Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems Nursing School Test Banks

Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems

Test Bank

MULTIPLE CHOICE

1. A client with asthma reports not being able to take deep breaths. The nurse auscultates decreased breath sounds in the bases, and no wheezes. What is the nurses best action?

a.

Encourage the client to stay calm and take deep breaths.

b.

Document the findings and continue to monitor.

c.

Have the client cough forcefully.

d.

Assess the clients oxygen saturation.

ANS: D

Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from mucus and from inflammation. The nurse should assess the clients oxygenation and determine whether additional interventions are needed. Coughing forcefully may cause the smaller airways to collapse and may not help the client. Encouraging the client to remain calm and to try to take deep breaths is not helpful. Although providing documentation is important, the nurse needs to do more than that.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

2. A client with asthma has been having frequent asthma attacks. What is the nurses best action?

a.

Teach the client to stay away from pets.

b.

Assist the client in using an incentive spirometer.

c.

Administer aspirin for its anti-inflammatory properties.

d.

Administer montelukast (Singulair).

ANS: D

A client who has been having increased attacks can have some chronic inflammation occurring. This inflammation is probably stimulated by mediators such as histamine and leukotriene and can be blocked by drugs like diphenhydramine (Benadryl) and montelukast (Singulair).

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

3. A client diagnosed with asthma has not responded well to medication. The client is concerned and asks the nurse, What is wrong with me, and why am I not getting better? What is the nurses best response?

a.

You just werent used to the medication yet.

b.

The medication dose has to be increased.

c.

It is possible that genetic testing may help.

d.

You should try homeopathic medicine.

ANS: C

Some genetic variations may cause the activity of beta-adrenergic receptors to change, meaning that the client would not respond as expected to beta agonists. Genetic testing may help to determine why the drug therapy is not working and may help the clinician to identify new therapy that will work.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

4. The nurse is caring for four clients with asthma. Which client does the nurse assess first?

a.

Client with a barrel chest and clubbed fingernails

b.

Client with an SaO2 level of 92% at rest

c.

Client whose expiratory phase is longer than the inspiratory phase

d.

Client whose heart rate is 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

5. The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate?

a.

Review pulmonary function test results.

b.

Assess use of medication for arthritis.

c.

Assess frequency of bronchodilator use.

d.

Review arterial blood gas results.

ANS: B

Aspirin and other 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is evaluating a clients response to medication therapy for asthma. The client has a peak flowmeter reading in the yellow zone. What does the nurse do next?

a.

Nothing; this is an acceptable range.

b.

Teach the client to take deeper breaths.

c.

Assist the client to use a rescue inhaler.

d.

Assess the clients lungs.

ANS: C

The client with a peak flow reading in the yellow zone needs to use a rescue inhaler, then have a reading taken again within a few minutes. The nurse has no reason to assess the clients lungs at this point in time, nor would the nurse take the time to teach at this moment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

7. Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications?

a.

I will not have to take this medication every day.

b.

I will take this medication when I have an asthma attack.

c.

I will take this medication daily to prevent an acute attack.

d.

I will eventually be able to stop using this medication.

ANS: C

This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)

8. Which statement indicates that a client understands teaching about the correct use of a corticosteroid medication?

a.

This drug can reverse my symptoms during an asthma attack.

b.

This drug is effective in decreasing the frequency of my asthma attacks.

c.

This drug can be used most effectively as a rescue agent.

d.

This drug can be used safely on a long-term basis for multiple applications daily.

ANS: B

Corticosteroids decrease inflammatory and immune responses in many ways, including preventing the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they are not effective in reversing symptoms during an asthma attack and should not be used as rescue drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate intermittent asthma and are used on a short-term basis for moderate asthma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)

9. A client is using omalizumab (Xolair) for the first time. What is the priority nursing action?

a.

Make sure the client takes the medication with water.

b.

Administer ibuprofen (Motrin) because Xolair often causes headaches.

c.

Teach the client how to use a syringe.

d.

Remain with the client and assess for anaphylaxis.

ANS: D

Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with the client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

10. A client is demonstrating diaphragmatic breathing for the nurse. Which action by the client shows adequate understanding of this breathing technique?

a.

Lying on his or her side with knees bent

b.

Having his or her hands on the abdomen

c.

Having his or her hands over the head

d.

Lying in the prone position

ANS: B

To perform diaphragmatic breathing correctly, the client should put the 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Teaching/Learning

11. A client is undergoing lung reduction surgery. What is the nurses highest priority preoperatively?

a.

Administer medications.

b.

Discuss the possibility of ventilator dependency.

c.

Teach how to cough and deep breathe.

d.

Teach about preoperative testing.

ANS: D

In addition to standard preoperative testing, the client who will undergo lung reduction surgery is tested to determine the location of greatest lung hyperinflation and poorest lung blood flow. These tests include pulmonary plethysmography, gas dilution, and perfusion scans. The other interventions are lower priorities.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first?

a.

Document the size of the sores.

b.

Perform mouth hygiene.

c.

Have the client rinse his or her mouth.

d.

Call the health care provider and hold chemotherapy.

ANS: D

Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

13. A client is undergoing radiation therapy as treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client?

a.

Spaghetti with meat sauce, ice cream

b.

Scrambled eggs, bacon, toast

c.

Omelet, 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. Toast is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 633

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)

14. A client with lung cancer refuses pain medications because he or she is afraid of addiction. What is the nurses best response?

a.

I can ask the physician to change your medication to a drug that is less potent.

b.

I can use other measures such as music therapy to distract you.

c.

It is unlikely you will become addicted from taking medicine for pain.

d.

I can just give you aspirin or acetaminophen (Tylenol) if you like.

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 medications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesPharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Implementation)

15. What is the best instruction for a client who has step II (mild persistent) asthma?

a.

Avoid participating in aerobic exercise.

b.

You will need daily inhaled low-dose steroids.

c.

You need to evaluate your diet for asthma triggers.

d.

Make sure you use a rescue inhaler three times per day.

ANS: B

The most important information for clients with step II (mild persistent) asthma is that they need daily preventive anti-inflammatory medication. Low-dose inhaled steroids are necessary. The client should exercise as tolerated; however, using a rescue inhaler frequently is not recommended and, if this is needed, it should be reported to the health care provider because a change in therapy is likely needed.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-2, p. 603

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

16. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation. What is the nurses best action?

a.

Perform peak expiratory flow readings.

b.

Assess for a midline trachea.

c.

Administer oxygen and a rescue inhaler.

d.

Call a code.

ANS: C

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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

17. The nurse is teaching a client with asthma about self-management. Which statement by the nurse is best?

a.

Keep a daily symptom and intervention diary.

b.

Measure your anterior/posterior diameter weekly.

c.

Note your symptoms when you dont take your medications.

d.

Exercise before and after taking inhalers and compare tolerance.

ANS: A

The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and responses to therapy in asthma. Chest circumference is not expected to change in clients with asthma. The client should not be instructed to discontinue medications. Comparing exercise tolerance before and after activity will not give the client the most complete information about his or her asthma.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 606

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

18. Which statement indicates that a client needs additional teaching about using an inhaler?

a.

I will not exhale into the inhaler.

b.

I will store the inhaler in a drawer in my bedroom.

c.

I will soak my inhaler in water to clean it.

d.

I will inhale and hold my breath.

ANS: C

Submerging an inhaler in water to wash it is not necessary and may cause the medication in the inhaler to clump together if it is a dry powder inhaler. The other statements are all correctthe client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need to inhale and hold breath slightly when using the inhaler.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

19. The home care nurse observes white patches on the oral mucosa of a client with severe, chronic airflow limitation. What is the nurses best action?

a.

Ask the client whether he or she uses a steroid inhaler.

b.

Inquire about any recent viral illnesses.

c.

Have the client rinse the mouth with salt water.

d.

Have the client brush the patches with a soft-bristled brush.

ANS: A

Excessive use of steroid inhalers reduces local immune function and increases the clients risk for oral-pharyngeal infection, including candidiasis, which manifests as white patches on the oral mucosa. The client should not brush the lesions, and salt water will not help the sores. Recent illnesses would have no effect on these lesions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

20. What statement indicates that a client needs further teaching regarding therapy with salmeterol (Serevent)?

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. The client does not have to keep this inhaler with him or her always because it is not used as a rescue medication. Salmeterol (Serevent) 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

21. The nurse is teaching a client about different medications for asthma. Which medication does the nurse teach the client to administer to control the prolonged inflammatory response?

a.

Diphenhydramine (Benadryl)

b.

Montelukast (Singulair)

c.

Aspirin

d.

Bitolterol (Tornalate)

ANS: B

Leukotriene and eotaxin cause later, prolonged inflammatory responses in asthma, which can be blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). No evidence suggests that aspirin helps this inflammatory response. Histamine starts an immediate inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl). Bitolterol (Tornalate) is a short-acting beta agonist that will enhance bronchodilation during an asthma attack, but it will not assist in controlling late inflammation.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-6, p. 606

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

22. A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do?

a.

Join a support group for people with COPD.

b.

Ask the clients physician for an antianxiety agent.

c.

Verbalize his or her thoughts and feelings.

d.

Participate in community activities.

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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC: Integrated Process: Nursing Process (Implementation)

23. The nurse is teaching a client with cystic fibrosis. What activity does the nurse teach as the priority?

a.

Taking daily antibiotics

b.

Having genetic screening

c.

Maintaining good nutrition

d.

Exercising daily

ANS: C

Clients with cystic fibrosis (CF) often are malnourished owing 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

24. The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first?

a.

The clients anterior-posterior chest diameter is 2:2.

b.

Clubbing of the finger tips is noted.

c.

The client has bilateral dependent leg edema.

d.

The client is pale.

ANS: C

The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

25. A client with lung cancer is lying flat in bed and reports shortness of breath. What action does the nurse take first?

a.

Notify the health care provider.

b.

Elevate the head of the bed.

c.

Assess oxygen saturation.

d.

Have the client take deep breaths.

ANS: B

The nurses first action should be to elevate the head of the bed. Next, assessing oxygen saturation will help the nurse determine the clients status. If the oxygen is low, the nurse would increase oxygen flow and have the client take deep breaths. The provider could be notified after the nurse performs the interventions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

26. The nurse observes hematuria in a client receiving IV cyclophosphamide (Cytoxan). After notifying the health care provider, what intervention is the nurses priority?

a.

Obtain a urine specimen.

b.

Assess laboratory studies.

c.

Increase hydration.

d.

Stop the medication.

ANS: D

Hemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy. The physician should be notified to prescribe co-administration of a bladder-protecting agent. The nurse then should stop the medication. Other actions would be to further assess the client and provide hydration to flush the medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

27. A client with pulmonary fibrosis is being discharged home. What is the highest priority teaching need?

a.

Dietary modifications

b.

Determining activity tolerance

c.

Avoiding infection

d.

Medication therapy

ANS: C

It is extremely important to teach the client with pulmonary fibrosis to avoid infection because the disease will quickly become worse as a result of decreased lung function. The client may take longer to recover from an infection, and the ability to recover may be severely limited owing to the progression of the disease. Teaching the client about modifications in diet, how to determine response to activity, and treatment medications would be secondary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

28. The nurse is caring for a client with bronchiolitis obliterans organizing pneumonia (BOOP) and assesses decreased vital capacity during pulmonary function testing. What is the nurses best action?

a.

Administer intermittent positive-pressure breathing treatments.

b.

Administer a short-acting beta-adrenergic medication.

c.

Prepare to administer IV antibiotics.

d.

Document the finding in the clients chart.

ANS: D

Decreased vital capacity is a common finding with this disorder because the white blood cells clump and obliterate airways. The nurse should note the finding and should assist the client in activities that help him or her maintain quality of life.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

29. The nurse is teaching a client with bronchiolitis obliterans organizing pneumonia (BOOP) about corticosteroid therapy. What statement is accurate for the nurse to teach the client?

a.

You will be on this drug the rest of your life.

b.

You will be prone to many long-term side effects of this drug.

c.

A short course of therapy will help with acute episodes.

d.

This medication cannot be taken with antibiotic therapy.

ANS: C

Corticosteroids are used for acute episodes and are very effective in decreasing manifestations. The client may never have another relapse after therapy. The client is not on the drug for life, and therefore is not prone to long-term side effects. Agents can be given with antibiotics.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 630

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

30. A client recently diagnosed with lung cancer is being taught by the nurse. What information does the nurse teach the client?

a.

You will receive 6 weeks of daily radiation therapy.

b.

Lung cancer has a very good prognosis.

c.

Further testing is not needed because lung cancer rarely metastasizes.

d.

It is very likely that surgery will be curative.

ANS: A

This is the only statement that is accurate. Small doses of radiation given over long periods are an effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes. Surgery often is only palliative.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 633

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

31. Which nursing intervention is an example of primary prevention for lung cancer?

a.

Teaching clients with lung cancer how to cough and deep breathe

b.

Teaching clients with lung cancer to avoid infection

c.

Teaching clients about prophylactic antibiotics

d.

Teaching people about smoking and secondhand smoke

ANS: D

Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are examples of secondary prevention.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 631

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

32. A clients chest tube is accidentally dislodged. What action by the nurse is best?

a.

No action is necessary because the area will reseal itself.

b.

Cover the insertion site with a sterile gauze and tape three sides.

c.

Obtain a suture kit and prepare for the physician to suture the site.

d.

Cover the area with an occlusive dressing.

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

33. Which is the highest priority problem for a client with late-stage lung cancer?

a.

Malnutrition

b.

Constipation

c.

Weakness and fatigue

d.

Pain

ANS: D

Although all of these problems are important issues, effective pain management is the most important issue for this client and family. The nurse must serve as a client advocate and must ensure that all appropriate measures for management of intractable, severe pain are implemented.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareIllness Management) MSC: Integrated Process: Nursing Process (Diagnosis)

34. The nurse assesses a clients chest tube and finds continuous bubbling in the water seal chamber. When the nurse clamps the chest tube close to the clients dressing, the bubbling stops. How does the nurse interpret this finding?

a.

An air leak is present at the chest tube insertion site or in the thoracic cavity.

b.

An air leak is present in the drainage system.

c.

More water needs to be added to the water seal.

d.

The system is functioning appropriately and no intervention is needed.

ANS: A

Bubbling in the water seal chamber indicates air drainage from the client and usually is seen when the clients intrathoracic pressure is greater than atmospheric pressure, such as during exhalation, coughing, or sneezing. When the air in the pleural space has been sufficiently removed, bubbling stops. Continuous bubbling indicates an air leak. If the air leak is in the thoracic cavity, air and air pressure increase in the thoracic cavity, forcing more air into the water seal chamber. This air movement is prevented when the chest tube is clamped close to the insertion site.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment)

35. A client was diagnosed with lung cancer and appears distressed. The client states, I am so afraid. What is the best action for the nurse to take?

a.

Provide comfort by holding the clients hand.

b.

Offer to give the client a back rub for relaxation.

c.

Offer the client a PRN antianxiety medication.

d.

Ask the client what is causing the most fear right now.

ANS: D

A diagnosis of lung cancer often causes fear for many reasons, usually poor prognosis, fear of pain, and fear of dyspnea. The nurse should assess what is worrying the client most at the moment so appropriate interventions can be planned. Touch is often a powerful tool, but the nurse should assess whether this is acceptable to the client. The nurse should assess the client further and provide assistance with coping before offering to medicate him.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

MSC: Integrated Process: Caring

36. The nurse is assessing a client who has a chest tube. Which assessment finding requires intervention by the nurse?

a.

Pain at the insertion site

b.

Bloody drainage in the collection chamber

c.

Intermittent bubbling in the water seal chamber

d.

Tidaling in the water seal chamber

ANS: A

Pain is the priority for the client. Bloody drainage may be normal, depending on the clients condition. Intermittent bubbling in the water seal indicates air escaping as the lung fully expands, and does not need to be addressed immediately. Tidaling often occurs with inspiration and expiration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

37. The nurse assesses a client who is on fluticasone (Flovent) and notes oral lesions. What is the nurses best action?

a.

Teach the client to rinse the mouth after Flovent use.

b.

Have the client use a mouthwash daily.

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 Flovent.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

38. A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide?

a.

Expect to experience weight gain.

b.

Watch your diet while on this medication.

c.

Take the drug with food or milk.

d.

Report any abdominal pain or dark-colored vomit.

ANS: D

All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Teaching/Learning

39. A client infected with Burkholderia cepacia is admitted to the unit. What is the nurses priority action when caring for this client?

a.

Instruct the client to wash his or her hands after contact with other people.

b.

Place the client on strict isolation.

c.

Keep the client isolated from other clients with cystic fibrosis.

d.

Administer IV vancomycin daily.

ANS: C

The infection is spread through casual contact between cystic fibrosis clients, thus the need for isolation of these clients from each other. 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 cystic fibrosis clients.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

40. The nurse assesses the following lung sounds in a client. What is the nurses best action? (Click the media button to hear the audio clip.)

a.

Administer a rescue inhaler.

b.

Administer oxygen.

c.

Assess vital signs.

d.

Elevate the clients head.

ANS: A

Stridor is the sound heard. This sound indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen will not help until the clients airways are open.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

41. The nurse assesses an older adult after an upper respiratory infection and notes the following lung sound on auscultation. What is the nurses best action? (Click the media button to hear the audio clip.)

a.

Assess the client for the development of asthma.

b.

Ask the client if he or she finished all the medication.

c.

Administer oxygen immediately.

d.

Assess arterial blood gas.

ANS: A

Scattered wheezes is the sound heard. New-onset asthma can occur in older clients after they recover from an upper respiratory infection or severe cold. The nurse should assess the client for other symptoms such as sputum production and response to activity. Finishing medication would not necessarily cause the client to have wheezing. The nurse should assess oxygen saturation before administering oxygen or assessing arterial blood gas.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. A client 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.

Oxygen saturation greater than 95%

d.

Sudden onset of shortness of breath

e.

Drainage greater than 70 mL/hr

f.

Pain at insertion site

g.

Disconnection at Y site

ANS: B, D, E, G

Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment)

2. What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (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.

Practice diaphragmatic breathing against resistance four times daily.

e.

Eat high-fiber foods to promote gastric emptying.

f.

Eat dry foods rather than wet foods, which are heavier.

g.

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. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine activity tolerance. Which questions elicit the most important information? (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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. A client has a chest tube. What assessment findings require immediate intervention from the nurse? (Select all that apply.)

a.

Intermittent bubbling in the water seal chamber in the client with a pneumothorax

b.

Silent chest in the client with a pneumothorax

c.

Tidaling in the water seal chamber in a client with a pneumothorax

d.

Bloody drainage in the tubing of a client with a hemothorax

e.

Tracheal deviation in a client after chest trauma

f.

No drainage in the chest tube of a client with a pneumothorax

g.

Constant bubbling in the water seal chamber in a client post chest surgery

ANS: B, E, G

The client with a silent chest could have a mucous plug, the client with tracheal deviation could have a collapsed lung or tension pneumothorax, and the client with constant bubbling in the water seal could have an air leak. All of these assessments require intervention. The others are normal for the condition stated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment)

5. Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.)

a.

Clubbed fingers

b.

Increased residual volume

c.

Decreased peak flow

d.

Increased anterior-posterior diameter

e.

Elevated platelets

f.

Expiratory wheezing

g.

Stridor

h.

Change in sputum color and amount

ANS: C, F, G, H

Decreased peak flow could indicate worsening of symptoms of airflow occlusion. Likewise, expiratory wheezing and stridor can indicate inflammation and fluid accumulation leading to airway occlusion. A change in the amount and color of sputum can indicate infection. The other symptoms normally occur with chronic disease.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse is teaching a client with asthma how to avoid attacks. What information does the nurse give the client? (Select all that apply.)

a.

You should not dust your furniture.

b.

Stay inside as much as possible.

c.

Stay away from people who are sick.

d.

Do not go out in the fall.

e.

Stay out of the snow.

f.

Do not take aspirin.

ANS: A, F

Dusting the furniture may increase dust in the air and cause an asthma attack. Aspirin may stimulate asthma. Staying inside probably will not help. Staying away from snow probably will not have an effect on the clients attacks; neither will going outside during the fall.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Planning)

7. The nurse is assessing a client with asthma. Scattered wheezes are noted, and the clients oxygen saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that apply.)

a.

Assess for accessory muscle use.

b.

Assess anterior-posterior diameter.

c.

Assess inspiration/expiration ratios.

d.

Assess the suprasternal notch.

e.

Perform a stress test.

f.

Assess a chest x-ray.

g.

Assess mucous membranes.

ANS: A, C, D, G

Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would not be beneficial.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

OTHER

1. The nurse is teaching a client to cough productively. Put the actions in proper sequence.

a. Have the client flex the head and hold a pillow to the stomach.

b. Assist the client to a sitting position with feet on the floor.

c. Instruct the client to bend forward and to cough two or three times.

d. Have the client return to an upright position and take a deep breath.

e. Encourage the client to take several deep breaths.

ANS:

b, a, e, c, d

When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow. The client should take several deep breaths followed by holding the breath slightly before coughing two or three times in a row. Then the client should cough at the end of exhalation; this should be followed by taking several deep breaths.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

2. Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur.

a. Take as deep a breath as possible.

b. Stand up (unless you have a physical disability).

c. Place the meter in your mouth, and close your lips around the mouthpiece.

d. Make sure the device reads zero or is at base level.

e. Blow out as hard and as fast as possible for 1 to 2 seconds.

f. Write down the value obtained.

g. Repeat the process two additional times, and record the highest number in your chart.

ANS:

d, b, a, c, e, f, g

The proper order for obtaining a peak expiratory flow rate is as follows: Make sure the device reads zero or is at base level. Stand up (unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two more times, and record the highest of the three numbers in your chart.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-4, p. 605

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Assessment)

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