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

8. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?
a. There are a variety of support groups for people who have COPD.
b. I will ask your provider to prescribe you with an antianxiety agent.
c. Share any thoughts and feelings that cause you to limit social activities.
d. Friends can be a good support system for clients with chronic disorders.
ANS: C
Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

DIF: Applying/Application REF: 561 KEY: Coping| support
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

9. A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching?
a. Take an antibiotic each day.
b. Contact your provider to obtain genetic screening.
c. Eat a well-balanced, nutritious diet.
d. Plan to exercise for 30 minutes every day.
ANS: C
Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

DIF: Applying/Application REF: 567
KEY: Nutrition| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

10. While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the provider and obtain a suture kit.
d. Reinsert the tube using sterile technique.
ANS: B
Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

DIF: Applying/Application REF: 578
KEY: Drains| surgical care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

11. A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
a. Encourage oral rinsing after fluticasone administration.
b. Obtain an oral specimen for culture and sensitivity.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.
ANS: A
The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

DIF: Applying/Application REF: 554
KEY: Medication| fungal infection
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

12. A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?
a. Instruct the client to wash his or her hands after contact with other people.
b. Implement Droplet Precautions and don a surgical mask.
c. Keep the client isolated from other clients with cystic fibrosis.
d. Obtain blood, sputum, and urine culture specimens.
ANS: C
Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.

DIF: Applying/Application REF: 568
KEY: Pulmonary infection| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

13. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the clients anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
ANS: D
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the clients discomfort and need to take deep breaths to prevent complications.

DIF: Applying/Application REF: 580
KEY: Pain| pharmacologic pain management| drain| surgical care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
a. When the insertion site becomes red and warm to the touch
b. When the tube drainage decreases and becomes sanguineous
c. When the client experiences pain at the insertion site
d. When the tube becomes disconnected from the drainage system
ANS: D
Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the clients risk for a pneumothorax.

DIF: Applying/Application REF: 578
KEY: Drain| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

15. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?
a. Increased pulmonary pressure creating a higher workload on the right side of the heart
b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles
c. Increased number and size of mucus glands producing large amounts of thick mucus
d. Left ventricular hypertrophy creating a decrease in cardiac output
ANS: A
Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

DIF: Remembering/Knowledge REF: 58
KEY: Heart failure| cor pulmonale
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

16. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?
a. Do you have a strong support system?
b. What do you understand about your disease?
c. Do you experience shortness of breath with basic activities?
d. What medications are you prescribed to take each day?
ANS: C
Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the clients support systems, current knowledge, and medications, these questions do not address the clients appearance.

DIF: Applying/Application REF: 561 KEY: Functional ability
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity

17. The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond?
a. You are using the inhaler incorrectly. This medication should be taken daily.
b. If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks.
c. Tell me more about your fears related to feelings of breathlessness.
d. It is important to use this type of inhaler every day. Lets identify potential community services to help you.
ANS: D
Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the clients financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the clients immediate concerns.

DIF: Applying/Application REF: 554
KEY: Case management| medication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity

18. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
a. A 46-year-old with a 30pack-year history of smoking
b. A 52-year-old in a tripod position using accessory muscles to breathe
c. A 68-year-old who has dependent edema and clubbed fingers
d. A 74-year-old with a chronic cough and thick, tenacious secretions
ANS: B
The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

DIF: Applying/Application REF: 559 KEY: Health screening
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

19. The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
a. I plan to wear my oxygen when I exercise and feel short of breath.
b. I will use my portable oxygen when grilling burgers in the backyard.
c. I plan to use cotton balls to cushion the oxygen tubing on my ears.
d. I will only smoke while I am wearing my oxygen via nasal cannula.
ANS: C
Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

DIF: Applying/Application REF: 563
KEY: Safety| patient education| oxygen therapy
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

20. A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
a. Strip the tubing to minimize clot formation and ensure patency.
b. Secure tubing junctions with clamps to prevent accidental disconnections.
c. Connect the chest tube to wall suction at the level prescribed by the provider.
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
ANS: D
Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the devices manufacturer, not the provider.

DIF: Remembering/Knowledge REF: 578
KEY: Drains| postsurgical care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

21. A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond?
a. Your children will be at high risk for the development of chronic obstructive pulmonary disease.
b. I will contact a genetic counselor to discuss your condition.
c. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.
d. This is a recessive gene and should have no impact on your health.
ANS: C
The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partners AAT levels. Contacting a genetic counselor may be helpful but does not address the clients current question.

DIF: Applying/Application REF: 558
KEY: Gene| allele| health screening| a1AT (alpha1-antitrypsin) gene
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

22. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
a. Since many of your family members are carriers, your children will also be carriers of the gene.
b. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
c. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.
d. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
ANS: C
Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

DIF: Applying/Application REF: 567
KEY: Gene| allele| health screening MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

23. A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication?
a. Bronchodilator Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators
b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system
c. Corticosteroid Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors
d. Cromone Disrupts the production of pathways of inflammatory mediators
ANS: B
Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

DIF: Remembering/Knowledge REF: 554 KEY: Medications
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

24. A nurse auscultates a clients lung fields. Which pathophysiologic process should the nurse associate with this breath sound?
(Click the media button to hear the audio clip.)
a. Inflammation of the pleura
b. Constriction of the bronchioles
c. Upper airway obstruction
d. Pulmonary vascular edema
ANS: A
A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lung wall. The other pathophysiologic processes would not cause a pleural friction rub. Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may be heard as stridor, and pulmonary vascular edema may be heard as crackles.

DIF: Applying/Application REF: 575
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

25. A nurse auscultates a clients lung fields. Which action should the nurse take based on the lung sounds?
(Click the media button to hear the audio clip.)
a. Assess for airway obstruction.
b. Initiate oxygen therapy.
c. Assess vital signs.
d. Elevate the clients head.
ANS: A
Stridor is the sound heard, and it indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen, assessing vital signs, and elevating the clients head will not help until the clients airways are open.

DIF: Applying/Application REF: 575
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

26. The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur?
1. Take as deep a breath as possible.
2. Stand up (unless you have a physical disability).
3. Place the meter in your mouth, and close your lips around the mouthpiece.
4. Make sure the device reads zero or is at base level.
5. Blow out as hard and as fast as possible for 1 to 2 seconds.
6. Write down the value obtained.
7. Repeat the process two additional times, and record the highest number in your chart.
a. 4, 2, 1, 3, 5, 6, 7
b. 3, 4, 1, 2, 5, 7, 6
c. 2, 1, 3, 4, 5, 6, 7
d. 1, 3, 2, 5, 6, 7, 4
ANS: A
The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the clients chart.

DIF: Applying/Application REF: 552
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

27. The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur?
1. Press down firmly on the canister to release one dose of medication.
2. Breathe in slowly and deeply.
3. Shake the whole unit vigorously three or four times.
4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer.
5. Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece.
6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
a. 2, 3, 4, 5, 6, 1
b. 3, 4, 5, 1, 6, 2
c. 4, 3, 5, 1, 2, 6
d. 5, 3, 6, 1, 2, 4
ANS: C
The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.

DIF: Applying/Application REF: 555 KEY: Medication safety
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

28. A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results Vital Signs
pH = 7.32
PaCO2 = 62 mm Hg
PaO2 = 46 mm Hg
HCO3 = 28 mEq/L Heart rate = 110 beats/min
Respiratory rate = 12 breaths/min
Blood pressure = 145/65 mm Hg
Oxygen saturation = 76%
Which action should the nurse take first?
a. Administer a short-acting beta2 agonist inhaler.
b. Document the findings as normal for a client with COPD.
c. Teach the client diaphragmatic breathing techniques.
d. Initiate oxygenation therapy to increase saturation to 92%.
ANS: D
Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the clients hypoxia, which is the priority.

DIF: Applying/Application REF: 563
KEY: Oxygen therapy| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
a. Administer prescribed salmeterol (Serevent) inhaler.
b. Assess the client for a tracheal deviation.
c. Administer oxygen to keep saturations greater than 94%.
d. Perform peak expiratory flow readings.
e. Administer prescribed albuterol (Proventil) inhaler.
ANS: C, E
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

DIF: Applying/Application REF: 575
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
ANS: B, D, E, F
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

DIF: Applying/Application REF: 579
KEY: Drain| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.)
a. Avoid drinking fluids just before and during meals.
b. Rest before meals if you have dyspnea.
c. Have about six small meals a day.
d. Eat high-fiber foods to promote gastric emptying.
e. Increase carbohydrate intake for energy.
ANS: A, B, C
Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the clients risk of for acidosis.

DIF: Applying/Application REF: 565
KEY: Nutrition| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

4. A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.)
a. What color is your sputum?
b. Do you have any difficulty sleeping?
c. How long does it take to perform your morning routine?
d. Do you walk upstairs every day?
e. Have you lost any weight lately?
ANS: B, C, E
Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the clients sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

DIF: Applying/Application REF: 559 KEY: Functional ability
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Sudden onset of shortness of breath
d. Pain at insertion site
e. Drainage of 75 mL/hr
ANS: B, C
Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

DIF: Applying/Application REF: 579
KEY: Drain| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
a. Ask the client to drink 2 liters of fluids daily.
b. Add humidity to the prescribed oxygen.
c. Suction the client every 2 to 3 hours.
d. Use a vibrating positive expiratory pressure device.
e. Encourage diaphragmatic breathing.
ANS: A, B, D
Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the clients ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

DIF: Applying/Application REF: 564
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the clients safety while on this medication? (Select all that apply.)
a. Keep an intravenous line dedicated strictly to the infusion.
b. Teach the client that this medication increases pulmonary pressures.
c. Ensure that there is always a backup drug cassette available.
d. Start a large-bore peripheral intravenous line.
e. Use strict aseptic technique when using the drug delivery system.
ANS: A, C, E
Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

DIF: Understanding/Comprehension REF: 571
KEY: Medication administration| safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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