NURS 441 Concepts Exam 1 | Questions, Answers and Rationales

NURS 441 Concepts Exam 1 | Questions, Answers and Rationales A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: a. Alcoholism and hypertension b. Obesity and diabetes c. Stress-related illnesses d. Cardiopulmonary disease and lung cancer Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer. A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? a. Increased breathlessness but increased activity tolerance b. Decreased breathlessness and decreased activity tolerance c. Increased activity tolerance and decreased breathlessness d. Decreased activity tolerance and increased breathlessness Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath. A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: a. Stimulates hyperventilation, causing respiratory alkalosis b. Forms a strong bond with hemoglobin, creating a functional anemia. c. Stimulates hypoventilation, causing respiratory acidosis d. Causes alveoli to overinflate, leading to atelectasis Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport. A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? a. Fever increases metabolic demands, requiring increased oxygen need. b. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. c. Carbon dioxide production increases as result of hyperventilation. d. Carbon dioxide production decreases as a result of hypoventilation. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing. A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? a. Sonorous wheezes in the left lower lung b. Rhonchi midsternum c. Crackles only in apex of lungs d. Inspiratory crackles in lung bases Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases. The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? a. Antibiotics b. Frequent change of position c. Oxygen humidification d. Chest physiotherapy Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? a. Coughing up thick sputum only occasionally b. Coughing up thin, watery sputum easily after nebulization c. Decreased independent ability to cough d. Lung sounds clear only after coughing Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia. A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? a. Sharp pleuritic pain that worsens on inspiration b. Crackles over lung bases of affected lung c. Tracheal deviation toward the affected lung d. Increased diaphragmatic excursion on side of rib fractures When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain. A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? a. "I'll make sure that I rest between activities so I don't get so short of breath." b. "I'll rest for 30 minutes before I eat my meal." c. "If I have trouble breathing at night, I'll use two to three pillows to prop up." d. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe. The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? a. Raise the head of the bed to 45 degrees. b. Take his oxygen saturation with a pulse oximeter. c. Take his blood pressure and respiratory rate. d. Notify the health care provider of his shortness of breath. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation. Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? a. "Suctioning the patient requires sterile technique." b. "I'll apply suction while rotating and withdrawing the suction catheter." c. "I'll suction the mouth after I suction the endotracheal tube." d. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed. Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? a. Postural drainage b. Chest percussion c. Incentive spirometer d. Suctioning An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min b. Allow continued bathroom privileges c. Obtain a bedside commode d. Suggest the client use a bedpan This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Take and record a full set of vitals per hospital protocol. b. Assist the client to the chair for meals and to the bathroom c. Have the client rate pain on a 0-10 scale and report to the nurse d. Ensure the client wears TED hose or sequential compression devices The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Hypertension b. Stress c. Age d. Obesity Hypertension, obesity, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the experienced nurse is best? a. "You need to make sure the client understands this illness." b. "Continue to educate the client on possible healthy changes." c. "Emphasize complications that can occur with noncompliance." d. "Tell the client that denial is normal and will soon go away." Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Notify the provider b. Call for an electrocardiogram (ECG) c. Administer an aspirin d. Maintain airway patency Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications. The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs b. Perform hand hygiene c. Don (put on) a mask and gown d. Gather needed supplies To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It increases the force of the heart's contractions." b. "It dilates vessels, which lessens the work of the heart." c. "It slows the heart rate down for better filling." d. "It constricts vessels, improving blood flow." A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Maybe the client has respiratory distress syndrome." b. "Breathing so rapidly interferes with oxygenation." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Obtain a new oximeter from central supply. b. Change the sensor on the pulse oximeter. c. Tell the client to take slow, deep breaths. d. Assess for other manifestations of hypoxia. Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Assess the respiratory rate. b. Ensure a patent airway. c. Apply oxygen at 100%. d. Start two large-bore IV lines. The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs. The nurse would identify which body systems as directly involved in the process of normal gas exchange? a. Hepatic system b. Endocrine system, Cardiovascular system c. Immune system, Hepatic system, Cardiovascular system d. Pulmonary system, Cardiovascular system, Neurological system The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection. The nurse knows that the primary function of the alveoli is to a. Carry out gas exchange. b. Store oxygen. c. Regulate tidal volume. d. Produce hemoglobin. The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin. The process of exchanging gases through the alveolar capillary membrane is known as a. Disassociation. b. Diffusion. c. Perfusion. d. Ventilation. Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Disassociation is not related to oxygenation. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Ventilation is the process of moving gases into and out of the lungs. The nurse would expect to see increased ventilations if a patient exhibits a. Increased oxygen saturation. b. Decreased carbon dioxide levels. c. Decreased pH. d. Increased hemoglobin levels. Retained CO2 creates H+ byproducts that lower pH. This sends a chemical signal to increase respiratory rate and would result in increased ventilation. All other options would cause the ventilation rate to normalize or decrease to increase carbon dioxide retention or as the result of delivery of higher levels of oxygen to tissues. While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate? a. Left-sided heart failure b. Right-sided heart failure c. Atrial fibrillation d. Myocardial ischemia Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, crackles, and discomfort when lying supine. Right-sided heart failure is systemic and results in peripheral edema and hepatojugular distention. Atrial fibrillation results in an irregular heart rate. Myocardial ischemia most often results in chest pain, along with shortness of breath, nausea, and fatigue. A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority? a. Call for the emergency response team to bring the defibrillator. b. Have the patient sit down in the nearest chair. c. Return the patient to the room and apply 100% oxygen. d. Ask a coworker to get the ECG machine STAT. The patient is experiencing cardiac distress for reasons unknown. The nurse should first secure the safety of the patient and decrease the workload on the patient's heart by putting him in a resting position; this will increase cardiac output by decreasing after load. Once the patient is stable, the nurse can obtain oxygen to put on the patient. Next, the nurse can begin to monitor the patient's oxygen and cardiac status. If necessary, the emergency team may be activated to defibrillate. The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the a. Nailbeds. b. Oral mucosa. c. Earlobe. d. Lower extremities. Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia. A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to a. Increased metabolic demands. b. Anxiety over illness. c. Decreased drive to breathe. d. Infection destroying lung tissues. Fever increases the metabolic demands of the body, increasing production of carbon dioxide. The body hyperventilates to get rid of excess carbon dioxide. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Hyperventilation decreases the drive to breathe. The cause of the fever in this question is unknown. What assessment finding is the earliest sign of hypoxia? a. Restlessness b. Decreased blood pressure c. Cardiac dysrhythmias d. Cyanosis Hypoxia is due to inadequate tissue oxygen at the cellular level. The earliest sign of hypoxia is restlessness; as it progresses, mental status changes, cardiac changes, and cyanosis can occur. Early hypoxia results in an elevated blood pressure. In later hypoxia, vital sign changes such as increased heart and respiratory rate occur. Cyanosis is a late sign of hypoxia. A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child's respiratory pattern? a. Hyperventilation to decrease serum levels of carbon dioxide b. Hypoventilation to compensate for metabolic alkalosis c. Flail chest to decrease the work of breathing d. Shallow respirations to decrease serum pH Aspirin causes an increase in carbon dioxide; the body compensates for this by increasing ventilations to blow off excess CO2. Hypoventilation would cause the body to retain even more carbon dioxide and therefore respiratory acidosis. Flail chest occurs with trauma to the chest wall. Shallow respirations would increase serum pH. The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change? a. Decreased lung defense mechanisms may cause ineffective airway clearance. b. Thickening of the heart muscle wall decreases cardiac output. c. Decreased lung capacity makes proper anesthesia induction more difficult. d. Alterations in mental status prevent patients' awareness of ineffective breathing. The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient? a. Assist patient to cough, turn, and deep breathe every 2 hours. b. Encourage patient to drink through a straw to prevent aspiration. c. Discontinue humidification delivery device to keep excess fluid from lungs. d. Monitor oxygen saturation, and frequently assess lung bases. The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Drinking through a straw increases the risk of aspiration. Humidification thins respiratory secretions, making them easier to expel. Monitoring oxygen status is important but is not a method of prevention The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician? a. Clubbing of the fingers b. Increased anterior-posterior diameter of the chest c. Hemoptysis d. Tachypnea Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest, and tachypnea are all normal findings in a patient with emphysema. A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic? a. "Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult." b. "Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting dressed." c. "Often patients with your disease lose mental status and forget how to perform daily tasks." d. "Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are losing sensory feedback in your extremities." Clubbing of the nail bed is a frequent symptom of COPD and can make activities of daily living difficult. Taking a nap decreases fatigue but does not help the patient perform fine motor skills. Loss of mental status is not a normal finding with COPD. Low oxygen not low circulating blood volume is the problem in COPD. Why is a humidified atmosphere recommended for a young child with an upper respiratory tract infection? a. It liquefies secretions. b. It improves oxygenation. c. It promotes ventilation. d. It is soothing to inflamed mucous membrane. By humidifying the inspired air, the membranes inflamed by the infection and dry air are soothed. The mother of a 20-month-old child tells the nurse that the child has a barking cough at night. The child's temperature is 37 °C (98.6 °F). Based on the nurse's knowledge of upper respiratory infections, this is a symptom of croup. What should the nurse instruct the mother to do? a. Control the fever with acetaminophen and call if the cough gets worse tonight. b. Try a cool-mist vaporizer at night and watch for signs of difficulty breathing. c. Try over-the-counter cough medicine and come to the clinic tomorrow if there is no improvement. d. Take the child to the hospital in case epiglottitis occurs. Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency department if they develop. Cool mist is recommended to provide relief. A child with asthma is having pulmonary function tests. Which phrase explains the purpose of the forced expiratory volume (FEV1)? a. It confirms the diagnosis of asthma. b. It determines the cause of asthma. c. It identifies the "triggers" of asthma. d. It assesses the severity of asthma. The forced expiratory volume measures the maximum amount of air that can be forcefully exhaled in the first second. This can provide an objective measure of pulmonary function compared with the child's baseline. A 4-year-old child needing to use a metered-dose inhaler to treat asthma cannot coordinate her breathing to use it effectively. The appropriate intervention by nurse is to use which piece of respiratory equipment? a. A spacer b. A nebulizer c. A peak expiratory flow meter d. Chest physiotherapy The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing. One of the goals for children with asthma is to prevent respiratory infections. Why is this goal so important? a. Respiratory infections encourage exercise-induced asthma. b. Allergen sensitivity is increased in the presence of infection. c. Asthma medication becomes less effective when a respiratory infection is present. d. Respiratory infections can trigger an episode or aggravate the asthmatic state. Respiratory infections can trigger an asthmatic attack. Annual influenza vaccine is recommended. All respiratory equipment should be kept clean. Cystic fibrosis may affect single or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations? a. Mechanical obstruction caused by increased viscosity of mucous gland secretions. b. Atrophic changes in mucosal wall of intestines. c. Hypoactivity of the autonomic nervous system. d. Hyperactivity of sweat glands. Children with cystic fibrosis have thick mucus gland secretions. The viscous secretions obstruct small passages in organs such as the pancreas. The parent of a child with cystic fibrosis calls the clinic nurse and describes signs and symptoms of tachypnea, tachycardia, dyspnea, pallor, and cyanosis. What does the nurse suspect the child is experiencing? a. A pneumothorax b. Bronchodilation c. Carbon dioxide retention d. Extremely thick sputum The child is exhibiting signs of increasing respiratory distress suggestive of a pneumothorax. The child needs to be seen as soon as possible. Absorption of fat-soluble vitamins is decreased in children with cystic fibrosis; therefore supplementation of which vitamins is necessary? A. C, D B. A, E, K C. A, D, E, K D. C, folic acid A, D, E, and K are the fat-soluble vitamins that need to be supplemented. A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31% Room air is 21% oxygen. Which blood gas value indicates that the client is experiencing hypercarbia? a. pH = 7.33 b. Bicarbonate = 20 mEq/L c. PaCO2 = 60 mm Hg d. PaO2 = 80 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia. Which clinical manifestation alerts you to the presence of hypoventilation when you are monitoring a client with chronic lung disease and hypercarbia who is receiving oxygen therapy? a. Coarse crackles and wheezes on auscultation b. Slow, shallow respirations c. Pulse oximetry of 90% d. Clubbing of the fingers As the client's PaO2 rises, the client's color and pulse oximetry improve and cannot be used to determine hypoventilation. As the client's PaO2 rises, respirations decrease in depth and rate, indicating hypoventilation. What is the most significant modifiable risk factor for the development of impaired gas exchange? a. Age. b. Tobacco use. c. Drug overdose. d. Prolonged immobility. Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use. When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? a. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. b. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. c. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. d. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas. The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? a. No observable respiratory difficulty or shortness of breath over the last 24 hours. b. A decrease in the amount of nasal drainage and sneezing. c. No sputum production, and a decrease in coughing episodes. d. Relief of an acute asthmatic attack. Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? a. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). b. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. c. Encourage coughing and deep breathing to clear the airway. d. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does. The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? a. A patient with asthma and severe shortness of breath. b A patient undergoing a bronchoscopy for a biopsy. c. A patient with a pleural effusion requiring fluid removal. d. A patient experiencing a problem with a pneumothorax. When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy. A nurse explains why a 4-year-old presenting with respiratory distress has retractions. Which statement by the parent indicates that the teaching was understood? a. "When distress occurs, children swallow air, leading to expansion of the rib cage and retractions." b. "Retractions occur in all children, because their ribs are soft and pliable. They are not related to respiratory distress." c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." d. "Children breathe primarily with the muscles between the ribs, so when distress occurs, the extra work of breathing causes retractions." Up to the age of 6 years, children breathe primarily with their diaphragm. The intercostal muscles assist by increasing the chest diameter. When distress occurs, the intercostal muscles between the rib cage work with extra effort to move air through narrow airways. This causes retractions. A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis Impaired Gas Exchange? a. Oxygen saturation of 62% b. Heart rate of 100 bpm c. Respiratory rate of 30/minute d. Bicarbonate level of 38 The incorrect options do not contain evidence of abnormal gas exchange values. Pallor, tachycardia, hypertension, and fever can occur with Impaired Gas Exchange but alone do not yield that nursing diagnosis. Bradycardia, lethargy, flushed, and hypothermia could be an option in unusual circumstances but are not the typical picture of Impaired Gas Exchange. Elevated bicarbonate, metabolic alkalosis, irritability, and pallor do not reflect gas exchange abnormalities. An 8-year-old child is diagnosed with viral pneumonia and sent home from the clinic with no antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever, listlessness, and a harsh, productive cough. The child's mother states, "I knew a prescription for antibiotics was needed." Which response by the nurse is the most appropriate? a. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars." b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." c. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." d. "Sometimes we just do not know. I'm glad you came back in." The nurse responds with the most informative, accurate response. The decision not to use antibiotics for viral pneumonia was based on sound rationale about the etiology of the illness, not cost. Following assessment, the nurse anticipates potential respiratory arrest for which child? a. A 5-month-old infant with RSV who is sleeping and has a respiratory rate of 24. b. A 2-year-old with epiglottitis who was intubated in the emergency department. c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds. d. A 4-year-old, status post-tension pneumothorax from a motor vehicle accident with a chest tube in place, who complains of pain. All of the children are acutely ill. A child with asthma who was wheezing and now has decreased breath sounds is acutely ill. This child's ability to move air is decreasing and is approaching respiratory arrest. Intubation protects the airway from closing in epiglottitis and a chest tube is the treatment for tension pneumothorax in a different room; therefore these children are stable. The infant with RSV is sleeping with a normal respiratory rate so there is no immediate danger here. A 4-year-old child with croup is brought to the emergency department. The child is anxious and crying and has a high-pitched stridor, retractions, and a barky cough. After administration of cool mist therapy, which assessment finding would indicate significant improvement in the child's respiratory status? a. The child is less anxious. b. The respiratory rate is decreased. c. Wheezing is less loud. d. The child drinks 8 ounces of fluid. All responses indicate conditions that are beneficial to the child. Respiratory distress and hypoxia cause anxiety as this vital life function is threatened. When anxiety improves, the nurse knows that the respiratory status must be improving as well even if signs and symptoms continue. Which comments by the parents of a 7-year-old child with asthma indicate comprehension of instructions regarding medication use for control of the illness? a. The medications are too complicated for a 7-year-old to understand. b. If a spacer is used, a whistling sound indicates that the medication is being inhaled correctly. c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. d. Dry powder inhalers are for adult use only. A 7-year-old is at an age when medication administration responsibility ought to be initiated. The spacer whistle is significant, although its significance varies with each type of spacer. Children may use dry powder inhalers when they are old enough to have a rapid inhalation. Which tasks should the nurse perform rather than delegate to an assistant? (Select all that apply.) a. Suctioning a 2-year-old with a tracheostomy. b. Changing the diaper of the 3-month-old infant recovering from RSV. c. Walking with a 2-year-old who has an IV receiving antibiotics for pneumonia. d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet. e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable. Respirations of 68 for an 8-month-old infant are high. The nurse needs to assess for retractions and wheezing. A 2-year-old who becomes quiet following respiratory distress could be experiencing decompensation and requires an evaluation. Suctioning is a sterile procedure that only the nurse should perform. A child in the early stages of impaired gas exchange will often have which diagnosis as well? a. Anxiety related to hypoxia b. Fatigue related to air trapping c. Injury related to fatigue and dehydration d. Delayed Development related to hypoxia Air trapping is not present in all cases of impaired gas exchange. Delayed development does not occur unless the condition is chronic or acutely damaging. The early phase of impaired gas exchange does not cause injury or dehydration, although fatigue can occur. A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? a. Ratio of hemoglobin and hematocrit b. Status of acid-base balance in arterial blood c. Adequacy of oxygen transport d. Presence of a pulmonary embolus The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus. 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 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. A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the client's 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. 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 client's 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 After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's 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." 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. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's 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. 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. After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's 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." 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 client's part allows the drug to escape through the nose and mouth. 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." 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