NURS 155 Exam 3

Delirium - Reversible state of confusion-usually caused by a medical condition Depression - Mood disorder; sense of hopelessness and persistent unhappiness dementia - a gradual and irreversible loss of intellectual function Hemiparesis - weakness on one side of the body *damage from right side of the brain affects the left side of the body and vis versa Types of sensory deficits and examples - Tactile: touch; peripheral neuropathy Smell: Olfactory; anosmia Taste: Gustatory; decreased gustatory cells Hearing: Auditory; conductive hearing loss, sensorineural hearing loss, and presbycusis (age related hearing loss) Equilibrium: motion sickness or Meniere's disease Vision: Visual; myopia, presbyopia (far sightedness-age related), cataracts (lens of the eye affected), glaucoma (pressure on optic nerve), diabetic retinopathy (blood vessels of eye are damaged due to diabetes), and macular degeneration If patient begins to complain of pair or if resistance to joint movement is met, range of motion exercises should be_____ - Range of motion exercises should be stopped; never hyperextend or flex a joint beyond position of comfort page 560 safety practice alert The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing - 2. Transparent dressing A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to manage a stage 1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing. Calcium alginate is absorbent and is used in stage 4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for pressure injuries that are infected. Test-Taking Strategy: Focus on the subject, the wound dressing that is appropriate in the treatment of a stage 1 pressure injury. Remember that dressing use is conservative in this type of pressure injury, and includes the use of transparent dressings or no dressing. The wound is expected to heal without epidermal loss over a period of 7 to 14 days. The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1. The nursing student tells the client to avoid soaking the feet. 2. The nursing student dries the feet thoroughly, including in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes. - 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes. Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming, a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention given to the areas between the toes, as skin breakdown or ulcers can go undetected in this area. Lotion needs to be applied to the dorsal and plantar surfaces of the foot. However, it would not be applied between the toes as this area needs to be kept dry. Therefore, option 4 is the action by the nursing student that requires a need for further teaching. As the nurse, you are providing care for a client and notice tiny, pinpoint red or purple spots. It would appropriate for you to document these spots as A)mottling B)petechiae C)cyanosis D)jaundice. - B) Petechiae As they nurse, you are performing a physical assessment of a client and find an area of bluish marbling. You should document this area as A) flushing B) mottling C) ecchymosis D) cyanosis. - C) Ecchymosis Fibrin - connective tissue that deposits in injured area and becomes framework for cell repair. Scab - consists of clots and dead/dying tissue and serves to aid hemostasis and inhibit contamination of wound by microorganisms. collagen - whitish protein substance that adds tensile strength to the wound. Granulation tissue - translucent red, fragile, bleeds easily. Has network of capillaries increasing the blood supply Eschar - dried plasma proteins and dead cells Scar - thick grey, fibrinous tissue Keloid - in some dark-skinned individuals an abnormal amount of collagen is laid down, resulting in a hypertrophic scar. Clean wound - uninfected wound sin which there is minimal inflammation and the respiratory, GI, genital, and urinary tracts are not entered. Primarily closed wounds. Clean-contaminated wound - surgical wounds in which the respiratory, GI, genital, or urinary tract has been entered. Show no signs of infection. Pressure injuries - areas of compromised tissue integrity as a result of sustained pressure on a particular area of the body * most common over bony prominences Risk factors for pressure ulcers - aging skin immobility moisture/incontinence obesity or lean body mass. poor or inadequate nutrition (low protein intake) Poor or inadequate hydration Illness-fever and dehydration anemia impaired circulation/Vascular disorders edema sensory deficits decreased loss of consciousness or under sedation skin friction/shearing Purple, dark red or brown discoloration on the skin but the skin is intact. Injury occurs under the skin and depth cannot be determined. Pain complaint prior to discoloration appears. Skin feels mushy, warm, firm, and cool compared to surrounding skin. - Suspected Deep Tissue Injury Slough or eschar covers the entire wound or part of the wound, and depth cannot be assessed. - Unstageable pressure injury Wound edges line up - approximated Factors affecting wound healing - Oxygenation and tissue perfusion Diabetes Nutrition Age Infection Position for relieving pressure from sacrum and greater trochanter - Side lying at 30 degrees. Scales that measure a person's risk factor for pressure injuries - Norton Scale and Braden Scale Nutritional needs for wound healing - Protein Vitamin C, A, E Copper Zinc Active range of motion - The patient has full independent movement of all joints. Also known as isotonic exercise Active assistive range of motion - The caregiver minimally assists the patient or the patient minimally assists himself or herself in the movement of joints through a full motion. Passive range of motion - The caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy. Underlying causing of clubbing - Chronic hypoxemia Modifiable risk factors for cardiovascular disease - Elevated serum Lipid level HTN/hypertension Cigarette Smoking Diabetes Obesity Sedentary Lifestyle Non-modifiable risk factors for cardiovascular disease - heredity age Gender What finding indicates presence of an MI -diarrhea -nausea -hiccups -headache - nausea Signs and symptoms of MI - epigastric discomfort, discomfort between neck and naval syncope diaphoresis/sweating nausea, vomiting shortness of breath Causes of heart failure - damage to a heart valve, pressure around the heart, vitamin B deficiency, and damage to blood vessels Chronic bronchitis - inflammation of the larger airways, increased production of mucus, and chronic cough; leads to damage on the inner lining, effecting way to clear mucous Risk: Environmental exposures, smoking, pollutants, second hand smoke Signs and symptoms of heart failure - Shortness of breath with exertion or supine Weight gain: 2-3 lbs. in 1 day or 5lbs In a week Increased cough with pink-tinged sputum New or increased swelling to the ankles, feel or abdomen (Ascites) Adventitious breath sounds Atelectasis is - alveoli are collapsing Cyanosis - blue discoloration of the skin caused by a lack of adequate oxygen in the blood Clinical manifestations of hypoxia - Increased pulse shallow respirations dyspnea increased restlessness cyanosis nasal flaring retractions Which mask is most appropriate for CHF - Non-rebreather Promotes vascular circulation - elevate legs dorsiflexion exercises What lab causes concern for heart issues - hyperkalemia The nurse is performing a physical assessment of a client. The nurse hears the "lub" "dub". In order to properly document this, the nurse documents "S1 and S2 audible". The nurse is correct if the nurse recognizes that the following valves are closing during the "lub" or S1? (Select all that apply.) Pulmonic Tricuspid Aortic Mitral - Tricuspid and Mitral Phases of wound healing - inflammatory, proliferative, maturation Inflammatory phase of wound healing - begins at the time of injury and lasts for 3- 5 days; manifestations include edema, pain, redness, and warmth proliferative phase of wound healing - begins the fourth day after injury and can last up to 4 weeks. Scar tissue forms, and granulation tissue forms in the tissue bed Maturation phase of wound healing - Begins as early as week 3 after injury and can last up to 1 year. Scar tissue becomes thinner and is firm and inelastic on palpation. Primary intention healing - wound edges are approximated and held in place until healing occurs. Wound is easily closed and dead space is eliminated Second intention healing - occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue Tertiary intention healing - involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by first intention. serous - clear or straw-colored and watery drainage Serosanguineous - Pale, pink, watery; mixture of clear and red fluid Sanguineous - red drainage that is abnormal and indicates active bleeding purulent - yellow, gray, tan, brown, or green drainage due to infection in the wound. Avoid ______ to a reddened skin area because it can damage the capillary beds and cause tissue breakdown and necrosis - direct massage. Pneumonia - an inflammation of the alveoli caused by an infectious process that may develop 3-5 days postoperatively as a result of infection, aspiration, and immobility Assessment: dyspnea and increased respiratory rate, crackles over involved lung area, elevated temperature, productive cough and chest pain. Atelectasis - collapsed or airless state of the lung that may be the result of airway obstruction caused by accumulated secretions or failure of the client to deepbreathe or ambulate after surgery; usually occurs 1-2 days after surgery hypoxemia - an inadequate concentration of oxygen in arterial blood; in the postoperative client, this can be due to shallow breathing from the effects of anesthesia or medications. Assessment: Restlessness, dyspnea, diaphoresis, tachycardia, hypertension, cyanosis, low pulse ox reading. pulmonary embolism - a clot blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lung Assessment: Sudden dyspnea, sudden sharp chest or abdominal pain, cyanosis, tachycardia, and low blood pressure. A client who had a right colectomy calls the nurse and reports a popping feeling in the incisional area. The nurse removes the abdominal dressing to assess the wound and notes that the incision line has opened and a loop of the bowel is protruding from the wound. The nurse takes action and implements the following intervention FIRST - Covers the wound with a sterile normal saline dressing and keeps the dressing moist. You would then notify the surgeon immediately and monitor vital signs. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism." - 1. "Use of an incentive spirometer will help prevent pneumonia." Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners help prevent this complication; however, it is not related to coughing and deep-breathing techniques. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold your breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. - 4- The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. For optimal lung expansion with the incentive spirometer, the client would assume the semi-Fowler's or high-Fowler's position. The mouthpiece needs to be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath would be held for 5 seconds before exhaling slowly. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Hard reddened skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin - 2. Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk. Advocacy - supporting the clients decision even when it conflicts with the advocates own preferences or choices Nurse practice act - series of statutes that have been enacted by a state legislature to regulate the practice of nursing within that state. Acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice. Additional issues covered include licensure requirements for protection of the public, grounds for disciplinary action, rights of the nurse licensee if a disciplinary action is taken, and related topics. All nurses are responsible for knowing the provisions of the act of the state or province in which they work. Standards of care - guidelines that identify what the client can expect to receive in terms of nursing care. Determine whether nurses have performed duties in an appropriate manner. If the nurse does not perform duties within accepted standards of care, the nurse may be in jeopardy of legal action. Negligence - conduct that falls below the standard of care; includes acts of commission and acts of omission. Malpractice - negligence on the part of the nurse and is determined if the nurse owed a duty to the client and did not carry out the duty and the client was injured because the nurse failed to perform the duty. Good Samaritan laws - encourage healthcare professionals to assist in emergency situations and limit liability and offer legal immunity for persons helping in an emergency provided that they give reasonable care and within their scope of practice. COPD definition - group of disorders characterized by impaired airflow in lungs emphysema - enlargement of gas-exchange airways and damage to the alveolar walls in the lungs Risk factors for COPD/emphysema - smoking, exposure to pollution, family history, childhood respiratory infections Homeostasis - the body's regulation of systems to maintain a steady state Fight-or-flight response - physiologic response to stress by activation of the autonomic nervous system Three stages of stress response - alarm, resistance, and exhaustion Alarm - hypothalamic and pituitary excitation (increased ADH and ACTH) Adrenal cortex: increased cortisol and increased glycogenesis, and increased fat and protein catabolism Increased Aldosterone, increased water and sodium retention, and increased potassium excretion Adrenal medulla stimulation: Increased epinephrine (higher heart rate, increased oxygen intake, increased glucose), increased norepinephrine (increased arterial BP, increased blood flow to the skeletal muscles) Distress - negative stress Eustress - positive stress Asthma definition and symptoms - chronic disorder that causes inflammation and constriction of the airways Symptoms, caused by airway spasm, bronchial narrowing or obstruction, mucous accumulation, and airway inflammation: dyspnea, intermittent cough, chest tightness, exertion wheezing, and prolonged expiration Resistance - attempts to stabilize, increased parasympathetic activity,, and adaptation to demand. Resolution and recovery - return to predemand state Exhaustion - decreasing energy as resources are depleted, inability to adapt, death. Laboratory of the cardiovascular and pulmonary system - PFT-pulmonary function test CBC-Complete blood count; provided information regarding oxygen and carbon dioxide transport capabilities and the status of the immune response. RBC, Hgb, and Act levels indicate oxygen-carrying capacity. Hgb is decreased in patient with heart failure and increased in patients with COPD. BMP-Basic Metabolic Panel; blood tests used to assess a patient's renal function, glucose level, and electrolytes (electrolyte abnormalities can cause cardiac arrhythmia, and some diuretics to treat heart failure cause hypokalemia and hypomagnesemia) ABG-Arterial blood gas; drawn from patients with decreased oxygenation and suspected acid-base imbalance. (COPD= respiratory acidosis=decreased oxygen levels and higher circulating levels of carbon dioxide) Lipids-diagnosis hyperlipidemia (high cholesterol)-->risk factor for CAD. Cardiac Enzymes: released when myocardial damage/necrosis occurs; Troponin T and I proteins are the most helpful biomarkers for determining a myocardial infarction diagnositic tests of the cardiovascular and pulmonary system - CXR-Chest X-ray; examines lungs, heart, and bony anatomy of the thoracic region. Can diagnosis tumors, rib fractures, pneumothorax, pneumonia, pleural effusion, pericardial effusion, enlarged heart, atelectasis. Can also confirm device location (Chest tubes, tracheostomy, central lines) ECG/EKG-Electrocardiogram; graphic representation of the electrical activity that occurs in the heart. Test results are interpreted for rate and rhythm of the heart, lack of blood supply, abnormalities of the conduction system and arrhythmias. Echocardiogram: ultrasound that uses sound waves to visualize the heart structure and evaluate the function of the heart. Shows movement of blood through the heart and is used to measure cardiac output. Can evaluate for congenital heart defects, pericardial effusion, disorders of the heart valves, heart size, and effectiveness of cardiac output. Cardiac Catheterization: uses contrast and a long, flexible catheter to visualize the heart chambers, coronary arteries, and great vessels. Evaluates chest pain, locates region of the coronary artery occlusion, and determine the effects of valvular heart disease. Anxiety - response to stress that causes apprehension or uncertainty; it differs from fear, which has an identifiable source of impending danger. Can manifest as vague nervousness or as a feeling of dread. A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicated a need for further teaching? A. Removes the cap and shakes the inhaler well before use. B. Press the canister down with your finger as he breathes in. C. Inhales the mist and quickly exhales. D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed. - C. Inhales the mist and quickly exhales. Take the inhaler out of the mouth. If the client can, he should hold his breath as he slowly counts to 10. This lets the medicine reach deep into the lungs. The client should be instructed to hold his or her breath at least 10 to 15 seconds before exhaling the mist. Rationale: Option A: If the client has not used the inhaler in a while, he may need to prime it. See the instructions that came with the inhaler for when and how to do this. Shake the inhaler hard 10 to 15 times before each use. Option B: Hold the inhaler with the mouthpiece down. Place lips around the mouthpiece so that the mouth forms a tight seal. As the client starts to slowly breathe in through the mouth, press down on the inhaler one time. Option D: If using inhaled, quick-relief medicine (beta-agonists), wait about 1 minute before taking the next puff. You do not need to wait a minute between puffs for other medicines. A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitation? A. Chronic obstructive bronchitis B. Emphysema C. Bronchial asthma D. Bronchial asthma and bronchitis - B. emphysema The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyper-resonant lungs to percussion. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she developed a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? A. It is likely that the client is developing a secondary bacterial pneumonia. B. The assessment findings are consistent with influenza and are to be expected. C. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions D. The client has not been taking her decongestants and bronchodilators as prescribed. - A. It is likely that the client is developing a secondary bacterial pneumonia. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection that is not consistent with a diagnosis of influenza. A client with COPD reports steady weight loss and being "too tired from just breathing to eat." Which of the following nursing diagnoses would be mostappropriate when planning nutritional interventions for this client? A. Altered nutrition: Less than body requirements related to fatigue. B. Activity intolerance related to dyspnea. C. Weight loss related to COPD. D. Ineffective breathing pattern related to alveolar hypoventilation. - A. Altered nutrition: Less than body requirements related to fatigue. The client's problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Instruct the patient to frequently eat high caloric foods in smaller portions. COPD patients expend an extraordinary amount of energy simply on breathing and require high caloric meals to maintain body weight and muscle mass. Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD? A. Increased anteroposterior chest diameter. B. Underdeveloped neck muscles. C. Collapsed neck veins. D. Increased chest excursions with respiration. - A. Increased anteroposterior chest diameter. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. In addition, coarse crackles beginning with inspiration may be heard. Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema? A. To promote oxygen intake. B. To strengthen the diaphragm. C. To strengthen the intercostal muscles. D. To promote carbon dioxide elimination. - D. To promote carbon dioxide elimination. Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles. The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected? A. Normal breath sounds B. Prolonged inspiration C. Normal chest movement D. Coarse crackles and rhonchi - D. Coarse crackles and rhonchi Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. Crackles are usually due to airway secretions within a large airway and disappear on coughing. These crackles are scanty, gravity-independent, usually audible at the mouth, and strongly associated with severe airway obstruction. Which of the following ABG abnormalities should the nurse anticipate in a client with advanced COPD? A. Increased PaCO2 B. Increased PaO2 C. Increased pH D. Increased oxygen saturation - A. Increased PaCO2 As COPD progresses, the client typically develops increased PaCO2 levels and decreased PaO2 levels. This results in decreased pH and decreased oxygen saturation. These changes are the result of air trapping and hypoventilation. Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity of disease exacerbation. Which of the following diets would be most appropriate for a client with COPD? A. Low fat, low cholesterol B. Bland, soft diet C. Low-Sodium diet D. High calorie, high-protein diet - D. High calorie, high-protein diet The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. Eat 20 to 30 grams of fiber each day, from items such as bread, pasta, nuts, seeds, fruits and vegetables. Eat a good source of protein at least twice a day to help maintain strong respiratory muscles. Good choices include milk, eggs, cheese, meat, fish, poultry, nuts and dried beans or peas. The nurse is planning to teach a client with COPD how to cough effectively. Which of the following instructions should be included? A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation. B. Lie flat on back, splint the thorax, take two deep breaths and cough. C. Take several rapid, shallow breaths and then cough forcefully. D. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing. - A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation. The goal of effective coughing is to conserve energy, facilitate the removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process 3 or 4 times, the client should take a deep abdominal breath, bend forward and cough 3 or 4 times upon exhalation ("huff" cough). A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client? A. Initiate oxygen therapy and reassess the client in 10 minutes. B. Draw blood for an ABG analysis and send the client for a chest x-ray. C. Encourage the client to relax and breathe slowly through the mouth. D. Administer bronchodilators. - D- administer bronchodilators In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline. The client with asthma should be taught which of the following is one of the most common precipitating factors of an acute asthma attack? A. Occupational exposure to toxins. B. Viral respiratory infections. C. Exposure to cigarette smoke. D. Exercising in cold temperatures. - B-Viral respiratory infections The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration. Basilar crackles are present in a client's lungs on auscultation. The nurse knows that these are discrete, non continuous sounds that are: A. Caused by the sudden opening of alveoli. B. Usually more prominent during expiration. C. Produced by airflow across passages narrowed by secretions. D. Found primarily in the pleura. - A. Caused by the sudden opening of alveoli. Basilar crackles are usually heard during inspiration and are caused by sudden opening of the alveoli. Basilar crackles are a bubbling or crackling sound originating from the base of the lungs. They may occur when the lungs inflate or deflate. They're usually brief, and may be described as sounding wet or dry. Excess fluid in the airways causes these sounds. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified? A. Serosanguineous drainage from the puncture site. B. Increased temperature and blood pressure. C. Increased pulse and pallor. D. Hypotension and hypothermia. - C. Increased pulse and pallor. Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually, no more than 1 L of fluid is removed at one time to prevent this from occurring. If a client continues to hypoventilate, the nurse will continually assess for a complication of: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis - A-Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. The respiratory centers in the pons and medulla control alveolar ventilation. Chemoreceptors for PCO2, PO2, and pH regulate ventilation. Central chemoreceptors in the medulla are sensitive to changes in the pH level. A decreased pH level influences the mechanics of ventilation and maintains proper levels of carbon dioxide and oxygen. When ventilation is disrupted, arterial PCO2 increases and an acid-base disorder develops. Auscultation of a client's lungs reveals crackles in the left posterior base. The nursing intervention is to: A. Repeat auscultation after asking the client to deep breathe and cough. B. Instruct the client to limit fluid intake to less than 2000 ml/day. C. Inspect the client's ankles and sacrum for the presence of edema. D. Place the client on bedrest in a semi-Fowler's position. - A. Repeat auscultation after asking the client to deep breathe and cough. Although crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and will clear after a deep breath or a cough. Assess cough effectiveness and productivity. Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions to patients. The most reliable index to determine the respiratory status of a client is to: A. Observe the chest rising and falling. B. Observe the skin and mucous membrane color. C. Listen and feel the air movement. D. Determine the presence of a femoral pulse. - C. Listen and feel the air movement. To check for breathing, the nurse places her ear and cheek next to the client's mouth and nose to listen and feel for air movement. During the inspection, the examiner should pay attention to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, coastal markings, and use of accessory breathing muscles. The use of accessory breathing muscles (i.e., scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing effort caused by pathologies. Assessing a client who has developed atelectasis postoperatively, the nurse will most likely find: A. A flushed face. B. Dyspnea and pain. C. Decreased temperature. D. Severe cough and no pain. - B. Dyspnea and pain. Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation. Clients become short of breath, have a high temperature, and usually experience severe pain but do not have a severe cough. The shortness of breath is a result of decreased oxygen-carbon dioxide exchange at the alveolar level. Postoperative atelectasis typically occurs within 72 hours of general anesthesia and is a wellknown postoperative complication. A fifty-year-old client has a tracheostomy and requires tracheal suctioning. The first intervention in completing this procedure would be to: A. Change the tracheostomy dressing. B. Provide humidity with a trach mask. C. Apply oral or nasal suction. D. Deflate the tracheal cuff. - C. Apply oral or nasal suction. Before deflating the tracheal cuff, the nurse will apply oral or nasal suction to the airway to prevent secretions from falling into the lung. Dressing change and humidity do not relate to suctioning. Airway suctioning is a procedure routinely done in most care settings, including acute care, sub-acute care, long-term care, and home settings. Suctioning is performed when the patient is unable to effectively move secretions from the respiratory tract. The best method of oxygen administration for client with COPD uses: A. Cannula B. Simple Face mask C. Non-rebreather mask D. Venturi mask - D. Venturi mask Venturi delivers controlled oxygen. An air-entrainment (also known as venturi) mask can provide a pre-set oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such a mask, the air-to-oxygen ratio decreases, causing the maximum concentration of oxygen provided by an air-entrainment mask to be around 40%. On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles. B. Absence of breaths sound in the right thorax. C. Inspiratory wheezes in the right thorax. D. Bilateral pleural friction rub. - B. Absence of breaths sound in the right thorax. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse. The degree of collapse determines the clinical presentation of pneumothorax. None of the other options are associated with pneumothorax. For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A. Encouraging the patient to drink three glasses of fluid daily. B. Keeping the patient in semi-Fowler's position. D. Administering a sedative, as prescribed. - C. Using a high-flow venturi mask to deliver oxygen as prescribed. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar - B. Venturi mask The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. An air-entrainment (also known as venturi) mask can provide a pre-set oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such a mask, the air to oxygen ratio decreases, causing the maximum concentration of oxygen provided by an airentrainment mask to be around 40%. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity. Option A: Face tents are used to provide a controlled concentration of oxygen and increase moisture for patients who have facial burn or a broken nose, or who are claustrophobic. The mask covers the nose and mouth and does not create a seal around the nose. It can provide 28% to 100% O2 Flow meter should be set to deliver O2 at a minimum of 15 L/min. It is difficult to achieve high levels of oxygenation with this mask. Option C: A mask used for the therapeutic administration of a nebulized solution, humidity, or high airflow with oxygen enrichment. It has a large-bore inlet and an exhalation port. When the required concentration needs to change during oxygen therapy, the adult aerosol mask, with the choice of 6 venturis or a multi venturi mask kit will offer the choice to suit the individual patient's requirements. The aerosol mask can be used with a nebuliser or 22mm corrugated tubing for combined oxygen therapy and humidification. Option D: One is to use a tracheostomy collar, which is placed over a breathing tube in a tracheotomy incision in the throat, and through which humidified oxygen is given. The other is to reduce the pressure support supplied vi