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Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Chapter 27: Concepts of Care for Patients With Noninfectious Lower Respiratory Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses several clients who have a history of respiratory disorders. Which client

would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min ANS: D

Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory distress, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse cares for a client with arthritis who reports frequent asthma attacks. What action

would the nurse take first? Review the client’s pulmonary function test results. Ask about medications the client is currently taking. Assess how frequently the client uses a bronchodilator. Consult the primary health care provider and request arterial blood gases.

a. b. c. d.

ANS: B

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client’s history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory distress, Adverse medication effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse

assesses the client’s understanding. Which statement indicates that the client comprehends the teaching? a. “I will carry this medication with me at all times in case I need it.” b. “I will take this medication when I start to experience an asthma attack.”

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) c. “I will take this medication every morning to help prevent an acute attack.” d. “I will be weaned off this medication when I no longer need it.” ANS: C

Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client’s

understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head. ANS: B

To perform diaphragmatic breathing correctly, the client would place his or her hands on the abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. 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? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole-wheat bread d. Pasta salad, custard, orange juice ANS: C

Side effects of radiation therapy may include inflammation of the esophagus. Clients would be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. After teaching a client who is prescribed salmeterol, the nurse assesses the client’s

understanding. Which statement by the client indicates a need for additional teaching?

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) a. b. c. d.

“I will be certain to shake the inhaler well before I use it.” “It may take a while before I notice a change in my asthma.” “I will use the drug when I have an asthma attack.” “I will be careful not to let the drug escape out of my nose and mouth.”

ANS: C

Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client’s part allows the drug to escape through the nose and mouth. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Medication, Client education MSC: Client Needs Category: Health Promotion and Maintenance 7. 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? a. “There are a variety of support groups for people who have COPD.” b. “I will ask your primary health care provider to prescribe an antianxiety agent.” c. “I’d like to hear about thoughts and feelings causing you to limit social activities.” d. “Friends can be a good support system for clients with chronic disorders.” ANS: C

Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. While friends can be good sources of support, the client specifically is discussing going out of the home. DIF: Applying TOP: Integrated Process: Caring KEY: Respiratory disorders, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse

include in this client’s teaching? a. “Take an antibiotic each day.” b. “You should get genetic screening.” c. “Eat a well-balanced, nutritious diet.” d. “Plan to exercise for 30 minutes every day.” ANS: C

Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening might be an option; however, the nurse would not just tell the client to do something like that. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Nutrition, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

9. 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? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the primary health care provider. d. Reinsert the tube using sterile technique. ANS: B

Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The nurse does not need to assess the site at this moment. The primary health care provider would be called to reinsert the chest tube or prescribe other treatment options. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Chest tubes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action

would the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect. ANS: A

The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse would document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is not necessary to care for this client. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Medication side effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. 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? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client separated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens. ANS: C

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients. Strict isolation measures will not be necessary. Although the client would wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with B. cepacia infection. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. 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? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client’s anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths. ANS: D

A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client’s discomfort and need to take deep breaths to prevent complications. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Pharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. 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? a. “Unfortunately, gene therapy is only provided to children upon diagnosis.” b. “Do you know that you will have to have genetic testing?” c. “There is a good treatment for the most common genetic defect in CF.” d. “Gene therapy will only help improve your pulmonary symptoms.” ANS: C

The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the F508del (also known as the Phe508del) mutation, the most common mutation involved in CF, even in patients who are homozygous for the mutation with both alleles being affected. The nurse would provide that information as the best response. Asking if the client understands he or she will have to undergo genetic testing is a correct statement, but is a yes/no question which is not therapeutic and might sound paternalistic. It also does not provide any information on the therapy itself. The drug is not limited to children and helps move chloride closer to the membrane surfaces so it would have an effect on any organ compromised by CF. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Gene therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) 14. 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 client’s history and clinical signs and symptoms? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output ANS: A

Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left-heart failure and is not directly caused by a 40-year smoking history. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Cor pulmonale MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears

thin and disheveled. Which question would the nurse ask first? a. “Do you have a strong support system?” b. “What do you understand about your disease?” c. “Do you experience shortness of breath with basic activities?” d. “What medications are you prescribed to take each day?” ANS: C

Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client’s support systems, current knowledge, and medications, these questions do not address the client’s appearance. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Functional ability MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 16. 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? a. “I still will use my rapid-acting inhaler for an asthma attack.” b. “I will always use the spacer with my dry powder inhaler.” c. “If I am stable for 3 months, I might be able to reduce my drugs.” d. “My inhaled corticosteroid must be taken regularly to work well.” ANS: B

Dry powder inhalers are not used with a spacer. The other statements are accurate.

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease

(COPD). Which client would the nurse assess first? A 46 year old with a 30–pack-year history of smoking A 52 year old in a tripod position using accessory muscles to breathe A 68 year old who has dependent edema and clubbed fingers A 74 year old with a chronic cough and thick, tenacious secretions

a. b. c. d.

ANS: B

The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. 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? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted. ANS: D

Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device’s manufacturer, not the primary health care provider. DIF: TOP: KEY: MSC:

Remembering Integrated Process: Nursing Process: Implementation Respiratory disorders, Chest tubes Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

19. A nurse ...