A nurse assesses several clients who have a history of respiratory disorders which client would the nurse assess first
A 27 yr old client with a heart rate of 120b beats/ min
A nurse cares for a client with arthritis who reports frequent asthma attacks what action would the nurse take first
Ask about medications the client is currently taking
After teaching a client who is prescribed a long-acting beta 2 agonist medication a nurse assesses the client's understanding which statement indicates that the client comprehends the teaching
I will take this medication every morning to help prevent an acute attack
After teaching a client how to perform diaphragmatic breathing the nurse assesses the clients understanding which action demonstrates that the client correctly understands the teaching
The client places his or her hands on the abdomen
A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer which diet selection would the nurse provide for this client
Omelet soft whole wheat bread
After teaching a client who is prescribed salmeterol the nurse assesses the clients understanding which statement by the client indicates a need for additional teaching
I will use the drug when I have an asthma attack
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) the client states that going out with friends is no longer enjoyable how would the nurse respond
I'd like to hear about thoughts and feelings causing you to limit social activities
A nurse is teaching a client who has cystic fibrosis(CF) which statement would the nurse include in this clients teaching
Eat a well balanced nutritious diet
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer a nurse notices that the chest tube is dislodged which action by the nurse is best
Cover the insertion site with sterile gauze
A nurse assesses a client who is prescribed fluticasone and notes oral lesions what action would the nurse take
Encourage oral rinsing after fluticasone administration
A nurse cares for a client who is infected with Burkholderia cepacia what action would the nurse take first when admitting this client to a pulmonary care unit
Keep the client separated from other clients with cystic fibrosis
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain what action would the nurse take
Administer pain medication and encourage the client to take deep breaths
The nurse is caring for a client who has cystic fibrosis (CF) the client asks for information about gene therapy what response by the nurse is best
There is good treatment for the most common genetic defect in CF
A nurse cares for a client with a 40 year smoking history who is experiencing distended neck veins and dependent edema which physiologic process would the nurse correlate with this clients history and clinical signs and symptoms
Increased pulmonary pressure creating a higher workload on the right side of the heart
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled which question would the nurse ask first
Do you experience shortness of breath with basic activities
A clinic nurse is reviewing care measures with a client who has asthma step 3 what statement by the client indicates the need to review the information
I will always use the spacer with my dry powder inhaler
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD) which client would the nurse assess first
A 52 year old in a tripod position using accessory muscles to breathe
A nurse cares for a client who has a pleural chest tube what action would the nurse take to ensure safe use of this equipment
Keep padded clamps at the bedside for use if the drainage system is interrupted
A nurse cares for a client who tests positive for alpha 1 antitrypsin (AAT) deficiency the client asks what does this mean how would the nurse respond
Your risk for chronic obstructive pulmonary disease is higher especially if you smoke
A nurse cares for a client who has a family history of cystic fibrosis the client asks will my children have cystic fibrosis how would the nurse respond
Since you have a family history of cystic fibrosis I would encourage you and your partner to be tested
A nurse administers medications to a client who has asthma which medication classification is paired correctly with its physiologic action
Cholinergic antagonist cause bronchodilation by inhibiting the parasympathetic nervous system
A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD)
Arterial Blood gas results
PH= 7.32
PaCo2 = 62 mmHg
Pa02= 46mmHg
HC03=28 mEq/L
Vital signs
heart rate = 110/beats/min
respiratory rate = 12 breaths/min
Blood pressure 145/65 mmHg
Oxygen Saturation= 76%
what action will the nurse take first
Initiate oxygenation therapy to increase saturation to 88% to 92%
A nurse assesses a client with asthma and notes liberal wheezing decreased pulse oxygen saturation and suprasternal retraction on inhalation what actions by the nurse are best(SATA)
Administer oxygen and place client on oximeter
Administer prescribed albuterol inhaler
Assess the clients lung sounds after administering the inhaler
A nurse assesses a client who has a mediastinal chest tube which symptoms require the nurses immediate intervention(SATA)
Tracheal deviation
Sudden onset of shortness of breath
Drainage greater than 70ml/hr
Disconnection at Y site
A nurse teaches a client who has chronic obstructive disease pulmonary disease which statements related to nutrition would the nurse include in this clients teaching (SATA)
Avoid drinking fluids just before and during meals
Rest before meals if you have dyspnea
Have about six small meals a day
Use pursed lip breathing during meals
Choose soft high calorie high protein foods
A nurse assesses a client with chronic obstructive pulmonary disease which questions would the nurse ask to determine the clients activity tolerance(SATA)
Do you have any difficulty sleeping
How long does it take to perform your morning routine
Have you lost any weight lately
How does your activity compare to this time last year
A client who has become increasingly dyspneic over a year has been diagnosed with pulmonary fibrosis what information would the nurse plan to include in the teaching this client (SATA)
The need to avoid large crowds and people who are ill
Safety measures to take if home oxygen is needed
Information about appropriate use of the drug nintedanib
Measures to avoid fatigue during the day
A nurse plans care for a client who has chronic obstructive pulmonary disease and thick tenacious secretions which interventions would the nurse include in this clients plan of care(SATA)
Ask the client to drink 2L of fluids daily
Add humidity to the prescribed oxygen
Use a vibrating chest physiotherapy device
Administer the ordered mucolytic agent
A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension what actions would the nurse take to ensure the clients safety while on this medication (SATA)
Keep an intravenous line dedicated strictly to the infusion
Ensure that there is always a backup drug cassette available
Use strict aseptic technique when using the drug delivery system
A home health nurse evaluates a client who has chronic obstructive pulmonary disease which assessments would the nurse include in this clients evaluation (SATA)
Examination of mucous membranes and nail beds
Measurement of rate depth and rhythm of respiration
Determine the clients need and use of oxygen
Ability to perform activities of daily living
A nurse is teaching a client how to perform pursed lip breathing which instructions would the nurse include in this teaching(SATA)
Use your abdominal muscles to squeeze air out of your lungs
Breath out slowly without puffing your cheeks
Exhale at least twice the amount of time it took to breathe in
A nurse is assessing a client with lung cancer what nonpulmonary signs and symptoms would the nurse be aware of(SATA)
Gynecomastia in male patients
Frequent shaking and sweating relieved by eating
Moon face and buffalo hump
General edema
The nurse is preparing to teach a community group about warning signs of lung cancer what information does the nurse include(SATA)
Persistent coughing
Rusty or blood tinged sputum
Dyspnea
Hoarseness