ATI Custom NUR 198 Exam 2 Summer ASN

Explanation:

Correct Answer: (B) Decreased breath sounds in the lung bases due to air trapping.

In COPD, chronic airway obstruction and loss of elastic recoil cause air trapping within the alveoli, particularly in the lower lung fields. This hyperinflation results in diminished or distant breath sounds upon auscultation, especially at the lung bases, because air movement is restricted, and the increased residual volume of trapped air dampens the transmission of normal breath sounds. This is one of the classic and expected auscultatory findings in clients with COPD.

Why Other Options are Incorrect:

A. Increased neck circumference — Increased neck circumference is not a recognized clinical finding associated with COPD. It is more commonly associated with conditions such as obesity or obstructive sleep apnea, which is a distinctly different respiratory condition.

C. Presence of stridor on auscultation of lung fields — Stridor is a high-pitched sound caused by upper airway obstruction, such as in croup, epiglottitis, or foreign body aspiration. COPD is a lower airway and alveolar disease process and does not typically produce stridor; wheezing is the more characteristic adventitious sound heard in COPD.

D. Decreased anterior-posterior diameter of the chest — COPD classically causes an increased anterior-posterior diameter of the chest, commonly described as a barrel chest, due to chronic hyperinflation of the lungs. A decreased diameter is the opposite of the expected finding in this condition.

1. A nurse is developing a teaching plan for an adult client with asthma. The nurse determines the teaching has been successful when the client makes which of the following statements?

A. "I should use my cortisone inhaler followed by my albuterol inhaler."

B. "I should closely monitor my symptoms using a peak expiratory flow (PEF) monitor."

C. "I should expect to use my rescue inhaler daily."

D. "I will avoid physical activity to prevent asthma attacks."

Explanation:

Correct Answer: (B) "I should closely monitor my symptoms using a peak expiratory flow (PEF) monitor."

Peak expiratory flow monitoring is a cornerstone of effective asthma self-management. It allows the client to objectively track lung function on a daily basis, identify early signs of airway narrowing before symptoms become severe, and recognize patterns or triggers that worsen their condition. Regular PEF monitoring empowers the client to adjust their action plan proactively, contact their provider when readings fall into the caution or danger zones, and prevent acute exacerbations through early intervention. This statement reflects a correct and successful understanding of asthma self-management.

Why Other Options are Incorrect:

A. "I should use my cortisone inhaler followed by my albuterol inhaler" — This statement reflects incorrect technique. The proper sequence is to use the short-acting bronchodilator, such as albuterol, first to open the airways, followed by the corticosteroid inhaler so that the anti-inflammatory medication can reach deeper into the now-dilated airways more effectively.

C. "I should expect to use my rescue inhaler daily" — Frequent or daily use of a rescue inhaler indicates poorly controlled asthma and signals the need for reassessment of the client's maintenance therapy regimen. This statement reflects a misunderstanding, as the goal of asthma management is to minimize rescue inhaler use, not normalize daily dependence on it.

D. "I will avoid physical activity to prevent asthma attacks" — This statement reflects a misunderstanding of asthma management. While exercise-induced bronchospasm can occur, the goal of treatment is to control asthma well enough that the client can safely participate in physical activity, often through prophylactic use of a bronchodilator prior to exercise, rather than avoiding activity altogether.

1. The nurse on the respiratory ward is caring for a client with pneumonia. The nurse notes that the client's temperature is 102.5°F (39.17°C). Which of the following actions should the nurse do first?

A. Measure the client's pulse and blood pressure

B. Obtain a blood sample for culturing and sensitivity

C. Contact the primary health care provider

D. Auscultation of the client's breath sounds

Explanation:

Correct Answer: (D) Auscultation of the client's breath sounds.

When a febrile finding is noted in a client with pneumonia, the nurse's first action should be to complete a focused respiratory assessment before taking any other action. Auscultating the client's breath sounds provides immediate, critical clinical data about the current status of the client's respiratory function, including the presence of crackles, diminished breath sounds, or worsening consolidation. This assessment data is necessary to fully understand the client's condition and will directly inform what should be reported to the provider and what other actions, such as obtaining vital signs or cultures, should follow.

Why Other Options are Incorrect:

A. Measure the client's pulse and blood pressure — While obtaining a full set of vital signs is important and will be done as part of the comprehensive assessment, auscultating breath sounds first provides the most directly relevant respiratory data given the client's pneumonia diagnosis and is the priority focused assessment in this scenario.

B. Obtain a blood sample for culturing and sensitivity — Blood cultures require a provider order and are typically obtained to identify the causative organism in the setting of fever, but this is not the first action the nurse should independently take. Assessment must precede diagnostic test collection.

C. Contact the primary health care provider — The nurse should complete a thorough assessment, including auscultating breath sounds and gathering a full set of vital signs, before contacting the provider. This ensures the nurse can provide complete and accurate clinical data when reporting the client's status, making premature notification without full assessment data less effective.

1. The nurse is caring for a client admitted with bacterial pneumonia. Which assessment finding is most concerning to the nurse?

A. Pleuritic chest pain when coughing

B. White blood cell (WBC) count of 13,500/mcL (nl. 5000-10,000/mcL)

C. Altered mental status

D. Dyspnea when lying supine

Explanation:

Correct Answer: (C) Altered mental status.

Altered mental status in a client with bacterial pneumonia is a critical and concerning finding because it can indicate severe hypoxia, sepsis, or impending respiratory failure. Changes in level of consciousness or cognitive function signal that the brain is not receiving adequate oxygenation or that a systemic infectious process is progressing to a more dangerous state, such as septic shock. This finding requires immediate further assessment and intervention, as it represents a potential life-threatening deterioration in the client's condition.

Why Other Options are Incorrect:

A. Pleuritic chest pain when coughing — Pleuritic chest pain is a common and expected finding in bacterial pneumonia due to inflammation of the pleura. While uncomfortable, it is an anticipated symptom and is not as immediately life-threatening as a change in mental status.

B. White blood cell (WBC) count of 13,500/mcL — An elevated white blood cell count is an expected finding in bacterial pneumonia, reflecting the body's normal immune response to infection. While it confirms an active infectious process, it is an anticipated laboratory finding rather than an acute, most concerning clinical deterioration.

D. Dyspnea when lying supine — Dyspnea when lying supine, or orthopnea, is a common symptom in respiratory illness related to positional changes in lung expansion and is an expected finding in pneumonia. While it should be addressed for comfort, it is not as immediately concerning as a change in neurological status, which suggests systemic compromise.

1. A nurse is suctioning the airway of a client with pneumonia when the suction catheter accidentally touches the bed rail. What is the nurse's priority action?

A. Discard the catheter and obtain a new sterile one.

B. Flush the catheter with normal saline and proceed.

C. Continue suctioning since it briefly touched a clean surface.

D. Wipe the catheter with an alcohol swab and continue.

Explanation:

Correct Answer: (A) Discard the catheter and obtain a new sterile one.

Suctioning requires strict sterile technique because the catheter is introduced directly into the lower airway, which is normally sterile. Once a suction catheter contacts any non-sterile surface, such as a bed rail, it becomes contaminated and is no longer safe to use. Continuing to use a contaminated catheter introduces pathogens directly into the client's airway, significantly increasing the risk of hospital-acquired infection, particularly concerning in a client already diagnosed with pneumonia. The only safe and appropriate action is to discard the contaminated catheter immediately and obtain a new sterile one before continuing the procedure.

Why Other Options are Incorrect:

B. Flush the catheter with normal saline and proceed — Flushing the catheter with saline does not sterilize it. Normal saline is not an antiseptic or sterilizing agent and will not remove or kill pathogens that have contaminated the catheter surface.

C. Continue suctioning since it briefly touched a clean surface — A bed rail is not a sterile or even clean surface in the clinical sense required for airway suctioning; it is a high-touch surface known to harbor significant numbers of microorganisms. Brief contact still constitutes contamination.

D. Wipe the catheter with an alcohol swab and continue — Wiping the catheter with an alcohol swab does not restore sterility. Alcohol swabs are not capable of achieving the level of sterilization required for a device being introduced into the sterile lower airway, and residual alcohol could also cause airway irritation.

1. A client is admitted to the emergency department with sudden onset of dyspnea, pleuritic chest pain, and anxiety. Vital signs show: HR 118/minute, RR 28/minute, BP 142/88 mmHg, and SpO2 89% on room air. Which symptom is most characteristic of a pulmonary embolism in this client?

A. Sudden onset dyspnea

B. Elevated blood pressure

C. Calf pain and edema

D. Pronounced bradycardia

Explanation:

Correct Answer: (A) Sudden onset dyspnea.

Sudden onset dyspnea is the most common and most characteristic presenting symptom of pulmonary embolism. When a thrombus lodges in the pulmonary vasculature, it acutely obstructs blood flow to a portion of the lung, creating a ventilation-perfusion mismatch that causes immediate and significant difficulty breathing. This is consistent with the client's presentation of dyspnea occurring abruptly alongside pleuritic chest pain, tachycardia, tachypnea, and hypoxia, all of which align directly with classic pulmonary embolism presentation.

Why Other Options are Incorrect:

B. Elevated blood pressure — While this client's blood pressure is mildly elevated at 142/88, hypertension is not a characteristic or diagnostic feature of pulmonary embolism. The hemodynamic hallmark of significant PE is more often hypotension due to obstructive shock, especially in massive PE.

C. Calf pain and edema — Calf pain and edema are signs of deep vein thrombosis, which is often the source of the embolus that travels to the lungs. However, this is a risk factor and potential underlying cause, not a symptom directly characteristic of the pulmonary embolism event itself as it presents in the emergency department.

D. Pronounced bradycardia — Pulmonary embolism classically causes tachycardia, not bradycardia, as the heart compensates for reduced oxygenation and increased pulmonary vascular resistance by increasing heart rate. This client's heart rate of 118 confirms tachycardia, the opposite of this answer choice.

1. A nurse is caring for a client recently diagnosed with lung cancer who reports difficulty resting due to breathing discomfort. During the assessment, the nurse observes several findings. Which findings should the nurse communicate to the healthcare provider to best support the client's comfort and safety?

Findings: Client reports shortness of breath when lying flat that prevents rest / Client becomes restless and frequently repositions to ease breathing / Oxygen saturation of 92% with activity but returns to baseline with rest / Client reports reduced appetite over the past week / Client reports intermittent dry cough without chest pain

Explanation:

Correct Answer: Communicate to Provider — Client reports shortness of breath when lying flat that prevents rest and Client becomes restless and frequently repositions to ease breathing. Do Not Communicate — Oxygen saturation of 92% with activity but returns to baseline with rest, Client reports reduced appetite over the past week, and Client reports intermittent dry cough without chest pain.

Shortness of breath when lying flat that prevents rest describes orthopnea, a finding that directly impacts the client's ability to rest and may indicate worsening pulmonary compromise from tumor burden, pleural effusion, or airway obstruction. This requires prompt provider communication so that interventions such as positioning, supplemental oxygen, or further diagnostic evaluation can be initiated. Restlessness and frequent repositioning to ease breathing are objective signs of increased work of breathing and air hunger, indicating the client is in active respiratory distress and requires prompt provider awareness to adjust the plan of care and ensure comfort and safety.

Why Other Options are Incorrect:

Oxygen saturation of 92% with activity but returning to baseline with rest reflects an expected and appropriately compensated physiological response to exertion in a client with lung cancer. Since the saturation normalizes with rest, this is not an urgent finding requiring immediate provider notification, though it should continue to be monitored and documented.

Reduced appetite over the past week is a common finding in clients with cancer related to disease progression, treatment effects, or psychological factors, but it is not an acute safety concern related to the current breathing discomfort and rest disturbance described in this scenario.

Intermittent dry cough without chest pain is a nonspecific and stable finding that does not indicate acute respiratory compromise. Without associated chest pain, hemoptysis, or worsening character, this finding does not require urgent provider communication.

1. A nurse is caring for a surgical client who is prescribed bedrest. Which intervention should the nurse implement to prevent atelectasis?

A. Consult the respiratory therapist to perform postural drainage each shift.

B. Administer nebulized bronchodilators and corticosteroids as prescribed.

C. Apply sequential compression devices.

D. Encourage the client to use an incentive spirometer every hour while awake.

Explanation:

Correct Answer: (D) Encourage the client to use an incentive spirometer every hour while awake.

Incentive spirometry is the standard and most effective nursing intervention to prevent atelectasis in clients on bedrest, particularly post-surgical clients. The device encourages slow, deep, sustained inspiration, which promotes maximal lung expansion, reinflates collapsed alveoli, and prevents the alveolar collapse that occurs with the shallow breathing patterns common in immobile or post-operative clients. Regular use every hour while awake maintains optimal lung volumes and significantly reduces the risk of atelectasis and subsequent pneumonia.

Why Other Options are Incorrect:

A. Consult the respiratory therapist to perform postural drainage each shift — Postural drainage is a technique used to mobilize and clear secretions in clients with excessive mucus production, such as those with cystic fibrosis or bronchiectasis. It is not the primary intervention for preventing atelectasis in a surgical client on bedrest, and prevention should be nurse-initiated and frequent, not dependent on therapist scheduling.

B. Administer nebulized bronchodilators and corticosteroids as prescribed — These medications are used to manage bronchospasm and airway inflammation in conditions such as asthma or COPD. They do not directly address the alveolar collapse mechanism responsible for atelectasis in an immobile surgical client.

C. Apply sequential compression devices — Sequential compression devices are used to prevent deep vein thrombosis in clients on bedrest by promoting venous return in the lower extremities. They have no role in preventing pulmonary atelectasis.

1. A client with obstructive sleep apnea (OSA) reports frequent nighttime awakenings and daytime fatigue. Which factor most directly affects gas exchange in this condition?

A. Decreased lung compliance during sleep

B. Repeated upper airway obstruction reducing airflow

C. Increased production of carbon dioxide

D. Increased oxygen diffusion across the alveoli

Explanation:

Correct Answer: (B) Repeated upper airway obstruction reducing airflow.

Obstructive sleep apnea is caused by repeated episodes of partial or complete collapse of the upper airway during sleep, typically due to relaxation of the pharyngeal muscles and soft tissue obstruction. This repeated obstruction directly reduces or completely stops airflow into the lungs for brief periods, preventing adequate oxygen from reaching the alveoli for gas exchange. This cyclical pattern of obstruction and arousal is the direct mechanical cause of the hypoxemia, hypercapnia, and fragmented sleep characteristic of OSA, making it the factor most directly responsible for impaired gas exchange in this condition.

Why Other Options are Incorrect:

A. Decreased lung compliance during sleep — Lung compliance refers to the elasticity and expandability of lung tissue itself. OSA is an upper airway obstructive process, not a condition caused by changes in lung tissue compliance, making this an inaccurate mechanism for this condition.

C. Increased production of carbon dioxide — Hypercapnia in OSA is a consequence of inadequate ventilation during obstructive episodes, not a primary cause of impaired gas exchange. The carbon dioxide elevation results from the airway obstruction rather than being the initiating factor itself.

D. Increased oxygen diffusion across the alveoli — OSA causes decreased, not increased, oxygen availability due to reduced airflow reaching the alveoli during obstructive episodes. This answer describes the opposite of what occurs in this condition.

1. The nurse is caring for a client who is receiving mechanical ventilation following a severe respiratory infection. The client is sedated and receiving continuous enteral nutrition. Which of the following interventions should the nurse prioritize?

A. Assessing the client's sedation level and adjusting sedation as necessary.

B. Ensuring proper positioning and turning the client to prevent pressure injuries.

C. Performing regular oral care to prevent ventilator-associated pneumonia (VAP).

D. Monitoring the client's fluid balance and adjusting enteral nutrition as needed.

Explanation:

Correct Answer: (C) Performing regular oral care to prevent ventilator-associated pneumonia (VAP).

Ventilator-associated pneumonia is one of the most serious and common complications affecting mechanically ventilated clients, and oral care is one of the most critical and evidence-based interventions for its prevention. Regular oral hygiene reduces the bacterial load in the oropharynx, decreasing the risk that bacteria-laden secretions will be aspirated into the lower airway around the endotracheal tube cuff. Given that this client is sedated, ventilated, and receiving continuous enteral nutrition, the combination of reduced airway protective reflexes and ongoing oral colonization risk makes consistent oral care the highest priority intervention to prevent this life-threatening complication.

Why Other Options are Incorrect:

A. Assessing the client's sedation level and adjusting sedation as necessary — Sedation assessment is important for preventing oversedation and promoting timely weaning from the ventilator, but it does not directly address the immediate and high-priority risk of ventilator-associated pneumonia in this clinical scenario.

B. Ensuring proper positioning and turning the client to prevent pressure injuries — Pressure injury prevention is an essential standard of care for any immobile, sedated client, but it is not the most immediate priority when weighed against the serious and potentially life-threatening risk of VAP in a mechanically ventilated client.

D. Monitoring the client's fluid balance and adjusting enteral nutrition as needed — Fluid balance and nutritional monitoring are important ongoing aspects of care for a ventilated client receiving enteral nutrition, but they are not the most urgent priority compared to actively preventing a life-threatening pulmonary infection through oral care.

1. A client who has recently entered the United States from India is being seen in the clinic for symptoms of persistent cough, fever, and night sweats. The nurse determines the most likely cause of this client's symptoms is which of the following?

A. Pulmonary embolism

B. Active tuberculosis

C. Viral pharyngitis

D. Latent tuberculosis

Explanation:

Correct Answer: (B) Active tuberculosis.

The triad of persistent cough, fever, and night sweats is the classic clinical presentation of active tuberculosis. India is among the countries with the highest global burden of tuberculosis, making recent immigration from this region a significant epidemiological risk factor. Active TB occurs when the mycobacterium is actively replicating and causing symptomatic disease, distinguishing it from latent infection. This combination of symptomatic presentation and high-risk geographic origin makes active tuberculosis the most likely diagnosis.

Why Other Options are Incorrect:

A. Pulmonary embolism — Pulmonary embolism presents with sudden onset dyspnea, pleuritic chest pain, and tachycardia, typically associated with risk factors such as immobility, recent surgery, or clotting disorders. It does not present with the chronic, progressive triad of cough, fever, and night sweats described here.

C. Viral pharyngitis — Viral pharyngitis presents with sore throat, mild fever, and upper respiratory symptoms that are typically self-limiting and resolve within days. It does not cause persistent night sweats or the prolonged symptom pattern described in this scenario.

D. Latent tuberculosis — By definition, latent tuberculosis is an asymptomatic state in which the bacteria are present in the body but inactive and not causing illness. Since this client is symptomatic with cough, fever, and night sweats, this presentation is inconsistent with latent infection and instead indicates active disease.

1. A nurse's assessment reveals that a client with asthma has a rapid, labored breathing pattern and expiratory wheezes. Which of the following complications will the nurse determine the client is most likely experiencing?

A. Bronchospasm

B. Fluid volume overload

C. Oxygen toxicity

D. Pleural effusion

Explanation:

Correct Answer: (A) Bronchospasm.

Bronchospasm is the sudden constriction of the smooth muscles lining the bronchi and bronchioles, which is the hallmark pathophysiological event in an asthma exacerbation. This airway narrowing produces the classic findings of rapid, labored breathing as the client struggles to move air through constricted passages, and expiratory wheezing as air is forced through the narrowed airways during exhalation. These findings are the direct and expected clinical manifestation of bronchospasm in a client with asthma.

Why Other Options are Incorrect:

B. Fluid volume overload — Fluid volume overload typically presents with crackles, edema, jugular venous distension, and signs of heart failure rather than wheezing and labored breathing specifically associated with airway constriction. This is not a typical asthma-related complication.

C. Oxygen toxicity — Oxygen toxicity results from prolonged exposure to high concentrations of supplemental oxygen and presents with symptoms such as substernal discomfort and nonproductive cough due to damage to lung tissue. It is unrelated to the bronchoconstrictive process occurring in this asthma exacerbation.

D. Pleural effusion — Pleural effusion involves fluid accumulation in the pleural space and typically presents with decreased or absent breath sounds over the affected area, dullness to percussion, and dyspnea, rather than the wheezing characteristic of bronchospasm in asthma.

1. A nurse is caring for a client with emphysema who is experiencing an acute exacerbation. Which nursing intervention should be the highest priority?

A. Place the client in high Fowler position.

B. Administer bronchodilators as prescribed.

C. Encourage increased fluid intake.

D. Monitor respiratory rate.

Explanation:

Correct Answer: (B) Administer bronchodilators as prescribed.

During an acute exacerbation of emphysema, the priority intervention is to directly address the underlying airway obstruction and bronchoconstriction causing the client's respiratory distress. Bronchodilators work to relax bronchial smooth muscle, widen the airways, and improve airflow, directly targeting the pathophysiology of the acute exacerbation. This pharmacological intervention provides the most immediate and direct relief of the client's respiratory compromise compared to supportive measures alone.

Why Other Options are Incorrect:

A. Place the client in high Fowler position — Positioning the client in high Fowler position is a beneficial supportive measure that maximizes lung expansion and eases the work of breathing, but it does not address the underlying bronchoconstriction and airway obstruction driving the acute exacerbation. It is a comfort and supportive measure rather than the priority treatment intervention.

C. Encourage increased fluid intake — Adequate hydration helps thin secretions and supports mucus clearance, which is beneficial in COPD management. However, this is a supportive, longer-term intervention and is not the priority action during an acute exacerbation requiring immediate airway relief.

D. Monitor respiratory rate — Monitoring respiratory rate is an important ongoing assessment to track the client's status and response to treatment, but assessment alone does not treat the acute exacerbation. Administering the bronchodilator is the priority active intervention that directly improves the client's respiratory status.

1. A client with chronic obstructive pulmonary disease (COPD) reports increased dyspnea after a prolonged coughing episode. The nurse's assessment reveals an SpO2 of 84%, asymmetrical chest movement, and decreased breath sounds on the right side. Which condition should the nurse suspect based on these clinical manifestations?

A. Atelectasis

B. Pneumonia

C. Flail chest

D. Pneumothorax

Explanation:

Correct Answer: (D) Pneumothorax.

Clients with COPD are at increased risk for spontaneous pneumothorax due to the rupture of weakened, bullous lung tissue, which can be precipitated by forceful or prolonged coughing episodes that increase intrathoracic pressure. The combination of asymmetrical chest movement, significantly decreased breath sounds on one side, and a sudden drop in oxygen saturation to 84% following a coughing episode is the classic clinical presentation of pneumothorax, in which air escapes into the pleural space and causes partial or complete lung collapse on the affected side.

Why Other Options are Incorrect:

A. Atelectasis — Atelectasis typically develops gradually due to shallow breathing, immobility, or airway obstruction rather than as a sudden event following a forceful coughing episode. While it can cause decreased breath sounds, it does not typically present with the abrupt asymmetrical chest movement described in this acute scenario.

B. Pneumonia — Pneumonia presents with fever, productive cough, crackles, and consolidation findings that develop over a period of illness rather than suddenly following a single coughing episode. The acute onset and asymmetrical findings described here are not consistent with the gradual infectious process of pneumonia.

C. Flail chest — Flail chest results from multiple rib fractures causing a free-floating segment of the chest wall, typically caused by significant blunt force trauma. There is no trauma history described in this scenario, making flail chest an inappropriate diagnosis for this clinical presentation.

1. A nurse is planning care for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse anticipate in the plan?

A. Placing the client in a supine position to facilitate breathing.

B. Administering bronchodilator medications to improve airway patency.

C. Administering high flow oxygen therapy via face mask or mechanical ventilation.

D. Encouraging the client to engage in physical activity to improve lung function.

Explanation:

Correct Answer: (C) Administering high flow oxygen therapy via face mask or mechanical ventilation.

Acute respiratory distress syndrome is characterized by severe, diffuse alveolar damage leading to profound hypoxemia that is often refractory to standard oxygen therapy. The hallmark of ARDS management is aggressive oxygenation support, frequently requiring high-flow oxygen delivery and, in many cases, intubation with mechanical ventilation using lung-protective strategies to maintain adequate gas exchange and prevent further alveolar damage. This intervention directly addresses the life-threatening hypoxemia that defines the syndrome.

Why Other Options are Incorrect:

A. Placing the client in a supine position to facilitate breathing — Clients with ARDS often benefit from prone positioning rather than supine positioning, as proning has been shown to improve oxygenation by promoting better ventilation-perfusion matching and recruitment of collapsed posterior lung segments. Supine positioning is not the recommended therapeutic positioning strategy for ARDS.

B. Administering bronchodilator medications to improve airway patency — ARDS is primarily a condition of diffuse alveolar damage and increased capillary permeability leading to pulmonary edema, not primarily a bronchoconstrictive process. Bronchodilators do not address the fundamental pathophysiology of ARDS and are not a primary anticipated intervention.

D. Encouraging the client to engage in physical activity to improve lung function — Clients with ARDS are critically ill, often requiring mechanical ventilation and sedation, making physical activity inappropriate and unsafe during the acute phase of this life-threatening condition. The priority is stabilizing oxygenation and ventilation, not promoting physical activity.

1. A client admitted with multiple traumatic injuries requires resuscitation with intravenous (IV) fluids and blood products. The following day, the healthcare provider suspects the client has aspirated gastric contents. Based on this clinical scenario, the nurse recognizes that the client is at highest risk for developing which of the following complications?

A. Acute respiratory distress syndrome (ARDS)

B. Tension pneumothorax

C. Chronic obstructive pulmonary disease (COPD)

D. Pulmonary embolus

Explanation:

Correct Answer: (A) Acute respiratory distress syndrome (ARDS).

Aspiration of gastric contents is one of the most common and well-established direct causes of ARDS. The acidic nature of gastric contents causes severe chemical injury to the alveolar-capillary membrane upon aspiration, triggering a massive inflammatory response, increased capillary permeability, and diffuse alveolar damage. This is compounded by the client's recent massive fluid and blood product resuscitation, which further increases the risk of pulmonary edema and inflammatory lung injury. The combination of aspiration and large-volume resuscitation places this client at the highest risk for developing ARDS.

Why Other Options are Incorrect:

B. Tension pneumothorax — Tension pneumothorax typically results from traumatic chest injury, mechanical ventilation barotrauma, or invasive procedures causing air to accumulate under pressure in the pleural space. It is not a direct or expected complication of gastric content aspiration.

C. Chronic obstructive pulmonary disease (COPD) — COPD is a chronic, progressive disease that develops over years, typically due to long-term exposure to irritants such as cigarette smoke. It is not an acute complication that develops from a single aspiration event following traumatic injury.

D. Pulmonary embolus — Pulmonary embolism is associated with risk factors such as immobility, venous stasis, and hypercoagulability, often arising from deep vein thrombosis. While trauma and resuscitation can be risk factors for clot formation, aspiration of gastric contents is not a direct causative mechanism for pulmonary embolism.

1. The nurse is assessing the respiratory function of a client who presented with acute dyspnea. Auscultation reveals continuous wheezes during inspiration and expiration. The nurse knows this finding is most suggestive of what condition?

A. Asthma exacerbation

B. Pneumothorax

C. Laryngeal obstruction

D. Pulmonary embolism

Explanation:

Correct Answer: (A) Asthma exacerbation.

Continuous wheezing heard during both inspiration and expiration is a classic and hallmark auscultatory finding of an asthma exacerbation. This occurs due to widespread bronchoconstriction and airway narrowing throughout the bronchial tree, causing turbulent airflow that produces the characteristic musical, high-pitched wheezing sound as air moves through the constricted passages during both phases of the respiratory cycle.

Why Other Options are Incorrect:

B. Pneumothorax — Pneumothorax typically presents with absent or significantly diminished breath sounds on the affected side due to lung collapse, not wheezing. The auscultatory finding in pneumothorax is the absence of sound rather than an adventitious sound like wheezing.

C. Laryngeal obstruction — Laryngeal obstruction typically produces stridor, a high-pitched sound heard primarily during inspiration due to upper airway narrowing, rather than the continuous bilateral inspiratory and expiratory wheezing characteristic of lower airway bronchoconstriction in asthma.

D. Pulmonary embolism — Pulmonary embolism does not typically present with wheezing as its primary auscultatory finding. Clients with PE more commonly present with clear breath sounds or possibly crackles, alongside the hallmark symptoms of sudden dyspnea, pleuritic chest pain, and tachycardia.

1. A client reports nasal congestion, sneezing, watery drainage from the nose, and itching of the throat, eyes, and ears. The nurse recognizes that these are consistent with what disorder?

A. Allergic rhinitis

B. Viral pharyngitis

C. Bacterial rhinosinusitis

D. Chronic sinusitis

Explanation:

Correct Answer: (A) Allergic rhinitis.

Allergic rhinitis is an IgE-mediated hypersensitivity response to environmental allergens such as pollen, dust mites, or pet dander. The classic symptom complex includes nasal congestion, sneezing, clear watery rhinorrhea, and notably, itching of the nose, throat, eyes, and ears, which results from histamine release affecting multiple mucosal surfaces simultaneously. This combination of itching across several areas is a distinguishing hallmark that differentiates allergic rhinitis from infectious causes of nasal symptoms.

Why Other Options are Incorrect:

B. Viral pharyngitis — Viral pharyngitis primarily presents with sore throat, throat erythema, and general malaise, but it does not typically cause the prominent itching of the eyes, ears, and throat or the clear watery rhinorrhea pattern characteristic of an allergic response.

C. Bacterial rhinosinusitis — Bacterial rhinosinusitis typically presents with thick, purulent nasal discharge, facial pain or pressure, and fever, which is distinctly different from the clear watery discharge and itching symptoms described, which point to an allergic rather than infectious or bacterial process.

D. Chronic sinusitis — Chronic sinusitis presents with persistent nasal congestion, facial pressure, and discolored discharge lasting beyond 12 weeks, often without the prominent itching component seen in allergic conditions. The itching of multiple areas described here is much more specific to an allergic etiology.

1. A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which nursing action is most important in the initial care plan?

A. Assessing the client's temperature every shift.

B. Wearing gloves for all client contact.

C. Monitoring the client's fluid intake and output.

D. Placing the client in respiratory isolation.

Explanation:

Correct Answer: (D) Placing the client in respiratory isolation.

The combination of productive cough, night sweats, and fever is highly suggestive of active tuberculosis until proven otherwise. Tuberculosis is transmitted via airborne droplet nuclei, making respiratory isolation, specifically airborne precautions, the most critical and immediate nursing priority to prevent transmission to healthcare workers, other clients, and visitors. Initiating isolation precautions immediately upon suspicion, before a definitive diagnosis is confirmed, is essential standard practice to contain potential airborne pathogens and protect the broader hospital population.

Why Other Options are Incorrect:

A. Assessing the client's temperature every shift — While temperature monitoring is a routine and important component of care for a febrile client, it is an ongoing assessment task rather than the most urgent priority action needed immediately upon admission with symptoms highly suggestive of a transmissible airborne disease.

B. Wearing gloves for all client contact — Gloves protect against contact transmission of pathogens through bodily fluids but do not protect against airborne transmission, which is the primary concern with a productive cough and symptoms suggestive of tuberculosis. Gloves alone are insufficient to prevent the spread of this type of infection.

C. Monitoring the client's fluid intake and output — Fluid balance monitoring is a standard and important nursing assessment for a febrile client at risk for dehydration, but it does not address the immediate and critical priority of preventing the potential airborne transmission of a serious infectious disease to others in the healthcare environment.

1. A nurse is caring for a client who has a tracheostomy.

Nurses' Notes:

Day 1, 1530: Client appears restless. SpO2 92% on 40% humidified oxygen via tracheostomy collar. Lung fields with scattered rhonchi throughout. Tracheostomy suctioned for thin clear secretions.

Day 1, 1545: Client appears less anxious. SpO2 98% on 40% humidified oxygen via tracheostomy collar. Breath sounds clear throughout.

Day 3, 1530: Client appears restless. Buccal mucosa dusky. SpO2 88% on 40% humidified oxygen via tracheostomy collar. Lung fields with coarse crackles, diminished at right lower lobe. Tracheostomy suctioned for thick yellow secretions.

Day 3, 1545: Client continues to appear restless. SpO2 94% on 40% humidified oxygen via tracheostomy collar. Breath sounds with intermittent crackles, diminished at right lower lobe.

Vital Signs:

Day 1, 1530: Temperature 36.9°C (98.5°F), Heart rate 100/min, Respiratory rate 22/min, Blood pressure 124/74 mm Hg, SpO2 92% on 40% humidified oxygen.

Day 3, 1530: Temperature 39.4°C (103°F), Heart rate 106/min, Respiratory rate 24/min, Blood pressure 128/76 mm Hg, SpO2 88% on 40% humidified oxygen.

Diagnostic Results:

Day 3: Chest x-ray — right lower lobe opacity.

The client has manifestations of Target 1 and Target 2.

Conditions: tension pneumothorax / pulmonary embolism / pneumonia / hypoxia / flail chest

Explanation:

Correct Answer: Pneumonia and Hypoxia.

The Day 3 clinical picture demonstrates a clear progression toward pneumonia. The client developed a fever of 39.4°C (103°F), thick yellow secretions on suctioning (indicating an active infectious process rather than the thin clear secretions seen on Day 1), coarse crackles with diminished breath sounds at the right lower lobe, and a chest x-ray confirming a right lower lobe opacity. This constellation of fever, purulent secretions, adventitious lung sounds, and radiographic consolidation is diagnostic of pneumonia. Simultaneously, the client exhibits clear manifestations of hypoxia, evidenced by a dusky buccal mucosa (a sign of inadequate oxygenation visible in mucous membranes), restlessness (an early neurological sign of cerebral hypoxia), and a significantly decreased SpO2 of 88% despite receiving the same 40% humidified oxygen that maintained 92-98% saturation on Day 1. Together, these findings show the client has developed pneumonia that is directly causing a hypoxic state.

Why Other Options are Incorrect:

Tension pneumothorax presents with sudden severe respiratory distress, absent breath sounds on the affected side, tracheal deviation, and hemodynamic instability with hypotension. This client's findings of crackles, fever, and purulent secretions are inconsistent with this acute traumatic or pressure-related emergency.

Pulmonary embolism typically presents with sudden onset dyspnea, pleuritic chest pain, and tachycardia, often without fever or purulent secretions. The gradual onset with fever, productive thick yellow secretions, and lobar consolidation on x-ray is far more consistent with an infectious pneumonia process than an embolic event.

Flail chest results from multiple rib fractures causing paradoxical chest wall movement, typically following significant blunt chest trauma. There is no trauma history in this scenario, and the clinical findings of fever, purulent secretions, and lobar opacity do not align with this traumatic mechanical condition.

1. A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Medical History:

75-year-old male client who reports increased dyspnea x 4 days. Denies cough or fever.

Past medical history: Two pack-a-day smoker for 50 years. Diagnosed with lung cancer 4 years ago and treated. Over the last year has developed frequent pleural effusions treated with thoracentesis. Hypertension.

Surgical history: Right lower lobectomy 4 years ago. Left hernia repair 25 years ago.

Nurses' Notes:

1000: Alert and oriented x3. Reports difficulty breathing. Respirations 28/min and labored. SpO2 91%. Crackles auscultated left lung base. Fremitus decreased left chest wall.

1200: Thoracentesis performed by healthcare provider. 1,000 mL cloudy yellow fluid removed, labeled, and sent to lab for testing. Dressing applied to puncture site. Puncture site dry. Decreased breath sounds. Subcutaneous emphysema noted. Trachea midline. Respiratory rate 24/min and regular. Heart rate 110/min and regular. SpO2 95%.

The nurse is caring for the client following a thoracentesis. Select the 3 post-procedure findings that require immediate follow-up.

Options: Lung sounds / Heart rate / SpO2 / Chest palpation assessment / Position of trachea / Puncture site assessment

Explanation:

Correct Answer: Lung sounds, Chest palpation assessment, and Position of trachea.

Lung sounds require immediate follow-up because the post-procedure note documents decreased breath sounds, which could indicate a pneumothorax, one of the most significant complications of thoracentesis. This finding must be promptly reassessed and reported to determine whether the lung has partially collapsed following the procedure. Chest palpation assessment requires immediate follow-up because subcutaneous emphysema was noted, which indicates air has escaped into the subcutaneous tissue, a finding strongly associated with pneumothorax following thoracentesis. This requires close monitoring to assess whether the air leak is progressing and to evaluate the extent of tissue involvement. Position of the trachea requires immediate follow-up because, although currently documented as midline, tracheal position is a critical indicator of a developing tension pneumothorax. Given the presence of subcutaneous emphysema and decreased breath sounds, the nurse must closely monitor for any tracheal deviation, which would signal a life-threatening shift of mediastinal structures requiring emergency intervention.

Why Other Options are Incorrect:

Heart rate, while elevated at 110/min, is a nonspecific finding that can result from pain, anxiety, or early compensatory response. While it should be monitored as part of the overall clinical picture, it is not as immediately concerning or specific to a thoracentesis complication as the respiratory findings of decreased breath sounds, subcutaneous emphysema, and tracheal positioning.

SpO2 has actually improved from 91% to 95% following the procedure, indicating that the removal of pleural fluid has improved the client's oxygenation. This is a reassuring trend rather than a finding requiring immediate concern.

Puncture site assessment is documented as dry with the dressing intact, which is a normal and expected post-procedure finding. There is no evidence of bleeding, drainage, or site complications requiring immediate follow-up at this time.

1. A nurse is preparing to administer a purified protein derivative (PPD) test to a client. Which of the following statements should be shared with the client?

A. "A positive reaction indicates that you have been exposed to tuberculosis (TB)."

B. "You should massage the injection site to help absorb the medication."

C. "A positive reaction indicates that you have active tuberculosis (TB)."

D. "Your purified protein derivative (PPD) test results must be read within 24 hours after I place the injection."

Explanation:

Correct Answer: (A) "A positive reaction indicates that you have been exposed to tuberculosis (TB)."

A positive PPD reaction indicates that the client's immune system has been exposed to and developed a cell-mediated immune response to the tuberculosis bacterium at some point. It does not confirm active disease; rather, it indicates exposure and the presence of TB infection, which may be latent or active. Further diagnostic workup, such as a chest x-ray and sputum culture, is required to determine whether the infection is latent or active. This is the accurate and appropriate information to share with the client regarding what a positive result means.

Why Other Options are Incorrect:

B. "You should massage the injection site to help absorb the medication" — The PPD test is administered intradermally to create a small wheal or bleb. Massaging the site would disperse the antigen into the surrounding tissue and away from the intended intradermal location, compromising the accuracy and interpretability of the test result.

C. "A positive reaction indicates that you have active tuberculosis (TB)" — This statement is inaccurate. A positive PPD only indicates exposure and immune sensitization to TB, not active disease. Many people with a positive PPD have latent TB infection and are asymptomatic and non-contagious. Active disease requires further diagnostic confirmation.

D. "Your purified protein derivative (PPD) test results must be read within 24 hours after I place the injection" — This is incorrect timing. PPD test results must be read between 48 and 72 hours after the injection is placed, not within 24 hours, as the delayed-type hypersensitivity reaction takes this time to fully develop and be accurately measured.

1. The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. What should the nurse assess first prior to allowing the client to drink fluids?

A. Signs of hypervolemia

B. Presence of bowel sounds

C. Ability to demonstrate deep inspiration

D. Presence of a gag reflex

Explanation:

Correct Answer: (D) Presence of a gag reflex.

Bronchoscopy involves the administration of local anesthesia to the throat and upper airway to suppress the gag reflex and facilitate passage of the bronchoscope. Following the procedure, the gag reflex remains diminished or absent for a period of time. If the client is given fluids before the gag reflex has returned, they are at significant risk for aspiration, since they would be unable to adequately protect their airway from accidentally inhaling liquid into the lungs. Confirming the return of the gag reflex is therefore the priority assessment before allowing oral intake.

Why Other Options are Incorrect:

A. Signs of hypervolemia — Hypervolemia is not a relevant or expected concern directly related to recovery from a bronchoscopy procedure and has no bearing on the immediate safety of allowing oral fluid intake.

B. Presence of bowel sounds — Bowel sounds are relevant to gastrointestinal procedures or abdominal surgery recovery, not to a respiratory procedure such as bronchoscopy, which involves the airway rather than the gastrointestinal tract.

C. Ability to demonstrate deep inspiration — While respiratory assessment is always important following any procedure involving the airway, the ability to take a deep breath does not directly determine whether the client can safely swallow fluids without aspirating. The gag reflex is the specific and most relevant safety assessment for this purpose.

1. The nurse is planning care for a client with laryngeal cancer who has undergone a partial laryngectomy. Which of the following nursing interventions is most important to meet the client's immediate post-operative needs?

A. Encouraging the client to complete activities of daily living (ADLs) independently

B. Collaborating with speech therapy to evaluate swallowing

C. Scheduling regular follow-up appointments for radiation therapy

D. Advising the client to avoid all forms of vocal communication

Explanation:

Correct Answer: (B) Collaborating with speech therapy to evaluate swallowing.

Following a partial laryngectomy, the structures involved in protecting the airway during swallowing are surgically altered, placing the client at significant risk for aspiration. Collaborating with speech therapy to perform a thorough swallowing evaluation is the most important immediate post-operative intervention because it directly addresses this critical safety concern. Speech-language pathologists are specially trained to assess swallowing function and safety, determine the appropriate diet consistency, and teach compensatory swallowing techniques to prevent aspiration in this immediate recovery period.

Why Other Options are Incorrect:

A. Encouraging the client to complete activities of daily living (ADLs) independently — While promoting independence is an important long-term goal in recovery, it is not the most pressing immediate post-operative priority compared to addressing the critical safety risk of aspiration following alteration of airway protective structures.

C. Scheduling regular follow-up appointments for radiation therapy — Radiation therapy follow-up is part of the long-term oncologic treatment plan and is not relevant to the client's immediate post-operative recovery needs following surgery.

D. Advising the client to avoid all forms of vocal communication — While voice rest may be recommended to some degree depending on the extent of surgery, completely avoiding all forms of communication is an overly restrictive and inaccurate blanket statement, and it does not address the most critical and immediate safety concern of swallowing and aspiration risk.

1. A client involved in a motor vehicle crash is diagnosed with a flail chest injury. When planning care, the nurse will prioritize what intervention?

A. Provide adequate analgesia to enhance ventilation.

B. Prepare the client for chest physiotherapy.

C. Assess for tenacious respiratory secretions.

D. Initiate aggressive airway suctioning to prevent respiratory complications.

Explanation:

Correct Answer: (A) Provide adequate analgesia to enhance ventilation.

Flail chest results from multiple adjacent rib fractures creating a free-floating segment of the chest wall that moves paradoxically with respiration, causing significant pain and impaired ventilation. This pain causes the client to take shallow breaths and avoid deep breathing or coughing, which leads to hypoventilation, atelectasis, and inadequate gas exchange. Providing adequate analgesia is the priority intervention because effective pain control allows the client to breathe more deeply and cough effectively, directly improving ventilation and preventing the secondary complications of shallow breathing such as atelectasis and pneumonia.

Why Other Options are Incorrect:

B. Prepare the client for chest physiotherapy — Chest physiotherapy techniques such as percussion and vibration would be extremely painful and potentially harmful in a client with multiple rib fractures and an unstable chest wall segment. This intervention is not appropriate in the acute management of flail chest.

C. Assess for tenacious respiratory secretions — While monitoring respiratory secretions is a relevant ongoing assessment, it is not the priority intervention. Addressing the client's pain to improve overall ventilation takes precedence over this secondary assessment finding.

D. Initiate aggressive airway suctioning to prevent respiratory complications — Aggressive suctioning is not indicated as a prophylactic or priority intervention for flail chest unless secretions are actually present and obstructing the airway. The priority is to improve the client's ability to breathe deeply and cough effectively through adequate pain management, not to perform unnecessary invasive suctioning procedures.

1. A provider prescribes oral acetaminophen for a client weighing 132 pounds. The acetaminophen is dosed at 15 mg/kg. The pharmacy provides the medication in a concentration of 160mg/5 mL. How many mL will the nurse need to administer per dose? (Round the answer to the nearest whole number.)

Explanation:

Correct Answer: 28 mL per dose.

First, convert the client's weight from pounds to kilograms by dividing 132 pounds by 2.2, which equals 60 kg. Next, calculate the prescribed dose by multiplying 60 kg by 15 mg/kg, which equals 900 mg. Finally, use the pharmacy concentration to determine the volume needed by setting up the proportion 160 mg is to 5 mL as 900 mg is to X mL. Dividing 900 mg by 160 mg and multiplying by 5 mL gives 28.125 mL, which rounds to 28 mL per dose.

1. The nurse is providing teaching to a client diagnosed with acute sinusitis. The nurse should instruct the client to perform which action to promote sinus drainage?

A. Increase intake of oral fluids unless contraindicated.

B. Massage the sinuses to loosen sections.

C. Apply an ice pack to the affected area twice daily.

D. Lie flat to allow the sinus to drain into the throat.

Explanation:

Correct Answer: (A) Increase intake of oral fluids unless contraindicated.

Increasing oral fluid intake helps thin and loosen thickened mucus and secretions within the sinus cavities, making it easier for the sinuses to drain naturally. Adequate hydration is a simple, safe, and evidence-based intervention that directly promotes sinus drainage and helps relieve the pressure and congestion associated with acute sinusitis.

Why Other Options are Incorrect:

B. Massage the sinuses to loosen sections — Massaging the sinuses is not an evidence-based intervention for promoting sinus drainage and is not a standard recommended technique in the management of acute sinusitis.

C. Apply an ice pack to the affected area twice daily — Cold therapy causes vasoconstriction, which would not promote drainage and may actually worsen congestion. Warm compresses, not ice packs, are generally recommended to promote vasodilation and facilitate sinus drainage.

D. Lie flat to allow the sinus to drain into the throat — Lying flat does not promote effective sinus drainage and can actually worsen congestion by increasing venous pressure in the head and sinus passages. Clients with sinusitis are typically instructed to keep the head elevated, such as using extra pillows, to facilitate gravity-assisted drainage.

1. A nurse is caring for a client who has pneumonia on a medical-surgical unit.

Nurse's Notes: Client admitted to the unit 12 hours ago with a COPD exacerbation and pneumonia. Over the last 1 hour the client has exhibited increased dyspnea and restlessness. Respiratory rate is currently 32/min with deep breaths. BP 198/78 mm Hg. Bilateral inspiratory wheezes auscultated. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current SpO2 is 91% on 50% facemask. Arterial blood gases drawn and sent to lab.

Diagnostic Results (ABGs): pH 7.25 (nl. 7.35 to 7.45), pCO2 62 mm Hg (nl. 35 to 45 mm Hg), HCO3 22 mEq/L (nl. 22 to 26 mEq/L).

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions to Take: Prepare the client for intubation / Obtain a blood glucose level / Start a 0.9% sodium chloride IV drip / Administer a bronchodilator / Administer sodium bicarbonate

Potential Condition: Metabolic alkalosis / Respiratory alkalosis / Metabolic acidosis / Respiratory acidosis

Parameters to Monitor: Calcium levels / Correct placement of the endotracheal tube (ETT) / Seizure activity / Arterial blood gases / Hyperglycemia

Explanation:

Correct Answer: Potential Condition — Respiratory acidosis. Actions to Take — Prepare the client for intubation and Administer a bronchodilator. Parameters to Monitor — Correct placement of the endotracheal tube (ETT) and Arterial blood gases.

The ABG results reveal a pH of 7.25, which is acidotic, paired with a markedly elevated pCO2 of 62 mm Hg and a normal HCO3 of 22 mEq/L. This pattern, an acidotic pH driven primarily by carbon dioxide retention with a normal bicarbonate level, is the classic presentation of acute respiratory acidosis caused by hypoventilation and impaired gas exchange. This client, with underlying COPD and pneumonia, is experiencing worsening respiratory failure as evidenced by increasing respiratory rate, restlessness, minimal improvement despite escalating oxygen therapy, and an SpO2 of only 91% on 50% facemask. Preparing the client for intubation is essential because the client is in worsening respiratory failure and is not responding adequately to noninvasive oxygen therapy, signaling the need for mechanical ventilatory support to correct the severe hypercapnia and acidosis. Administering a bronchodilator directly addresses the underlying bronchoconstriction contributing to the COPD exacerbation, helping to improve airflow and ventilation. Monitoring correct placement of the endotracheal tube is critical immediately following intubation to ensure adequate ventilation is being delivered and to prevent complications such as right mainstem intubation or esophageal placement. Monitoring arterial blood gases allows the healthcare team to track the client's response to treatment and assess whether the respiratory acidosis is improving with the interventions implemented.

Why Other Options are Incorrect:

Metabolic alkalosis would present with an elevated pH and elevated bicarbonate level, which is the opposite of this client's acidotic pH and normal bicarbonate.

Respiratory alkalosis would present with an elevated pH and decreased pCO2 due to hyperventilation, which is the opposite of the acidotic pH and elevated pCO2 seen in this client.

Metabolic acidosis would present with a decreased pH and decreased bicarbonate level. This client's bicarbonate is within normal range, and the primary driver of the acidosis is the elevated pCO2, confirming a respiratory rather than metabolic origin.

Obtaining a blood glucose level, starting a 0.9% sodium chloride IV drip, and administering sodium bicarbonate do not address the underlying respiratory failure and bronchoconstriction causing this client's acute decompensation and are not appropriate priority actions for respiratory acidosis caused by COPD exacerbation and pneumonia.

Calcium levels, seizure activity, and hyperglycemia are not the priority parameters to monitor in this scenario, as they are not directly related to assessing the progression or resolution of acute respiratory acidosis and impending respiratory failure.

1. The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal chamber rises and falls in rhythm with the client's respirations. What is the best response by the nurse after noting this assessment finding?

A. Gently advance the chest tube 1 to 2 cm and observe if the water level stabilizes.

B. Promptly notify the healthcare provider that there is a leak in the drainage system.

C. Document that the chest drainage system is operating as it is intended.

D. Encourage the client to take a few deep breaths then cough forcefully.

Explanation:

Correct Answer: (C) Document that the chest drainage system is operating as it is intended. Tidaling, the rise and fall of the water level in the water seal chamber with respiration, is a normal and expected finding that confirms the chest tube system is patent and functioning correctly. It occurs because pressure changes in the pleural space during inspiration and expiration are transmitted through the tubing to the water seal chamber.

Why Other Options are Incorrect:

A. Advancing the chest tube is not within the nurse's scope of practice and is not indicated by this normal finding.

B. Notifying the provider is unnecessary since tidaling does not indicate a leak in the system.

D. Encouraging forceful coughing is not warranted based on this normal, expected assessment finding.

1. A client with asthma who uses a combination inhaler containing a corticosteroid and a long-acting beta-agonist reports experiencing oral thrush and hoarseness. Which of the following should the nurse recognize as the most likely cause of these symptoms?

A. Preventable adverse effects of inhaled corticosteroids

B. Signs of an allergic reaction requiring immediate discontinuation of inhaled corticosteroids

C. Expected side effects that will resolve with continued inhaled corticosteroid use

D. Indicators that the inhaled medications are being used too frequently during the day

Explanation:

Correct Answer: (A) Preventable adverse effects of inhaled corticosteroids Oral thrush and hoarseness are common local adverse effects of inhaled corticosteroids caused by deposition of the medication in the mouth and throat, and they are largely preventable through proper technique, such as rinsing the mouth with water and spitting after each use, and using a spacer device.

Why Other Options are Incorrect:

B. These symptoms are a local drug effect, not an allergic reaction requiring discontinuation.

C. The symptoms will not simply resolve with continued use unless preventive technique is corrected.

D. The symptoms result from local deposition of medication, not from overuse frequency.

1. The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal chamber rises and falls in rhythm with the client's respirations. What is the best response by the nurse after noting this assessment finding?

A. Gently advance the chest tube 1 to 2 cm and observe if the water level stabilizes.

B. Promptly notify the healthcare provider that there is a leak in the drainage system.

C. Document that the chest drainage system is operating as it is intended.

D. Encourage the client to take a few deep breaths then cough forcefully.

Explanation:

Correct Answer: (C) Document that the chest drainage system is operating as it is intended.

Tidaling, the rise and fall of the water level in the water seal chamber with respiration, is a normal and expected finding that confirms the chest tube system is patent and functioning correctly. It occurs because pressure changes in the pleural space during inspiration and expiration are transmitted through the tubing to the water seal chamber.

Why Other Options are Incorrect:

A. Advancing the chest tube is not within the nurse's scope of practice and is not indicated by this normal finding.

B. Notifying the provider is unnecessary since tidaling does not indicate a leak in the system.

D. Encouraging forceful coughing is not warranted based on this normal, expected assessment finding.

1. A client with asthma who uses a combination inhaler containing a corticosteroid and a long-acting beta-agonist reports experiencing oral thrush and hoarseness. Which of the following should the nurse recognize as the most likely cause of these symptoms?

A. Preventable adverse effects of inhaled corticosteroids

B. Signs of an allergic reaction requiring immediate discontinuation of inhaled corticosteroids

C. Expected side effects that will resolve with continued inhaled corticosteroid use

D. Indicators that the inhaled medications are being used too frequently during the day

Explanation:

Correct Answer: (A) Preventable adverse effects of inhaled corticosteroids

Oral thrush and hoarseness are common local adverse effects of inhaled corticosteroids caused by deposition of the medication in the mouth and throat, and they are largely preventable through proper technique, such as rinsing the mouth with water and spitting after each use, and using a spacer device.

Why Other Options are Incorrect:

B. These symptoms are a local drug effect, not an allergic reaction requiring discontinuation.

C. The symptoms will not simply resolve with continued use unless preventive technique is corrected.

D. The symptoms result from local deposition of medication, not from overuse frequency.

1. A nurse providing community education states, "The treatment of most cases of acute pharyngitis is through the management of symptoms." What rationale guides the nurse's teaching?

A. Most cases of acute pharyngitis become chronic if not treated promptly with antibiotics.

B. Most cases of acute pharyngitis are caused by a bacterial infection.

C. Most cases of acute pharyngitis affect infants.

D. Most cases of acute pharyngitis are caused by a viral infection.

Explanation:

Correct Answer: (D) Most cases of acute pharyngitis are caused by a viral infection.

Viral pharyngitis is not responsive to antibiotic therapy, so treatment focuses on symptom management such as rest, hydration, and analgesics until the infection resolves on its own.

Why Other Options are Incorrect:

A. Acute pharyngitis becoming chronic without antibiotics is not the rationale for symptom-focused care, since most cases are self-limiting regardless of antibiotic use.

B. If most cases were bacterial, antibiotic treatment rather than symptom management would be the priority approach.

C. Acute pharyngitis is not primarily an infant-specific condition, and age is not the rationale behind symptom-based treatment.

1. A nurse is providing education to a client diagnosed with viral pharyngitis. Which of the following topics should the nurse include in the education?

A. Administration of antibiotics to treat the infection

B. Use of over-the-counter cough suppressants to alleviate symptoms

C. Importance of staying hydrated by drinking plenty of fluids

D. Avoidance of contact with individuals who have upper respiratory infections

Explanation:

Correct Answer: (C) Importance of staying hydrated by drinking plenty of fluids

Adequate hydration helps soothe the throat, thin secretions, and supports overall recovery from viral pharyngitis, making it an appropriate and essential component of client education for a self-limiting viral illness.

Why Other Options are Incorrect:

A. Antibiotics are not effective against viral infections and would not be appropriate teaching for viral pharyngitis.

B. Cough suppressants are not a primary focus of viral pharyngitis education, since pharyngitis is characterized mainly by throat pain rather than cough as the predominant symptom.

D. Avoiding individuals with upper respiratory infections relates to preventing the client from acquiring additional illness rather than managing or treating the current diagnosis.

1. A client with a pneumothorax has a chest tube connected to a closed drainage system. Which nursing action takes priority in the management of the chest tube?

A. Ensure the chest tube is secured and the drainage system remains below chest level.

B. Position the client flat to promote lung re-expansion.

C. Clamp the chest tube during client repositioning.

D. Empty the drainage chamber every shift.

Explanation:

Correct Answer: (A) Ensure the chest tube is secured and the drainage system remains below chest level.

Keeping the drainage system below chest level uses gravity to promote proper drainage and prevent backflow of fluid or air into the pleural space, while securing the tube prevents accidental dislodgement, making this the priority nursing action.

Why Other Options are Incorrect:

B. Positioning the client flat does not promote lung re-expansion and may actually impair effective drainage; a semi-Fowler's position is generally preferred.

C. Clamping the chest tube is contraindicated in most circumstances, as it can lead to a tension pneumothorax by trapping air in the pleural space.

D. Emptying the drainage chamber is not typically done since most systems are disposable and replaced as a whole unit rather than emptied; this is not the priority action.

1. A nurse is developing a plan of care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the teaching plan?

A. Limiting physical activity to prevent exacerbation

B. Using bronchodilators only for severe shortness of breath

C. Providing instructions on the proper use of prescribed inhalers

D. Administering antibiotics for a chronic cough

Explanation:

Correct Answer: (C) Providing instructions on the proper use of prescribed inhalers

Proper inhaler technique ensures that the client receives the full therapeutic dose of medication, which is essential for effective management of COPD symptoms and prevention of exacerbations, making this an appropriate and necessary component of client teaching.

Why Other Options are Incorrect:

A. Limiting physical activity is not recommended for COPD management, as clients are encouraged to engage in regular, tolerable activity and pulmonary rehabilitation to maintain function.

B. Bronchodilators are typically used on a scheduled basis for maintenance, not reserved only for severe shortness of breath.

D. Antibiotics are not routinely administered for a chronic cough unless there is evidence of a bacterial infection, and this is not a standard teaching point for COPD management.

1. A client is receiving oxygen via a simple face mask. Which observation requires immediate nursing intervention?

A. Client reports feeling warm

B. Client removes mask intermittently

C. Oxygen saturation of 94%

D. Oxygen flow rate set at 2 L/min

Explanation:

Correct Answer: (D) Oxygen flow rate set at 2 L/min

A simple face mask requires a minimum flow rate of 5 to 6 L/min to flush exhaled carbon dioxide from the mask and prevent rebreathing; a flow rate of 2 L/min is insufficient and places the client at risk for CO2 accumulation, requiring immediate nursing intervention.

Why Other Options are Incorrect:

A. Feeling warm is a mild, nonspecific complaint that does not indicate an urgent problem related to oxygen therapy.

B. Intermittent mask removal warrants follow-up and client education but is not an immediate safety concern requiring urgent intervention.

C. An oxygen saturation of 94% is within an acceptable range for many clients and does not require immediate intervention.

1. The nurse is providing teaching for a client regarding the purified protein derivative (PPD) test for tuberculosis. Which statement by the client indicates an understanding of the teaching?

A. "Because I had a previous reaction to this test, this time I need to get a chest x-ray."

B. "I will come back in 7-10 days to have the test read."

C. "I will isolate myself from my family until I get my test results."

D. "If the test area gets hard and swollen, that means I have active tuberculosis."

Explanation:

Correct Answer: (A) "Because I had a previous reaction to this test, this time I need to get a chest x-ray."

Clients with a documented history of a prior positive PPD reaction should not be retested with the PPD, as repeat testing in someone already sensitized can cause a severe local reaction; instead, a chest x-ray is the appropriate follow-up to evaluate for active disease, showing correct understanding of the teaching.

Why Other Options are Incorrect:

B. The PPD test must be read within 48 to 72 hours after placement, not 7 to 10 days, as induration measured outside this window is not reliable.

C. A positive PPD result alone does not require isolation, since it only indicates exposure or latent infection and further testing such as a chest x-ray and sputum culture is needed to determine if active disease is present.

D. Induration at the test site indicates a positive reaction suggestive of exposure or latent infection, not necessarily active tuberculosis, which requires further diagnostic evaluation to confirm.

1. A client who was admitted to the hospital one day ago with a diagnosis of thrombophlebitis suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for additional manifestations of which disease process?

A. Tension pneumothorax

B. Pulmonary edema

C. Pneumonia

D. Pulmonary embolism

Explanation:

Correct Answer: (D) Pulmonary embolism

A client with thrombophlebitis is at high risk for a deep vein thrombus dislodging and traveling to the lungs, and the sudden onset of chest pain, shortness of breath, and anxiety are classic manifestations of a pulmonary embolism, making this the priority concern for immediate assessment.

Why Other Options are Incorrect:

A. Tension pneumothorax is typically associated with trauma or invasive procedures rather than thrombophlebitis, making it an unlikely cause of these symptoms in this client.

B. Pulmonary edema is most often associated with heart failure or fluid overload rather than a history of thrombophlebitis.

C. Pneumonia would typically present with a more gradual onset of symptoms, often accompanied by fever and productive cough, rather than the sudden onset described in this scenario.

1. A trauma client with a right flail chest suddenly develops absent breath sounds on the right side, left-sided tracheal deviation, and severe dyspnea. Which actions should the nurse take immediately? (Select all that apply.)

A. Prepare for needle decompression

B. Arrange a chest x-ray before any intervention

C. Place client in Trendelenburg position

D. Activate the rapid response team

E. Administer humidified high-flow oxygen

Explanation:

Correct Answer: (A) Prepare for needle decompression, (D) Activate the rapid response team, and (E) Administer humidified high-flow oxygen

The client's presentation of absent breath sounds, tracheal deviation, and severe dyspnea following trauma indicates a tension pneumothorax, a life-threatening emergency requiring immediate needle decompression to relieve pressure, activation of the rapid response team to mobilize emergency care, and high-flow oxygen administration to support oxygenation while definitive treatment is arranged.

Why Other Options are Incorrect:

B. Arranging a chest x-ray before intervention would dangerously delay life-saving treatment in a clinical emergency that should be diagnosed based on assessment findings rather than imaging confirmation.

C. Trendelenburg position is not indicated for tension pneumothorax and would not help relieve the pressure causing the client's respiratory distress; it could worsen breathing difficulty by increasing pressure on the diaphragm.

1. A nurse is preparing to administer an albuterol nebulizer treatment to a client with asthma. The prescription reads: Albuterol 2.5 mg via nebulizer, one time. According to the medication dispensing system, the pharmacy supplies albuterol 0.083% solution (0.83 mg/mL). The client has a frequent productive cough, and unit policy requires nurses to follow standard precautions during all respiratory treatments. How many milliliters should the nurse administer, and which action is required to reduce exposure risk during the nebulizer treatment? (Round to the nearest whole number.)

Explanation:

Correct Answer: The nurse should administer 3 mL, and should wear a mask (or appropriate personal protective equipment) during the treatment to reduce exposure risk.

Dividing the prescribed dose of 2.5 mg by the concentration of 0.83 mg/mL gives approximately 3.01 mL, which rounds to 3 mL. Because the client has a frequent productive cough and nebulizer treatments aerosolize respiratory secretions, the nurse should follow standard precautions, including wearing a mask, to reduce the risk of exposure to airborne droplets during the treatment.

1. A nurse in the emergency department (ED) is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

A. Confusion

B. Hypertension

C. Crepitus upon chest palpation

D. Nonproductive cough

Explanation:

Correct Answer: (A) Confusion

Older adults with pneumonia often present atypically, with confusion or altered mental status frequently being the first or most prominent sign due to hypoxia, rather than the classic respiratory symptoms seen in younger clients, making this an expected finding the nurse should anticipate.

Why Other Options are Incorrect:

B. Hypotension, not hypertension, is more commonly associated with pneumonia, particularly if the client is becoming septic.

C. Crepitus upon chest palpation is associated with subcutaneous emphysema, not a typical or expected finding in community-acquired pneumonia.

D. A productive cough, not a nonproductive cough, is a more typical finding in pneumonia due to increased mucus production and inflammation in the lungs.

1. A nurse is caring for a client who is experiencing an asthma attack. Which of the following would the nurse administer first to alleviate this client's airflow obstruction?

A. Corticosteroids by metered-dose inhaler

B. Oxygen via nasal cannula

C. An inhaled anticholinergic medication

D. An inhaled beta-adrenergic agonist

Explanation:

Correct Answer: (D) An inhaled beta-adrenergic agonist

A short-acting inhaled beta-adrenergic agonist works rapidly to relax bronchial smooth muscle and relieve bronchospasm, making it the priority medication to administer first during an acute asthma attack to alleviate airflow obstruction.

Why Other Options are Incorrect:

A. Corticosteroids reduce airway inflammation but have a delayed onset of action and are not effective for immediate relief of acute bronchospasm.

B. Oxygen addresses hypoxemia but does not directly relieve the airflow obstruction caused by bronchospasm, which is the priority concern in this scenario.

C. Inhaled anticholinergic medications have a slower onset of action compared to beta-adrenergic agonists and are typically used as an adjunct rather than the first-line treatment for acute bronchospasm.

1. This is a drag-and-drop clinical judgment item rather than a multiple-choice question, so let me work through it using all the data provided (nurses notes, physical exam, diagnostic results) to identify the most likely condition, the two actions to take, and the two parameters to monitor.

A nurse is caring for a client who is 1 day postoperative following a right-sided thoracotomy with a chest tube insertion. A nurse prioritizes care after completing the assessment and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Explanation:

Correct Answer: Condition Most Likely Experiencing: Air leak

Actions to Take: Check the drainage system and tubing and Assess for subcutaneous emphysema

Parameters to Monitor: Respiratory status and Chest tube drainage

Continuous bubbling in the water-seal chamber, as documented in the nurses' notes, is a hallmark sign of an air leak in the chest drainage system rather than the intermittent bubbling expected during expiration or coughing. Checking the drainage system and tubing helps the nurse locate the source of the leak, whether at the insertion site, tubing connections, or within the system itself, while assessing for subcutaneous emphysema evaluates for air escaping into the subcutaneous tissue, a common complication of an air leak. Monitoring respiratory status is essential because an unresolved air leak can compromise lung re-expansion and oxygenation, and monitoring chest tube drainage helps the nurse track the resolution of the leak and ensure the system continues to function properly.

Why Other Options are Incorrect:

Pneumonia is not supported by the data, as the client's WBC count of 9,500/mm3 is within normal limits, there is no fever mentioned, and lung sounds are simply diminished at the bases bilaterally rather than presenting with crackles or rhonchi typically associated with pneumonia.

Pulmonary edema is not supported, as there are no adventitious breath sounds noted, and the client does not exhibit signs such as frothy sputum, severe dyspnea, or jugular venous distension consistent with this condition.

Bleeding is not the priority concern, as the hemoglobin of 15 g/dL and hematocrit of 35% are within normal limits, and the 50 mL of sanguineous drainage since 0700 is an expected and unremarkable amount following a thoracotomy.

Obtaining blood cultures is not indicated, as there is no evidence of infection such as fever or elevated WBC count.

Administering prescribed blood products is not appropriate, as the client's hemoglobin and hematocrit values do not indicate a need for transfusion.

Observing the surgical dressing, while a reasonable general nursing action, is not specific to identifying or managing an air leak.

Client's ability to perform lung expansion exercises, blood pressure, and sputum are not the priority parameters for monitoring an air leak specifically, though they remain part of overall postoperative care.

1. A client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. What is the nurse's priority action?

A. Manage the client's anxiety.

B. Assess the client's cardiopulmonary status.

C. Arrange for an electrocardiogram (ECG).

D. Schedule a CT scan of the lungs.

Explanation:

Correct Answer: (B) Assess the client's cardiopulmonary status.

Using the nursing process, assessment is always the priority action, and given this client's history and acute symptoms suggestive of a recurrent pulmonary embolism, assessing cardiopulmonary status allows the nurse to gather critical data on oxygenation and hemodynamic stability to guide immediate interventions.

Why Other Options are Incorrect:

A. Managing anxiety may be appropriate later, but addressing the client's physiological status takes priority over psychosocial concerns in this acute situation.

C. Arranging for an ECG is a diagnostic intervention that would follow the nurse's initial assessment rather than precede it.

D. Scheduling a CT scan is a diagnostic and provider-driven intervention that occurs after the nurse has assessed the client and stabilized any immediate concerns.

1. A client being treated for latent tuberculosis (TB) on an outpatient basis tells the nurse, "I've been feeling pretty good lately, so I haven't actually been all that consistent with taking my drugs." The nurse should emphasize which teaching point about medication therapy for the treatment of TB?

A. The fact that nonadherence will necessitate the use of antiviral drugs

B. The fact that nonadherence to treatment exacerbates the risks of adverse medication effects

C. The need to consistently take the prescribed drugs in order to cure TB

D. The need to match drug dosages carefully to signs and symptoms of latent disease

Explanation:

Correct Answer: (C) The need to consistently take the prescribed drugs in order to cure TB

Consistent, complete adherence to the full course of prescribed medication therapy is essential to cure TB and prevent the development of drug-resistant strains, making this the priority teaching point for a client who has become inconsistent with their regimen.

Why Other Options are Incorrect:

A. Nonadherence to TB treatment does not necessitate antiviral drugs, as TB is a bacterial infection treated with antitubercular medications, not antivirals.

B. While nonadherence can contribute to other issues, the primary concern with inconsistent dosing is treatment failure and drug resistance rather than an increased risk of adverse medication effects.

D. Drug dosages for latent TB are not adjusted based on signs and symptoms, since latent TB is by definition asymptomatic; dosing is based on standardized regimens.

1. A client abruptly sits up in bed, reports having difficulty breathing, and has an SpO2 of 86%. When providing supplemental oxygen, which delivery method would provide the highest concentration of inspired oxygen?

A. Simple face mask

B. Nonrebreather mask

C. Face tent

D. Nasal cannula

Explanation:

Correct Answer: (B) Nonrebreather mask

A nonrebreather mask can deliver the highest concentration of inspired oxygen, up to 90-100%, among the options listed, making it the most appropriate choice for a client experiencing significant hypoxemia with an SpO2 of 86%.

Why Other Options are Incorrect:

A. A simple face mask delivers a lower concentration of oxygen, typically 40-60%, compared to a nonrebreather mask.

C. A face tent delivers a variable and generally lower concentration of oxygen and is often used for clients who cannot tolerate a mask, rather than for delivering high-concentration oxygen.

D. A nasal cannula delivers the lowest concentration of supplemental oxygen among these options, typically 24-44%, making it insufficient for this client's severe hypoxemia.

1. A nurse is developing a teaching plan for a client with asthma. Which teaching point should have the priority in the plan of care for this client?

A. Gradually increase levels of physical exertion.

B. Take prescribed medications as scheduled.

C. Avoid goose-down pillows.

D. Change filters on heaters and air conditioners frequently.

Explanation:

Correct Answer: (B) Take prescribed medications as scheduled.

Consistent adherence to prescribed asthma medications, including controller medications, is essential for managing airway inflammation and preventing exacerbations, making it the priority teaching point over environmental or activity-related recommendations.

Why Other Options are Incorrect:

A. Gradually increasing physical exertion is a reasonable health-promoting recommendation but is not the priority compared to consistent medication adherence for controlling the underlying disease process.

C. Avoiding goose-down pillows addresses an environmental trigger, which is important but secondary to ensuring proper medication use.

D. Changing filters on heaters and air conditioners is also an environmental control measure that is helpful but not the priority over medication adherence.

1. A nurse is caring for a client receiving treatment for lung cancer. During the initial assessment, the nurse notes several findings. The nurse must determine which finding requires priority implementation of standard precautions to protect client and staff safety. Which assessment finding should the nurse address first to ensure appropriate use of standard precautions?

A. The client prefers family members to remain in the room during care

B. The client avoids direct eye contact during conversation

C. The client has blood-streaked sputum noted during coughing

D. The client has a scaly rash on the arms and legs related to psoriasis

Explanation:

Correct Answer: (C) The client has blood-streaked sputum noted during coughing

Blood-streaked sputum represents a body fluid that poses a risk of bloodborne pathogen exposure, requiring the nurse to implement standard precautions, such as proper hand hygiene and personal protective equipment, to protect both the client and staff from exposure.

Why Other Options are Incorrect:

A. A client's preference to have family present during care is a psychosocial consideration and does not relate to standard precautions or exposure risk.

B. Avoiding direct eye contact may reflect cultural or personal communication styles and does not present a safety or exposure concern requiring standard precautions.

D. A scaly rash related to psoriasis is a noninfectious, chronic skin condition and does not pose a risk of pathogen transmission requiring specific standard precautions beyond routine care.

1. A nurse is caring for a client hospitalized with a severe asthma exacerbation who has also tested positive for influenza. The client is placed on droplet precautions per facility policy. Nursing interventions include: Consistent use of appropriate personal protective equipment (PPE), masking the client during transport, scheduled bronchodilator therapy, supportive respiratory care and monitoring. After 48 hours, the nurse evaluates whether the nursing interventions and droplet precautions have been effective. Which assessment finding best indicates that the nursing interventions and transmission-based precautions are effective in promoting client and staff safety?

A. Temperature remains 101.5°F (38.6°C) after 48 hours, and the client reports worsening fatigue and shortness of breath with activity.

B. Wheezing has resolved, SpO2 increased from 88% to 94% on the same oxygen setting, temperature decreased from 101.5°F to 99.0°F, and no new influenza cases are reported among staff or other clients.

C. Respiratory rate decreased from 30/min to 26/min, the client ambulates independently, and intermittent cough and chest tightness persist.

D. Oxygen requirements increased from 2 L/min to 4 L/min, wheezing remains diffuse, and work of breathing has increased.

Explanation:

Correct Answer: (B) Wheezing has resolved, SpO2 increased from 88% to 94% on the same oxygen setting, temperature decreased from 101.5°F to 99.0°F, and no new influenza cases are reported among staff or other clients.

This option demonstrates both improved respiratory status from the asthma interventions, such as resolved wheezing and improved oxygenation, as well as resolution of infectious symptoms and absence of viral transmission, confirming that both the clinical nursing interventions and the droplet precautions have been effective in promoting client and staff safety.

Why Other Options are Incorrect:

A. A persistent fever along with worsening fatigue and shortness of breath indicates that the client's condition has not improved, suggesting the interventions have not been effective.

C. While some improvement is noted in respiratory rate, persistent cough and chest tightness indicate the asthma exacerbation has not fully resolved, and this option does not address whether transmission-based precautions were effective in preventing spread.

D. Increased oxygen requirements, persistent diffuse wheezing, and increased work of breathing all indicate a worsening respiratory status, demonstrating that interventions have not been effective.

1. A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

A. Decreased level of consciousness

B. Headache

C. Hypotension

D. Severe dyspnea

E. Nausea

Explanation:

Correct Answer: (A) Decreased level of consciousness, (B) Headache, and (D) Severe dyspnea

Acute respiratory failure results in impaired gas exchange leading to hypoxemia and/or hypercapnia, which can manifest as a decreased level of consciousness due to inadequate oxygen delivery to the brain, headache due to cerebral vasodilation from elevated carbon dioxide levels, and severe dyspnea as the body struggles to compensate for inadequate ventilation and oxygenation.

Why Other Options are Incorrect:

C. Hypotension is not a classic manifestation of acute respiratory failure; clients more commonly present with tachycardia and may have normal or elevated blood pressure as a compensatory response to hypoxemia.

E. Nausea is not a typical or expected manifestation of acute respiratory failure.

1. A nurse is preparing to administer ticarcillin/clavulanate 3.1 g by intermittent IV bolus over 30 min. Available is ticarcillin/clavulanate 3.1 g in 50 mL 0.9% sodium chloride (NSS). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Explanation:

Correct Answer: 0100 mL/hr

Dividing the total volume of 50 mL by the infusion time of 0.5 hours gives 100 mL/hr, which is the rate the nurse should set on the IV pump to infuse the medication over the prescribed 30-minute period.

1. The nurse is assessing a client following a motor vehicle crash and observes that the client has developed right-sided chest pain on inspiration, dyspnea, and accessory muscle use. Nursing assessment reveals diminished breath sounds on the right side. Based on the clinical scenario, which condition would be most likely for the nurse to suspect?

A. Pneumothorax

B. Laryngeal obstruction

C. Bronchospasm

D. Pulmonary embolism

Explanation:

Correct Answer: (A) Pneumothorax

The combination of unilateral right-sided chest pain on inspiration, dyspnea, accessory muscle use, and diminished breath sounds on the affected side following trauma is classic for a pneumothorax, in which air enters the pleural space and causes partial or complete lung collapse.

Why Other Options are Incorrect:

B. Laryngeal obstruction would present with stridor and difficulty moving air at the level of the upper airway, not unilateral diminished breath sounds localized to one side of the chest.

C. Bronchospasm typically presents with bilateral wheezing rather than unilateral diminished breath sounds following trauma.

D. Pulmonary embolism may cause dyspnea and chest pain but would not typically cause diminished breath sounds localized to one side following a traumatic mechanism like this.

1. A nurse is providing care to a client who is prescribed postural drainage. Which nursing action would best assist the client in successfully performing this prescribed therapy?

A. Encourage the client to cough forcefully before positioning.

B. Assist the client into a position that will enable secretions to mobilize through gravity.

C. Use the inhaled bronchodilator after the postural drainage.

D. Administer the treatment with the client in a high-Fowler or semi-Fowler position.

Explanation:

Correct Answer: (B) Assist the client into a position that will enable secretions to mobilize through gravity.

Postural drainage relies on positioning the client so that gravity assists in moving secretions from specific lung segments toward the central airways, where they can then be cleared through coughing, making correct positioning the key nursing action for successful therapy.

Why Other Options are Incorrect:

A. Coughing forcefully before positioning is not appropriate, as effective coughing to clear mobilized secretions should occur after, not before, the postural drainage positioning has taken place.

C. The inhaled bronchodilator is typically administered before postural drainage, not after, to help open the airways and enhance the effectiveness of secretion clearance.

D. A high-Fowler or semi-Fowler position would not utilize gravity to drain most lung segments and is not the position typically used for postural drainage, which often requires varying positions, including head-down tilts, depending on the targeted lung segment.

1. A client with newly diagnosed obstructive sleep apnea (OSA) is being discharged with a continuous positive airway pressure (CPAP) machine. Which statement by the client indicates the need for additional teaching?

A. "I should clean the CPAP mask and tubing regularly."

B. "Using my CPAP every night can help reduce long-term complications."

C. "If I lose weight, my sleep apnea may improve."

D. "If I feel tired, I will take a sedative at night to help me sleep with the CPAP."

Explanation:

Correct Answer: (D) "If I feel tired, I will take a sedative at night to help me sleep with the CPAP."

Sedatives relax the muscles of the upper airway and can worsen airway obstruction in clients with obstructive sleep apnea, making this statement an indication that the client needs additional teaching, as sedatives should generally be avoided in this population unless specifically approved by the provider.

Why Other Options are Incorrect:

A. Regularly cleaning the CPAP mask and tubing is correct and important self-care to prevent infection and maintain proper equipment function.

B. Consistent nightly use of the CPAP machine is accurate teaching, as it is essential for reducing long-term complications associated with OSA, such as cardiovascular disease.

C. Weight loss can reduce the severity of obstructive sleep apnea in many clients, so this statement reflects correct understanding of the teaching.

1. A client with small cell lung cancer is receiving chemotherapy and is admitted with serum sodium of 118 mEq/L (nl. 136-146 mEq/L). Which intervention should the nurse anticipate?

A. Restrict sodium intake.

B. Encourage oral fluid intake.

C. Administer intravenous (IV) hypertonic saline.

D. Administer potassium supplements.

Explanation:

Correct Answer: (C) Administer intravenous (IV) hypertonic saline.

Small cell lung cancer is commonly associated with syndrome of inappropriate antidiuretic hormone (SIADH), and a severely low serum sodium level of 118 mEq/L represents a critical, symptomatic hyponatremia that requires IV hypertonic saline to safely and gradually correct the sodium level and prevent serious neurological complications.

Why Other Options are Incorrect:

A. Restricting sodium intake would worsen the client's hyponatremia rather than correct it, as the client needs additional sodium, not less.

B. Encouraging oral fluid intake would further dilute the serum sodium and worsen the hyponatremia, as fluid restriction, not increased intake, is typically indicated in SIADH.

D. Potassium supplements address a different electrolyte imbalance and would not correct this client's critically low sodium level.

1. A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care?

A. Taking prophylactic antibiotics to prevent respiratory infection

B. Increasing caloric intake by eating 4-6 high-calorie meals per day

C. Using pursed-lip breathing when experiencing shortness of breath

D. Using inhaled corticosteroids on an as-needed basis for severe shortness of breath

Explanation:

Correct Answer: (C) Using pursed-lip breathing when experiencing shortness of breath

Pursed-lip breathing helps slow the rate of breathing, keeps airways open longer by creating positive pressure, and helps clients with emphysema control episodes of shortness of breath, making it a priority self-management technique to include in discharge teaching.

Why Other Options are Incorrect:

A. Prophylactic antibiotics are not routinely recommended for clients with emphysema to prevent respiratory infection, as this can contribute to antibiotic resistance and is not standard practice.

B. While adequate nutrition is important for clients with emphysema, eating smaller, more frequent meals to reduce the energy expenditure of digestion and prevent abdominal distension that can impair breathing is generally more appropriate than simply increasing caloric intake through larger or more frequent high-calorie meals.

D. Inhaled corticosteroids for COPD/emphysema are typically used on a scheduled, maintenance basis to reduce airway inflammation, not strictly on an as-needed basis for acute symptoms.

1. A nurse is caring for a client with pancreatitis who is at risk of acute respiratory distress syndrome (ARDS). Which assessment finding is the priority cue indicating the client may be developing ARDS?

A. Temperature of 38.1°C (100.6°F)

B. Blood pressure of 105/70 mm Hg

C. Bilateral crackles and dyspnea

D. Productive cough with sputum

Explanation:

Correct Answer: (C) Bilateral crackles and dyspnea

Bilateral crackles and dyspnea are hallmark early findings of ARDS, reflecting the development of noncardiogenic pulmonary edema and impaired gas exchange that occurs as the condition progresses, making this the priority assessment finding for the nurse to recognize.

Why Other Options are Incorrect:

A. A temperature of 38.1°C is a mild elevation that may be related to the underlying pancreatitis and is not a specific or priority indicator of developing ARDS.

B. A blood pressure of 105/70 mm Hg is within a normal range and does not indicate the respiratory compromise associated with ARDS.

D. A productive cough with sputum is not a classic or priority finding of ARDS, which is more specifically characterized by bilateral infiltrates, severe hypoxemia, and noncardiogenic pulmonary edema rather than increased sputum production.

1. A home health nurse visits a client who has chronic obstructive pulmonary disease (COPD) and receives oxygen at 2 L/min via nasal cannula. What is the nurse's priority action if the client reports dyspnea?

A. Check the client's medication administration history.

B. Assess the client's respiratory status.

C. Administer a bronchodilator medication via nebulizer.

D. Instruct the client to use pursed-lip breathing techniques.

Explanation:

Correct Answer: (B) Assess the client's respiratory status.

Following the nursing process, assessment is always the priority action when a client reports a new or worsening symptom such as dyspnea, allowing the nurse to gather essential data about the client's current respiratory status before determining the appropriate intervention.

Why Other Options are Incorrect:

A. Checking the medication administration history may be a useful part of the overall assessment, but it does not take priority over directly assessing the client's current respiratory status.

C. Administering a bronchodilator is an intervention that should be guided by an assessment of the client's current condition rather than performed before assessment.

D. Instructing the client on pursed-lip breathing is a helpful technique, but performing a respiratory assessment should precede any teaching or intervention to first determine the severity and cause of the client's dyspnea.

1. The nurse is assessing a client for a possible pulmonary embolism. Which of the following common clinical manifestations would the nurse anticipate during the assessment?

A. Tachypnea

B. Hematemesis

C. Rhonchi

D. Tracheal deviation

Explanation:

Correct Answer: (A) Tachypnea

Tachypnea, or rapid breathing, is one of the most common clinical manifestations of a pulmonary embolism, occurring as the body attempts to compensate for impaired gas exchange and hypoxemia caused by the obstruction of pulmonary blood flow.

Why Other Options are Incorrect:

B. Hematemesis, or vomiting blood, is not a typical manifestation of pulmonary embolism and is more commonly associated with gastrointestinal bleeding.

C. Rhonchi are coarse breath sounds typically associated with secretions in the larger airways, such as in bronchitis or pneumonia, rather than a common finding in pulmonary embolism.

D. Tracheal deviation is associated with conditions causing a significant mediastinal shift, such as a tension pneumothorax, rather than a typical finding in pulmonary embolism.

1. A nurse is caring for a client who is experiencing an exacerbation of COPD. The nurse should expect which of the following acid-base imbalances?

A. Respiratory alkalosis with full compensation

B. Respiratory acidosis with partial compensation

C. Respiratory acidosis with full compensation

D. Respiratory alkalosis with partial compensation

Explanation:

Correct Answer: (B) Respiratory acidosis with partial compensation

During an acute exacerbation of COPD, impaired ventilation leads to retention of carbon dioxide, causing respiratory acidosis, and because the exacerbation is acute, the kidneys do not have sufficient time to fully compensate by retaining bicarbonate, resulting in only partial metabolic compensation.

Why Other Options are Incorrect:

A. Respiratory alkalosis occurs with hyperventilation and excess elimination of carbon dioxide, which is not characteristic of a COPD exacerbation involving impaired ventilation.

C. Full compensation would require the renal system to have sufficient time to completely normalize the blood pH, which typically does not occur during the acute timeframe of an exacerbation.

D. Respiratory alkalosis with partial compensation is incorrect because COPD exacerbations are characterized by carbon dioxide retention and acidosis, not alkalosis.