AH2 Asthma/Pneumonia NCLEX

AH2 Asthma/Pneumonia NCLEX Leave the first rating Students also studied Terms in this set (56) Science MedicineNursing Save Pneumonia NCLEX practice questio...34 terms Daniel_Griffiths2 Preview NCLEX Eye Disorders 27 terms natashakressPreview Ortho NCLEX Questions 41 terms conleysa19Preview NCLEX 20 terms mar 1) In a client with a tracheostomy, the nurse should monitor for complications related to the loss of which protective mechanism?

• Filtration and humidification of inspired air
• The ability to cough
• Decrease in oxygen-carrying capacity of the trachea
• The sneeze reflex initiated by irritants in the nasal

passages

• Filtration and humidification of inspired air

Rationale:

When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.What factors should the nurse assess in a client who has been diagnosed with lung disease but has no history of smoking? Select all that apply.

• Participation in recreational activities
• Cardiac status
• Exposure to airborne pollutants
• Exposure to second-hand smoke
• Nutritional status
• Exposure to airborne pollutants
• Exposure to second-hand smoke

Rationale:

The nurse should assess the client for exposure to airborne pollutants and secondhand smoke. A number of factors affect a healthy respiratory system. The air an individual breathes, either indoors or outdoors, may be polluted. Exposure to airborne irritants may produce an inflammatory response within the airways.Assessing the client's participation in recreational activities and nutritional status is important; however, it might not provide the needed information regarding the client's exposure to pollutants. The client's cardiac status may or may not be affected by the lung disease.

A firefighter has been admitted to the ED. He has no visible burn injuries. He is somewhat inattentive and uncoordinated and is frequently attempting to get off the gurney and leave the ED. What might the nurse hypothesize about his condition? Select all that apply.

• The firefighter is exhibiting normal anxiety after a

traumatic event and is ready for discharge.

• The firefighter is showing signs of mild cerebral

hypoxia related to smoke inhalation.

• The firefighter has severe cerebral hypoxia.
• The firefighter is suffering from ARDS.
• Further tests are indicated to determine the extent of

the problem.

• The firefighter is showing signs of mild cerebral hypoxia related to smoke

inhalation.

• Further tests are indicated to determine the extent of the problem.

Rationale:

Symptoms of mild cerebral hypoxia include change in attention, poor judgment, and uncoordinated movement. Symptoms of severe cerebral hypoxia include complete unawareness and unresponsiveness, no breathing, and no response of the pupils of the eye to light. ARDS is a severe form of acute respiratory failure.Inattention and lack of coordination are not anxiety-related symptoms. X-rays and blood tests may be used to further assess the problem.What therapies may the nurse expect to provide to a client with asthma? Select all that apply.

• Ventilatory support
• Oral and nasal suctioning
• Instruction on aggravating factors
• How to measure daily peak expiratory flow rates
• Oxygen therapy
• Instruction on aggravating factors
• How to measure daily peak expiratory flow rates

Rationale:

Treatment for the client with asthma includes instruction on the identification and avoidance of aggravating factors and measuring daily peak expiratory flow rates.Oral and nasal suctioning is not indicated with the treatment of asthma. Clients with asthma are not prescribed oxygen therapy. Clients with asthma do not usually need ventilatory support.When auscultating the lungs of a client with shortness of breath, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate?

• Narrow bronchi
• Narrow trachea passages
• Blocked large airway passages
• Inflamed pleural surfaces
• Blocked large airway passages

Rationale:

The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder. Which laboratory finding would be most significant for this client?

• Hemoglobin level 12 mg/dL
• Oxygen saturation 96%
• Serum sodium 140 mg/dL
• Blood pH 7.32
• Blood pH 7.32

Rationale:

The blood pH of 7.32 indicates acidosis, which indicates inadequate oxygenation.The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.A client with chronic obstructive lung disease is prescribed oxygen 24% 2 L/min. What does the nurse determine to be the best method of providing oxygen to this client?

• Face mask
• Nasal cannula
• Nonrebreather mask
• Venturi mask
• Nasal cannula

Rationale:

The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

The nurse is planning care for a client with shortness of breath. What should the nurse do to address the client's activity intolerance?

• Encourage activity.
• Consult a dietitian for low-calorie meals.
• Consult physical therapy for endurance and

musculoskeletal function.

• Encourage independence with activities of daily living.
• Consult physical therapy for endurance and musculoskeletal function.

Rationale:

The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with Physical Therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage activity or independence with the activities of daily living.A client is admitted for acute symptoms of asthma and lung inflammation. What would the nurse expect the physician to prescribe to this client?

• Xenopenex
• Atrovent
• Slo-Bid
• Advair
• Xenopenex

Rationale:

The client is experiencing acute symptoms of asthma due to lung inflammation. A bronchodilator of short duration, such as Xenopenex, would be indicated. Advair would be more applicable for the client with chronic obstructive pulmonary disease. Atrovent is an anticholinergic medication. Slo-Bid is a xanthine.The nursing instructor preparing a lecture on alterations in oxygenation is aware that which of the following are manifestations of tachypnea?Select all that apply.

• Excessive rapid breathing
• Chest pain
• Rapid breathing at rest
• Shallow breathing
• Cyanosis
• Excessive rapid breathing
• Rapid breathing at rest
• Shallow breathing

Rationale:

Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax.Cyanosis is a late manifestation of hypoxemia.The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client admitted with asthma. Which action observed would indicate to the charge nurse the need to intervene immediately?

• The newly licensed nurse is observed obtaining the

pulse oximetry reading 10 minutes after the client used an albuterol inhaler.

• The newly licensed nurse is observed continuing to ask

the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.

• The newly licensed nurse is observed assessing the

client's thoracic wall, skin, and nail beds.

• The newly licensed nurse is observed auscultating

breath sounds with a stethoscope.

• The newly licensed nurse is observed continuing to ask the client questions

regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.

Rationale:

The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

The newly licensed nurse is having a discussion with the charge nurse about alterations in oxygenation. The newly licensed nurse is aware that which of the following are examples independent nursing interventions when providing care to clients with alterations in oxygenation?Select all that apply.

• Encouraging deep breathing exercises
• Assisting with positioning
• Providing suctioning
• Administering bronchodilators
• Monitoring activity intolerance
• Encouraging deep breathing exercises
• Assisting with positioning
• Providing suctioning
• Monitoring activity intolerance

Rationale:

Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs).Administration of bronchodilators requires a physician's order and is considered a collaborative intervention and not an independent nursing intervention.Which assessment findings indicate that a client with asthma needs immediate attention? Select all that apply.

• Retractions and fatigue
• Tachycardia and tachypnea
• Inaudible breath sounds
• Diffuse wheezing and the use of accessory muscles

when inhaling

• Reduced wheezing and an ineffective cough
• Inaudible breath sounds
• Reduced wheezing and an ineffective cough

Rationale:

Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure. During an asthma attack, tachycardia, tachypnea, and prolonged expirations are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing and the use of accessory muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still occurring; therefore, they do not require the most urgent action. Retractions and fatigue are also a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging.An older client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration.What would be an appropriate nursing diagnosis for this client?

• Ineffective Airway Clearance
• Impaired Tissue Perfusion
• Ineffective Breathing Pattern
• Activity Intolerance
• Ineffective Breathing Pattern

Rationale:

The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion