Respiratory
Disorders
Any piece of knowledge I acquire today has a value at this
moment exactly proportional to my skill to deal with it.
6
Tomorrow when I know more, I recall that piece of knowledge
and use it better.
—Mark Van Doren
Respiratory disorders include some of the most common disorders that nurses and other
health-care providers encounter. They range from the simple cold to chronic conditions
such as asthma to life-threatening diseases such as lung cancer. Whether it is teaching a
client the correct way to blow the nose; administering oxygen, antibiotics, or pain-relieving
medications; or checking ventilators, chest tubes, and other equipment used in the treat-
ment of clients with respiratory disorders, the nurse must know the correct procedures,
medications, and interventions to use. One of the most important interventions—and per-
haps, the most important—is assessment and monitoring of the client’s breathing status and
oxygenation level. Oxygenation is the first priority in Maslow’s hierarchy—and in terms of
saving lives.
KEYWORDS ABBREVIATIONS
Adenoidectomy Acute respiratory distress syndrome (ARDS)
Ambu Arterial blood gases (ABG)
Antral Blood pressure (BP)
Aphonia Capillary refill time (CRT)
Bronchoscopy Chronic obstructive pulmonary disease (COPD)
Caldwell-Luc Continuous positive airway pressure (CPAP)
Dorsiflexion Directly observed treatment (DOT)
Enteral Electrocardiogram (ECG)
Eupnea Endotracheal tube (ET)
Exacerbation Exercise-induced asthma (EIA)
Extrinsic Health-care provider (HCP)
Hypoxemia Hemoglobin and hematocrit (H&H)
Iatrogenic International normalized ratio (INR)
Intrinsic Intravenous (IV)
Laryngectomy Intravenous piggyback (IVPB)
Laryngoscopy Intravenous push (IVP)
Lobectomy Licensed practical nurse (LPN)
Pleurodesis Liters per minute (LPM)
Pneumonectomy Magnetic resonance imaging (MRI)
Polysomnography
Copyright © 2016. F. A. Davis Company. All rights reserved. Nothing by mouth (NPO)
Rhinitis Partial thromboplastin time (PTT)
Rhinorrhea Percutaneous endoscopic gastrostomy (PEG) tube
189
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, 190 M ED -S U RG S UC CESS
Rhonchi Prothrombin time (PT)
Thoracentesis Rule out (R/O)
Thoracotomy Severe acute respiratory syndrome (SARS)
Shortness of breath (SOB)
Total parenteral nutrition (TPN)
Unlicensed assistive personnel (UAP)
Upper respiratory infection (URI)
When required; as needed (prn)
PRACTICE QUESTIONS
Upper Respiratory Infection (URI) 4. The client has been diagnosed with chronic
sinusitis. Which sign/symptom alerts the nurse to
1. The home health-care nurse is talking on the a potentially life-threatening complication?
telephone to a male client diagnosed with 1. Muscle weakness.
hypertension and hears the client sneezing. The 2. Purulent sputum.
client tells the nurse he has been blowing his nose 3. Nuchal rigidity.
frequently. Which question should the nurse ask 4. Intermittent loss of muscle control.
the client? 5. The client diagnosed with tonsillitis is scheduled
1. “Have you had the flu shot in the last two (2) to have surgery in the morning. Which assessment
weeks?” data should the nurse notify the health-care
2. “Are there any small children in the home?”
provider about prior to surgery?
3. “Are you taking over-the-counter medicine for 1. The client has a hemoglobin of 12.2 g/dL and
these symptoms?” hematocrit of 36.5%.
4. “Do you have any cold sores associated with 2. The client has an oral temperature of 100.2˚F
your sneezing?” and a dry cough.
2. The school nurse is presenting a class to students 3. There are one (1) to two (2) white blood cells
at a primary school on how to prevent the (WBCs) in the urinalysis.
transmission of the common cold virus. Which 4. The client’s current international normalized
information should the nurse discuss? ratio (INR) is 1.
1. Instruct the children to always keep a tissue or 6. The influenza vaccine is in short supply. Which
handkerchief with them. group of clients would the public health nurse
2. Explain that children current with consider priority when administering the vaccine?
immunizations will not get a cold. 1. Elderly and chronically ill clients.
3. Tell the children they should go to the doctor if 2. Child-care workers and children less than four
they get a cold. (4) years of age.
4. Demonstrate to the students how to wash 3. Hospital chaplains and health-care workers.
hands correctly. 4. Schoolteachers and students living in a
3. Which information should the nurse teach the dormitory.
client diagnosed with acute sinusitis?
7. The client diagnosed with chronic sinusitis who
1. Instruct the client to complete all the ordered has undergone a Caldwell-Luc procedure is
antibiotics. complaining of pain. Which intervention should
2. Teach the client how to irrigate the nasal the nurse implement first?
passages. 1. Administer the narcotic analgesic intravenous
3. Have the client demonstrate how to blow the push (IVP).
nose. 2. Perform gentle oral hygiene.
4. Give the client samples of a narcotic analgesic 3. Place the client in semi-Fowler’s position.
for the headache. 4. Assess the client’s pain.
Copyright © 2016. F. A. Davis Company. All rights reserved.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, C HAPT ER 6 R ESPIRAT ORY D ISO RDERS 191
8. The charge nurse on a surgical floor is 12. The nurse is caring for a client diagnosed with
making assignments. Which client should be a cold. Which is an example of an alternative
assigned to the most experienced registered therapy?
nurse (RN)? 1. Vitamin C, 2,000 mg daily.
1. The 36-year-old client who has undergone an 2. Strict bedrest.
antral irrigation for sinusitis yesterday and has 3. Humidification of the air.
moderate pain. 4. Decongestant therapy.
2. The six-(6)-year-old client scheduled
for a tonsillectomy and adenoidectomy
this morning who will not swallow Lower Respiratory Infection
medication.
3. The 18-year-old client who had a Caldwell- 13. The nurse is assessing a 79-year-old client
Luc procedure three (3) days ago and has diagnosed with pneumonia. Which signs and
purulent drainage on the drip pad. symptoms should the nurse expect to assess in
4. The 45-year-old client diagnosed with a the client?
peritonsillar abscess who requires VPB 1. Confusion and lethargy.
antibiotic therapy four (4) times a day. 2. High fever and chills.
3. Frothy sputum and edema.
9. The client diagnosed with influenza A is being 4. Bradypnea and jugular vein distention.
discharged from the emergency department with
a prescription for antibiotics. Which statement 14. The nurse is planning the care of a client
by the client indicates an understanding of this diagnosed with pneumonia and writes a problem
prescription? of “impaired gas exchange.” Which is an
1. “These pills will make me feel better fast and expected outcome for this problem?
I can return to work.” 1. Performs chest physiotherapy three (3) times
2. “The antibiotics will help prevent me from a day.
developing a bacterial pneumonia.” 2. Able to complete activities of daily living.
3. “If I had gotten this prescription sooner, 3. Ambulates in the hall several times during
Icould have prevented this illness.” each shift.
4. “I need to take these pills until I feel better; 4. Alert and oriented to person, place, time, and
then I can stop taking the rest.” events.
10. The nurse is developing a plan of care for a 15. The nurse in a long-term care facility is planning
client diagnosed with laryngitis and identifies the care for a client with a percutaneous
the client problem “altered communication.” endoscopic gastrostomy (PEG) feeding tube
Which intervention should the nurse used for bolus feedings. Which intervention
implement? should the nurse include in the plan of care?
1. Instruct the client to drink a mixture of 1. Inspect the insertion line at the naris prior to
brandy and honey several times a day. instilling formula.
2. Encourage the client to whisper instead of 2. Elevate the head of the bed (HOB) after
trying to speak at a normal level. feeding the client.
3. Provide the client with a blank note pad for 3. Place the client in the Sims position following
writing any communication. each feeding.
4. Explain that the client’s aphonia may become 4. Change the dressing on the feeding tube
a permanent condition. every three (3) days.
11. Which task is most appropriate for the nurse 16. The client diagnosed with a community-
to delegate to an unlicensed assistive personnel acquired pneumonia is being admitted to the
(UAP)? medical unit. Which nursing intervention has
1. Feed a client who is postoperative the highest priority?
tonsillectomy the first meal of clear liquids. 1. Administer the ordered oral antibiotic
2. Encourage the client diagnosed with a cold to immediately (STAT).
drink a glass of orange juice. 2. Order the meal tray to be delivered as soon as
3. Obtain a throat culture on a client diagnosed possible.
with bacterial pharyngitis. 3. Obtain a sputum specimen for culture and
Copyright © 2016. F. A. Davis Company. All rights reserved.
4. Escort the client diagnosed with laryngitis sensitivity.
outside to smoke a cigarette. 4. Have the unlicensed assistive personnel weigh
the client.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, 192 M ED -S U RG S UC CESS
17. The 56-year-old client diagnosed with 21. The day shift charge nurse on a medical unit is
tuberculosis (Tb) is being discharged. Which making rounds after report. Which client should
statement made by the client indicates an be seen first?
understanding of the discharge instructions? 1. The 65-year-old client diagnosed with
1. “I will take my medication for the full three tuberculosis who has a sputum specimen to
(3) weeks prescribed.” be sent to the laboratory.
2. “I must stay on the medication for months 2. The 76-year-old client diagnosed with
if I am to get well.” aspiration pneumonia who has a clogged
3. “I can be around my friends because I have feeding tube.
started taking antibiotics.” 3. The 45-year-old client diagnosed with
4. “I should get a Tb skin test every three (3) pneumonia who has a pulse oximetry reading
months to determine if I am well.” of 92%.
4. The 39-year-old client diagnosed with
18. The employee health nurse is administering
bronchitis who has an arterial oxygenation
tuberculin skin testing to employees who have
level of 89%.
possibly been exposed to a client with active
tuberculosis (Tb). Which statement indicates 22. The client is admitted with a diagnosis of
the need for radiological evaluation instead rule-out tuberculosis. Which type of isolation
of skin testing? procedures should the nurse implement?
1. The client’s first skin test indicates a purple 1. Standard Precautions.
flat area at the site of injection. 2. Contact Precautions.
2. The client’s second skin test indicates a red 3. Droplet Precautions.
area measuring four (4) mm. 4. Airborne Precautions.
3. The client’s previous skin test was read as
23. The nurse observes the unlicensed assistive
positive.
personnel (UAP) entering an airborne isolation
4. The client has never shown a reaction to the
room and leaving the door open. Which action
tuberculin medication.
is the nurse’s best response?
19. The nurse is caring for the client diagnosed with 1. Close the door and discuss the UAP’s action
pneumonia. Which information should the nurse after coming out of the room.
include in the teaching plan? Select all that 2. Make the UAP come back outside the room
apply. and then reenter, closing the door.
1. Place the client on oxygen delivered by nasal 3. Say nothing to the UAP but report the
cannula. incident to the nursing supervisor.
2. Plan for periods of rest during activities of 4. Enter the client’s room and discuss the matter
daily living. with the UAP immediately.
3. Place the client on a fluid restriction of
1,000 mL/day. 24. The client is admitted to a medical unit with
a diagnosis of pneumonia. Which signs and
4. Restrict the client’s smoking to two (2) to
symptoms should the nurse assess in the client?
three (3) cigarettes per day.
1. Pleuritic chest discomfort and anxiety.
5. Monitor the client’s pulse oximetry readings
2. Asymmetrical chest expansion and pallor.
every four (4) hours.
3. Leukopenia and CRT <three (3) seconds.
20. The nurse is feeding a client diagnosed 4. Substernal chest pain and diaphoresis.
with aspiration pneumonia who becomes
dyspneic, begins to cough, and is turning blue.
Which nursing intervention should the nurse Chronic Obstructive Pulmonary
implement first? Disease (COPD)
1. Suction the client’s nares.
2. Turn the client to the side. 25. The nurse is assessing the client with COPD.
3. Place the client in Trendelenburg position. Which health promotion information is most
4. Notify the health-care provider. important for the nurse to obtain?
1. Number of years the client has smoked.
2. Risk factors for complications.
Copyright © 2016. F. A. Davis Company. All rights reserved.
3. Ability to administer inhaled medication.
4. Willingness to modify lifestyle.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
Disorders
Any piece of knowledge I acquire today has a value at this
moment exactly proportional to my skill to deal with it.
6
Tomorrow when I know more, I recall that piece of knowledge
and use it better.
—Mark Van Doren
Respiratory disorders include some of the most common disorders that nurses and other
health-care providers encounter. They range from the simple cold to chronic conditions
such as asthma to life-threatening diseases such as lung cancer. Whether it is teaching a
client the correct way to blow the nose; administering oxygen, antibiotics, or pain-relieving
medications; or checking ventilators, chest tubes, and other equipment used in the treat-
ment of clients with respiratory disorders, the nurse must know the correct procedures,
medications, and interventions to use. One of the most important interventions—and per-
haps, the most important—is assessment and monitoring of the client’s breathing status and
oxygenation level. Oxygenation is the first priority in Maslow’s hierarchy—and in terms of
saving lives.
KEYWORDS ABBREVIATIONS
Adenoidectomy Acute respiratory distress syndrome (ARDS)
Ambu Arterial blood gases (ABG)
Antral Blood pressure (BP)
Aphonia Capillary refill time (CRT)
Bronchoscopy Chronic obstructive pulmonary disease (COPD)
Caldwell-Luc Continuous positive airway pressure (CPAP)
Dorsiflexion Directly observed treatment (DOT)
Enteral Electrocardiogram (ECG)
Eupnea Endotracheal tube (ET)
Exacerbation Exercise-induced asthma (EIA)
Extrinsic Health-care provider (HCP)
Hypoxemia Hemoglobin and hematocrit (H&H)
Iatrogenic International normalized ratio (INR)
Intrinsic Intravenous (IV)
Laryngectomy Intravenous piggyback (IVPB)
Laryngoscopy Intravenous push (IVP)
Lobectomy Licensed practical nurse (LPN)
Pleurodesis Liters per minute (LPM)
Pneumonectomy Magnetic resonance imaging (MRI)
Polysomnography
Copyright © 2016. F. A. Davis Company. All rights reserved. Nothing by mouth (NPO)
Rhinitis Partial thromboplastin time (PTT)
Rhinorrhea Percutaneous endoscopic gastrostomy (PEG) tube
189
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, 190 M ED -S U RG S UC CESS
Rhonchi Prothrombin time (PT)
Thoracentesis Rule out (R/O)
Thoracotomy Severe acute respiratory syndrome (SARS)
Shortness of breath (SOB)
Total parenteral nutrition (TPN)
Unlicensed assistive personnel (UAP)
Upper respiratory infection (URI)
When required; as needed (prn)
PRACTICE QUESTIONS
Upper Respiratory Infection (URI) 4. The client has been diagnosed with chronic
sinusitis. Which sign/symptom alerts the nurse to
1. The home health-care nurse is talking on the a potentially life-threatening complication?
telephone to a male client diagnosed with 1. Muscle weakness.
hypertension and hears the client sneezing. The 2. Purulent sputum.
client tells the nurse he has been blowing his nose 3. Nuchal rigidity.
frequently. Which question should the nurse ask 4. Intermittent loss of muscle control.
the client? 5. The client diagnosed with tonsillitis is scheduled
1. “Have you had the flu shot in the last two (2) to have surgery in the morning. Which assessment
weeks?” data should the nurse notify the health-care
2. “Are there any small children in the home?”
provider about prior to surgery?
3. “Are you taking over-the-counter medicine for 1. The client has a hemoglobin of 12.2 g/dL and
these symptoms?” hematocrit of 36.5%.
4. “Do you have any cold sores associated with 2. The client has an oral temperature of 100.2˚F
your sneezing?” and a dry cough.
2. The school nurse is presenting a class to students 3. There are one (1) to two (2) white blood cells
at a primary school on how to prevent the (WBCs) in the urinalysis.
transmission of the common cold virus. Which 4. The client’s current international normalized
information should the nurse discuss? ratio (INR) is 1.
1. Instruct the children to always keep a tissue or 6. The influenza vaccine is in short supply. Which
handkerchief with them. group of clients would the public health nurse
2. Explain that children current with consider priority when administering the vaccine?
immunizations will not get a cold. 1. Elderly and chronically ill clients.
3. Tell the children they should go to the doctor if 2. Child-care workers and children less than four
they get a cold. (4) years of age.
4. Demonstrate to the students how to wash 3. Hospital chaplains and health-care workers.
hands correctly. 4. Schoolteachers and students living in a
3. Which information should the nurse teach the dormitory.
client diagnosed with acute sinusitis?
7. The client diagnosed with chronic sinusitis who
1. Instruct the client to complete all the ordered has undergone a Caldwell-Luc procedure is
antibiotics. complaining of pain. Which intervention should
2. Teach the client how to irrigate the nasal the nurse implement first?
passages. 1. Administer the narcotic analgesic intravenous
3. Have the client demonstrate how to blow the push (IVP).
nose. 2. Perform gentle oral hygiene.
4. Give the client samples of a narcotic analgesic 3. Place the client in semi-Fowler’s position.
for the headache. 4. Assess the client’s pain.
Copyright © 2016. F. A. Davis Company. All rights reserved.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, C HAPT ER 6 R ESPIRAT ORY D ISO RDERS 191
8. The charge nurse on a surgical floor is 12. The nurse is caring for a client diagnosed with
making assignments. Which client should be a cold. Which is an example of an alternative
assigned to the most experienced registered therapy?
nurse (RN)? 1. Vitamin C, 2,000 mg daily.
1. The 36-year-old client who has undergone an 2. Strict bedrest.
antral irrigation for sinusitis yesterday and has 3. Humidification of the air.
moderate pain. 4. Decongestant therapy.
2. The six-(6)-year-old client scheduled
for a tonsillectomy and adenoidectomy
this morning who will not swallow Lower Respiratory Infection
medication.
3. The 18-year-old client who had a Caldwell- 13. The nurse is assessing a 79-year-old client
Luc procedure three (3) days ago and has diagnosed with pneumonia. Which signs and
purulent drainage on the drip pad. symptoms should the nurse expect to assess in
4. The 45-year-old client diagnosed with a the client?
peritonsillar abscess who requires VPB 1. Confusion and lethargy.
antibiotic therapy four (4) times a day. 2. High fever and chills.
3. Frothy sputum and edema.
9. The client diagnosed with influenza A is being 4. Bradypnea and jugular vein distention.
discharged from the emergency department with
a prescription for antibiotics. Which statement 14. The nurse is planning the care of a client
by the client indicates an understanding of this diagnosed with pneumonia and writes a problem
prescription? of “impaired gas exchange.” Which is an
1. “These pills will make me feel better fast and expected outcome for this problem?
I can return to work.” 1. Performs chest physiotherapy three (3) times
2. “The antibiotics will help prevent me from a day.
developing a bacterial pneumonia.” 2. Able to complete activities of daily living.
3. “If I had gotten this prescription sooner, 3. Ambulates in the hall several times during
Icould have prevented this illness.” each shift.
4. “I need to take these pills until I feel better; 4. Alert and oriented to person, place, time, and
then I can stop taking the rest.” events.
10. The nurse is developing a plan of care for a 15. The nurse in a long-term care facility is planning
client diagnosed with laryngitis and identifies the care for a client with a percutaneous
the client problem “altered communication.” endoscopic gastrostomy (PEG) feeding tube
Which intervention should the nurse used for bolus feedings. Which intervention
implement? should the nurse include in the plan of care?
1. Instruct the client to drink a mixture of 1. Inspect the insertion line at the naris prior to
brandy and honey several times a day. instilling formula.
2. Encourage the client to whisper instead of 2. Elevate the head of the bed (HOB) after
trying to speak at a normal level. feeding the client.
3. Provide the client with a blank note pad for 3. Place the client in the Sims position following
writing any communication. each feeding.
4. Explain that the client’s aphonia may become 4. Change the dressing on the feeding tube
a permanent condition. every three (3) days.
11. Which task is most appropriate for the nurse 16. The client diagnosed with a community-
to delegate to an unlicensed assistive personnel acquired pneumonia is being admitted to the
(UAP)? medical unit. Which nursing intervention has
1. Feed a client who is postoperative the highest priority?
tonsillectomy the first meal of clear liquids. 1. Administer the ordered oral antibiotic
2. Encourage the client diagnosed with a cold to immediately (STAT).
drink a glass of orange juice. 2. Order the meal tray to be delivered as soon as
3. Obtain a throat culture on a client diagnosed possible.
with bacterial pharyngitis. 3. Obtain a sputum specimen for culture and
Copyright © 2016. F. A. Davis Company. All rights reserved.
4. Escort the client diagnosed with laryngitis sensitivity.
outside to smoke a cigarette. 4. Have the unlicensed assistive personnel weigh
the client.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
, 192 M ED -S U RG S UC CESS
17. The 56-year-old client diagnosed with 21. The day shift charge nurse on a medical unit is
tuberculosis (Tb) is being discharged. Which making rounds after report. Which client should
statement made by the client indicates an be seen first?
understanding of the discharge instructions? 1. The 65-year-old client diagnosed with
1. “I will take my medication for the full three tuberculosis who has a sputum specimen to
(3) weeks prescribed.” be sent to the laboratory.
2. “I must stay on the medication for months 2. The 76-year-old client diagnosed with
if I am to get well.” aspiration pneumonia who has a clogged
3. “I can be around my friends because I have feeding tube.
started taking antibiotics.” 3. The 45-year-old client diagnosed with
4. “I should get a Tb skin test every three (3) pneumonia who has a pulse oximetry reading
months to determine if I am well.” of 92%.
4. The 39-year-old client diagnosed with
18. The employee health nurse is administering
bronchitis who has an arterial oxygenation
tuberculin skin testing to employees who have
level of 89%.
possibly been exposed to a client with active
tuberculosis (Tb). Which statement indicates 22. The client is admitted with a diagnosis of
the need for radiological evaluation instead rule-out tuberculosis. Which type of isolation
of skin testing? procedures should the nurse implement?
1. The client’s first skin test indicates a purple 1. Standard Precautions.
flat area at the site of injection. 2. Contact Precautions.
2. The client’s second skin test indicates a red 3. Droplet Precautions.
area measuring four (4) mm. 4. Airborne Precautions.
3. The client’s previous skin test was read as
23. The nurse observes the unlicensed assistive
positive.
personnel (UAP) entering an airborne isolation
4. The client has never shown a reaction to the
room and leaving the door open. Which action
tuberculin medication.
is the nurse’s best response?
19. The nurse is caring for the client diagnosed with 1. Close the door and discuss the UAP’s action
pneumonia. Which information should the nurse after coming out of the room.
include in the teaching plan? Select all that 2. Make the UAP come back outside the room
apply. and then reenter, closing the door.
1. Place the client on oxygen delivered by nasal 3. Say nothing to the UAP but report the
cannula. incident to the nursing supervisor.
2. Plan for periods of rest during activities of 4. Enter the client’s room and discuss the matter
daily living. with the UAP immediately.
3. Place the client on a fluid restriction of
1,000 mL/day. 24. The client is admitted to a medical unit with
a diagnosis of pneumonia. Which signs and
4. Restrict the client’s smoking to two (2) to
symptoms should the nurse assess in the client?
three (3) cigarettes per day.
1. Pleuritic chest discomfort and anxiety.
5. Monitor the client’s pulse oximetry readings
2. Asymmetrical chest expansion and pallor.
every four (4) hours.
3. Leukopenia and CRT <three (3) seconds.
20. The nurse is feeding a client diagnosed 4. Substernal chest pain and diaphoresis.
with aspiration pneumonia who becomes
dyspneic, begins to cough, and is turning blue.
Which nursing intervention should the nurse Chronic Obstructive Pulmonary
implement first? Disease (COPD)
1. Suction the client’s nares.
2. Turn the client to the side. 25. The nurse is assessing the client with COPD.
3. Place the client in Trendelenburg position. Which health promotion information is most
4. Notify the health-care provider. important for the nurse to obtain?
1. Number of years the client has smoked.
2. Risk factors for complications.
Copyright © 2016. F. A. Davis Company. All rights reserved.
3. Ability to administer inhaled medication.
4. Willingness to modify lifestyle.
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
Created from galen-ebooks on 2024-07-30 16:01:48.
