Question 1

A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply?

Accepted Answer

The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and permits the client to eat and drinkfluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication. The client is alert and oriented and able to follow directions. Because pain relief is effective according to the pain scale, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option B) The non-rebreather mask is used in emergencies, delivers high concentrations of oxygen (up to 90%-95%), requires a tight face seal, and is restrictive and uncomfortable. (Option C) The simple face mask delivers a higher concentration of oxygen (40%-60%), is more uncomfortable and restrictive, must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia does not resolve. (Option D) The Venturi mask is a more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease. These clients cannot tolerate changes in oxygen concentration. Educational objective: The nasal cannula is an inexpensive, comfortable, low-flow oxygen delivery device capable of delivering oxygen concentrations of up to 44%. It can be used in the short term in responsive postoperative clients to treat hypoventilation and reverse hypoxemia effectively.

Question 2

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

Accepted Answer

11ecbb05_ca56_32de_b433_658531ee6b77_MD0009_00 Clients with chronic obstructive pulmonary disease (COPD) often develop ineffective coughing patterns due to weakened muscles and narrowed airways prone to collapse under increased pressure. Therefore, clients with COPD are unable to cough effectively and require additional teaching to effectively expectorate secretions and prevent overexertion. Huff coughing is a series of low-pressure coughs using the following steps: Sit upright in a chair with feet spread shoulder-width apart and lean forward with shoulders relaxed; forearms supported on thighs or pillows; head and knees slightly flexed; and feet touching the floor (Option E). Perform a slow, deep inhalation through the mouth or nose using the diaphragmatic muscle (Option B). Hold breath for 2-3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible "huff" sound (Option A). Repeat the "huff" once or twice more to expectorate any mucus (Option C). Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared (Option D). Educational objective: Clients with chronic obstructive pulmonary disease benefit from breathing techniques to facilitate effective coughing. Huff coughing is a forced expiratory technique in which the client sits relaxed, upright, and leaning forward; slowly inhales using the diaphragmatic muscle; holds breath for 2-3 seconds and then quickly exhales; and repeats as necessary until remaining secretions are clear.

Question 3

The nurse is assisting a client with asthma perform a peak flow meter measurement. Place the instructions for measuring peak expiratory flow using a peak flow meter in the correct order. All options must be used.

Accepted Answer

11ecbb05_ca5f_0c8c_b433_cf4a4477acc1_MD0009_00 A peak flow meter is a handheld device that measures the client's ability to push air out of the lungs. Measurements from a peak flow meter often guide the client's use of respiratory medications and the need to schedule an appointment with a health care provider. To obtain the most accurate readings to help guide, maintain, and evaluate treatment in clients with asthma, the procedure is performed in the following order: Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as upright as possible (Option C). Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal (Option B). Exhale as quickly and completely as possible and note the reading on the numbered scale (Option A). Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations (Option E). Record the highest reading (ie, personal best) in the peak flow log (Option D). Educational objective: When performing peak flow measurements, set the indicator to the lowest value; assume an upright position; inhale deeply; place the mouthpiece in the mouth and form a seal with the lips; exhale quickly and completely; note the value; repeat 2 more times; and then record the highest value in the peak flow log.

Question 4

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.

Accepted Answer

11ecbb05_ca59_4021_b433_c79aa4edf0c6_MD0009_00 Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs from relaxation of the pharyngeal muscles. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia and hypercarbia. Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions include: Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction (Option B) Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA (Option C). Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness (Option A) Eating before bedtime can interfere with sleep and contribute to excess weight. (Option D) Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction. (Option E) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can cause insomnia. (Option F) Napping during the day can make it more difficult to sleep through the night. Educational objective: Obstructive sleep apnea is characterized by partial or complete airway obstruction during sleep. Interventions to relieve symptoms include a continuous positive airway pressure device during sleep and lifestyle changes (eg, weight loss; exercise; avoiding food, alcohol, and sedatives at bedtime).

Question 5

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question?

Accepted Answer

This client has exacerbation (wheezing) of chronic obstructive pulmonary disease (COPD). Restlessness is an early, subtle sign of hypoxemia. Although morphine can be used to decrease restlessness and slow the respiratory rate to decrease oxygen demand, it can depress respirations. Morphine and other medications (eg, benzodiazepines) that can depress the respiratory center should not be used in clients with COPD exacerbation as they can further worsen CO₂ retention. The oxygen and medications should increase saturation and decrease restlessness, pulse, and respiratory rate. ₂ (Option A) Albuterol is a beta agonist and is appropriate for the immediate relief of bronchoconstriction because of its rapid, short action. (Option B) Methylprednisolone (Solu-Medrol) is a corticosteroid and is appropriate for decreasing inflammation of the lungs during an acute exacerbation of COPD. (Option D) The initiation of low flow, low concentration oxygen at 2 L/min by nasal cannula is appropriate in a client with COPD. It is best to start oxygen at a lower concentration and titrate upward if the saturation does not reach 90% within 20-30 minutes as many clients with COPD rely on their hypoxemic drive to breathe. Educational objective: Morphine and other medications (eg, benzodiazepines) that can depress the respiratory center should not be used in clients with COPD exacerbation as they can further worsen CO₂ retention.

Question 6

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax.  Where would the nurse expect gentle, continuous bubbling?

Accepted Answer

11ecbb05_ca55_216d_b433_419e4308a099_MD0009_00 The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level. (Option A) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here indicates the presence of an air leak. (Option B) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record as output. (Option D) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will gradually reduce in intensity as the lung reexpands. Educational objective: The nurse should observe gentle, continuous bubbling in the suction control chamber. This indicates patency and the appropriate level of suction being applied to the drainage system.

Question 7

A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite. The client states that bloating, exhaustion, and shortness of breath make eating "not worth the effort." Which statements by the nurse are appropriate to help improve the client's nutritional status? Select all that apply.

Accepted Answer

Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease (COPD), as chewing and swallowing increase work of breathing and a full stomach increases pressure on the diaphragm. As a result, clients often lose weight because their energy expenditure is greater than their nutritional intake. To optimize nutritional intake, clients should: Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating (Option A). Eat small, frequent meals, snacks, and supplements that are high in calories and protein. Smaller meals require less energy to chew and swallow, resulting in less fatigue and dyspnea (Option B). Perform oral hygiene before meals. Chronic mouth breathing leads to dry mouth; excessive sputum and medication side effects can alter the taste of food, decreasing the appetite (Option E). (Option C) For clients with advanced COPD, exercise is discouraged for 1 hour before and 1 hour after eating as it increases oxygen demand and fatigue. (Option D) Gas-forming foods (eg, broccoli, beans, cabbage) and carbonated beverages should be avoided as they cause intestinal bloating and increased pressure on the diaphragm. Educational objective: Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease as eating increases dyspnea and fatigue. To optimize nutrition, clients should avoid drinking fluids while eating; eat small, frequent, high-calorie, high-protein meals and snacks; avoid exercising for 1 hour before and 1 hour after eating; and perform oral hygiene before meals.

Question 8

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediateaction does the RN take to correct the problem?

Accepted Answer

11ecbb05_ca5d_10b5_b433_bba03cd6c454_MD0009_00 A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option A) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option C) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option D) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. Educational objective: A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.

Question 9

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid?

Accepted Answer

In clients with asthma, the airways are chronically inflamed with varying degrees of airway obstruction that can be exacerbated by exposure to triggering agents. Common asthma triggers include: Allergens: Dander (eg, cat, dog), dust mites, pollen Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin Environmental: Chemicals, sawdust, soaps/detergents Infectious: Upper respiratory infections Intrinsic: Emotional stress, gastrointestinal reflux disease Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air (Option C) Clients must be able to identify their individual triggers and avoid or learn to manage them. (Options A and B) Penicillin antibiotics and latex-containing products may commonly trigger allergic reactions in many clients but do not commonly trigger asthma exacerbations in clients without these allergies. (Option D) Although physical activity is an asthma trigger, athletes with asthma do not need to avoid activity altogether. Rather, they may take an inhaled bronchodilator 20 minutes before activity to help prevent exercise-induced asthma attacks. In addition, this client may be prone to minor musculoskeletal injuries (eg, sprains, strains) due to an active lifestyle; the nurse should teach about alternatives to common over-the-counter nonsteroidal anti-inflammatory medications that may be used for analgesia (eg, acetaminophen [Tylenol]). Educational objective: The nurse should teach an active young adult with asthma to identify and manage common triggers of asthma attacks, including cigarette smoke and nonsteroidal anti-inflammatory medications. Clients with asthma should take an inhaled bronchodilator 20 minutes before athletic activity to prevent exercise-induced asthma attacks.

Question 10

A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply.

Accepted Answer

11ecbb05_ca5d_fb1a_b433_3d693b325dbe_MD0009_00 Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema, hypersecretion of mucus, and bronchospasm. Narrowing of the airways culminates in increased airway resistance, air trapping, and lung hyperinflation. In severe asthma, breath sounds may be diminished due to closure of bronchioles. Absent breath sounds in a client with asthma are a medical emergency. Clinical manifestations of an asthma exacerbation include: Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue (Option A) Chest tightness related to air trapping (Option B) Chest tightness related to air trapping (Option B) Cough from airway inflammation and increased mucus production Cough from airway inflammation and increased mucus production Diminished breath sounds related to hyperinflation Diminished breath sounds related to hyperinflation High-pitched expiratory wheezing caused by narrowing airways (Option C); wheezing may be heard on both inspiration and expiration as asthma worsens High-pitched expiratory wheezing caused by narrowing airways (Option C); wheezing may be heard on both inspiration and expiration as asthma worsens Tachypnea related to inability to take a full, deep breath (Option E) Tachypnea related to inability to take a full, deep breath (Option E) (Option D) Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease) develop prolonged expiratory phase as a physiologic response to hyperinflation and trapped air. Educational objective: Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Clinical manifestations of an asthma exacerbation include accessory respiratory muscle use, chest tightness, diminished breath sounds, high-pitched wheezing on expiration, prolonged expiratory phase, tachypnea, and cough.

Question 11

The nurse is caring for a 72-year-old client 1 day postoperative colectomy.  The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen.  There is no jugular venous distension or peripheral edema.  Pain is regulated with client-controlled morphine.  Which prescription does the nurse anticipate?

Accepted Answer

During the initial postoperative period, a client needs respiratory interventions to keep the lungs expanded and prevent atelectasis and postoperative pneumonia. Atelectasis is maximal during the second postoperative night. Clients can be asymptomatic or have increased work of breathing, hypoxia, and basal crackles. Postoperative pain, opioid respiratory depression, limited mobility, and reluctance to take a deep breath due to anticipated pain contribute to postoperative atelectasis. The elderly and postoperative abdominal and thoracic surgery clients are at increased risk for atelectasis. The incentive spirometer encourages the client to breathe deeply with maximum inspiration. This action improves ventilation and oxygenation by expanding the lungs, encourages coughing, and prevents or improves atelectasis. It is the most appropriate prescription for this client. incentive spirometer (Option A) In a client whose pain is regulated with client-controlled analgesia (eg, morphine), administration of a bolus dose is not indicated and may increase the risk for respiratory depression. (Option C) Fine crackles in the lungs usually indicate atelectasis. The presence of coarse crackles, elevated jugular venous distension, and peripheral edema usually indicates volume overload (fluid in the alveoli). In addition, clients with fluid overload breathe at a rapid rate (tachypnea) rather than take slow, shallow breaths. IV furosemide (Lasix) is an appropriate intervention for volume overload but not for atelectasis. (Option D) As-needed oxygen may be prescribed postoperatively, especially with blood loss. A non-rebreather mask, which has 100% oxygen, is not indicated in this client as the pulse oximeter shows 96% saturation, indicating adequate oxygenation. Educational objective: The incentive spirometer is a handheld, inexpensive breathing device. It encourages the client to breathe deeply with maximum inspiration, which improves ventilation and oxygenation and encourages coughing. The incentive spirometer is used to prevent or improve atelectasis in clients who are postoperative, have respiratory problems (eg, pneumonia), or have experienced trauma.

Question 12

A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client?

Accepted Answer

The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD. Venturi mask oxygen delivery device (Option A) The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed. (Option B) The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation. (Option C) An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired oxygen concentration is not guaranteed. Educational objective: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type II respiratory failure [hypercarbic]).

Question 13

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones?

Accepted Answer

11ecbb05_ca60_1dfd_b433_63dcf7ec64a4_MD0009_00 An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option A). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option B). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option D). Educational objective: A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications.

Question 14

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention?

Accepted Answer

Normal adult ABG values at sea level are as follows: 11ecbb05_ca5a_78a3_b433_e7edca736667_MD0009_00 ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O₂ transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO₂) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO₂ ≤60 mm Hg (8.0 kPa) or PaCO₂ ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O₂ concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary. (Option B) PaO₂ 64 mm Hg (8.5 kPa) indicates hypoxemia, and PaCO₂ 45 mm Hg (6.0 kPa) is within the normal range, but results do not meet the criteria for ARF. (Option C) PaO₂ 70 mm Hg (9.3 kPa) indicates hypoxemia, and PaCO₂ 30 mm Hg (4.0 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. (Option D) PaO₂ 86 mm Hg (11.5 kPa) is within normal range, and PaCO₂ 25 mm Hg (3.33 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. Educational objective: Type I hypoxemic failure is associated with an alteration in O₂ transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type II hypercapnic, or ventilatory, failure is associated with CO₂ retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO₂ ≤60 mm Hg (8.0 kPa), PaCO₂ ≥50 mm Hg (6.67 kPa), and pH ≤7.30.

Question 15

The nurse is evaluating how well a client with chronic obstructive pulmonary disease understands the discharge teaching. Which statements made by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

Accepted Answer

11ecbb05_ca58_caf0_b433_05311aad6436_MD0009_00 The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease (COPD). Clients with COPD are taught to use this technique when experiencing dyspnea as it increases ventilation and decreases work of breathing. Regular practice (eg, 5-10 minutes 4 times daily) enables the client to do pursed lip breathing when short of breath, without conscious effect. Clients are taught the following steps: Relax the neck and shoulders Inhale for 2 seconds through the nose with the mouth closed (Option D) Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling (Option B). (Option A) Exhalation through pursed lips is done for 4 seconds, not 2 seconds, or twice as long as inhalation. (Option C) Inhalation is done through the nose, not the mouth. (Option E) Inhalation is done for 2 seconds, not 4 seconds. Educational objective: The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease. Clients are taught to relax the shoulders and neck, inhale through the nose for 2 seconds with the mouth closed, and exhale through pursed lips for 4 seconds (or twice as long as inhalation).

Question 16

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply.

Accepted Answer

Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include the following: Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin Cool mist humidifier increases room humidity of inspired air Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid; drinking a full glass of water after taking the medication is recommended. Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large airways so that they can be expectorated huff Chest physiotherapy (postural drainage, percussion, vibration) Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when the client exhales through the mouthpiece (Option E) Pursed lip breathing prolongs exhalation, reduces air trapping in the lungs, and decreases dyspnea. It does not help to thin secretions. Pursed lip breathing Educational objective: Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort in clients with chronic bronchitis include the following: Increasing oral fluids to 2-3 L/day if not contraindicated Cool mist humidifier to increase room humidity Guaifenesin (Robitussin), an expectorant, to reduce viscosity of secretions Huff coughing

Question 17

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow.  Which statement made by the client indicates an understanding of the nurse's teaching?

Accepted Answer

11ecbb05_ca5e_be6b_b433_d13c79007e60_MD0009_00 The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath. Use of the device permits self-management and provides information to guide and evaluate treatment. (Option B) The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the device. (Option C) The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when asthma is in good control. (Option D) The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a corticosteroid MDI. Educational objective: The peak flow meter is used to measure PEFR and is most helpful for clients with moderate to severe asthma. A reading is obtained by exhaling as quickly and forcibly as possible through the mouthpiece of the device.

Question 18

A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to bestevaluate the client's oxygenation and ventilation status?

Accepted Answer

11ecbb05_ca5a_0372_b433_ad0556b75ab0_MD0009_00 Arterial blood gas (ABG) assessment parameters provide objective data about the efficiency of gas exchange in the lungs and effectively evaluate the following: Acid-base balance (pH, HCO₃) Oxygenation status (PaO₂, partial pressure of oxygen in the arterial blood) Tissue oxygenation (SaO₂, percentage of available hemoglobin saturated with oxygen) Ventilation (PaCO₂, partial pressure of carbon dioxide in the arterial blood) Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). The adequacy of oxygenation and ventilation in a client with respiratory failure is best evaluated through ABG analysis. (Option B) Chest x-ray is used to determine structural abnormality (eg, enlarged heart, fractured ribs), presence of air, fluid, infiltrates, lesions, and response to treatment. It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option C) Decreased serum hematocrit and hemoglobin levels can affect the carrying capacity and delivery of oxygen to the tissues. They do not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option D) The serum lactate level provides information about anaerobic tissue metabolism (perfusion). It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. Educational objective: Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). Arterial blood gas analysis provides objective data about the efficiency of gas exchange in the lungs.

Question 19

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter.  The client is short of breath with an oxygen saturation of 78%.  After applying oxygen, the nurse should place the client in which position to improve oxygenation?

Accepted Answer

11ecbb05_ca5b_ff44_b433_d3b504c1d869_MD0009_00 Pneumonia is a lung infection resulting in decreased gas exchange in the affected lung lobes. The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. This ventilation-to-perfusion (V/Q) mismatch, or pulmonary shunt, may result in hypoxia and respiratory distress. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood (Option B). (Option A) Left lateral positioning will worsen hypoxia by decreasing blood flow to the unaffected (ie, right) lung. (Options C and D) Positioning in supine or Trendelenburg position does not promote increased perfusion to the unaffected lung, which is needed to improve hypoxia. Educational objective: Pneumonia (ie, infection of the lungs) causes decreased gas exchange in the affected lung lobes, which can lead to hypoxia and respiratory distress. Clients with unilateral pneumonia should be positioned with the unaffected (ie, good) lung down to improve perfusion and oxygenation.

Question 20

The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply.

Accepted Answer

11ecbb05_ca56_f62f_b433_6909b1f787fd_MD0009_00 Chronic obstructive pulmonary disease (COPD) generally refers to two conditions: emphysema and chronic bronchitis. A combination of the two is common. COPD affects approximately 12 million people and is the third leading cause of death in the United States, occurring most commonly in the seventh decade of life. It is characterized by slowly progressive, persistent airflow obstruction, and its etiology is closely associated with chronic airway inflammation. The major risk factor for COPD is current or former tobacco smoking (eg, cigarette, pipe, cigar). An additional contributing factor is prolonged exposure to respiratory irritants (eg, chemical fumes, smoke, dust) related to the client's occupation (eg, car mechanic, firefighter, coal miner). Risk for COPD is even higher if the client both smokes tobacco and has occupational exposure to respiratory irritants (Options C and E). Chronic exposure to air pollution and genetic predisposition (eg, alpha₁-antitrypsin deficiency) also contribute. (Option A) Alcohol consumption is not associated with the development of COPD. (Options B and D) Although obesity can worsen COPD symptoms by contributing to dyspnea, obesity and poor nutrition are not factors that directly contribute to the development of COPD. Educational objective: Chronic airway inflammation is closely associated with the development of chronic obstructive pulmonary disease. Specific etiologic factors include current or former tobacco smoking, prolonged exposure to occupational respiratory irritants, chronic exposure to air pollution, and genetic predisposition.

Exam 1: Adult Health

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

The nurse is assisting a client with asthma perform a peak flow meter measurement. Place the instructions for measuring peak expiratory flow using a peak flow meter in the correct order. All options must be used.

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question?

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling?

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediateaction does the RN take to correct the problem?

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid?

A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply.

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones?

The nurse is evaluating how well a client with chronic obstructive pulmonary disease understands the discharge teaching. Which statements made by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching?

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation?

The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD) . Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply.