MS2 Iggy chp 27 Flashcards


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1

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

2

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

3

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

4

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

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

Omelet soft whole wheat bread

6

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

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

I'd like to hear about thoughts and feelings causing you to limit social activities

8

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

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

Cover the insertion site with sterile gauze

10

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

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

Keep the client separated from other clients with cystic fibrosis

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

Administer pain medication and encourage the client to take deep breaths

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

There is good treatment for the most common genetic defect in CF

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 clients history and clinical signs and symptoms

Increased pulmonary pressure creating a higher workload on the right side of the heart

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

Do you experience shortness of breath with basic activities

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

I will always use the spacer with my dry powder inhaler

17

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

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

Keep padded clamps at the bedside for use if the drainage system is interrupted

19

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

20

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

21

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

22

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%

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

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