Oxygen Therapy and Respiratory Issues NCLEX Practice Questions

Oxygen Therapy and Respiratory Issues (NCLEX Practice Questions) ScienceMedicineNursing Bridget_Austin2 Save NURS 2160 Oxygen therapy NCLEX ...15 terms Gunveen_dureja Preview Respiratory Disorders NCLEX questi...43 terms SetfiretoitPreview NCLEX-style questions for Fluid & El...83 terms katra_schirmer Preview Fluids a 37 terms reb The client is experiencing acute rhinitis. Which intervention is most important for the nurse to include in this client's plan of care?

• Teach the client that he is most contagious during the 2 to 3 days prior to symptoms beginning.
• Verify that the client is taking large doses of vitamin C along with echinacea daily.
• Monitor for drug side effects such as vertigo, hypertension, urinary retention, and insomnia.
• Teach the client to use nasal sprays or drops on a frequent basis and as needed.

ANS: C

Drug therapy, including antihistamines and decongestants, is prescribed but must be used with caution because of side effects such as vertigo, hypertension, urinary retention, and insomnia. Antihistamines block the chemicals released by white blood cells from binding to receptor sites on blood vessels and nasal tissues, preventing local edema and itching. Rhinitis caused by overuse of nose drops or sprays is treated by discontinuing the offending drug. The use of vitamin C or echinacea will probably not affect acute rhinitis. The time period for contagion is not the most important part of the plan of care.Which is the highest priority teaching need for a client with sinusitis?

• Use cold packs over the sinus area.
• Increase his fluid intake to more than 10 glasses of fluid daily.
• Avoid using nasal saline irrigations because of the risk of spreading the infection.
• Keep the room air dehumidified to dry out the nasal sinuses.

ANS: B

Teach the client to increase fluid intake to more than 10 glasses of water or juice daily unless another medical problem requires fluid restriction.Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. If this treatment plan is not successful, the client may need to be evaluated with sinus films and computed tomography (CT). Surgical intervention may be needed.

The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the nurse's highest priority intervention?

• Verify that the client has undergone HIV testing.
• Verify that the client understands that he should avoid gargling with saline.
• Verify that other members of the client's family have been tested for bacterial pharyngitis.
• Verify that the client understands the importance of completing the entire antibiotic prescription.

ANS: D

The management of bacterial pharyngitis involves the use of antibiotics and the same supportive care provided for viral pharyngitis. Stress the importance of completing the entire antibiotic prescription, even when symptoms improve or subside. Although it is important for overall health that the client know his or her HIV status, it is not the highest priority intervention in the treatment plan. Also, gargling with warm saline may actually provide symptomatic relief. Testing the client's family for bacterial pharyngitis will not be a high priority because a preliminary diagnosis will be made from their symptoms.What is essential for the nurse to teach the client who is believed to have developed pneumonia about using a nebulizer at home?

• Explain to the client that he will need a pneumonia vaccine annually.
• Determine if the client should be changed to another type of nebulizer while he is ill.
• Use tactile fremitus and percussion to assess the client. Determine chest expansion.
• Assess whether the client's home cleaning level of nebulizer equipment is adequate.

ANS: D

If the client has chronic respiratory problems, initially ask whether respiratory equipment is used in the home. Assess whether the client's home cleaning level is adequate to prevent infection. Also, ask him or her when the last influenza or pneumococcal vaccine was received. Changing to another type of nebulizer or using tactile fremitus would be irrelevant in terms of preventing pneumonia.Which is the nurse's priority intervention for a confused client who is to start oxygen therapy?

• Determine which method of oxygen delivery the client will best tolerate.
• Instruct the client about the importance of leaving the oxygen delivery device on.
• Explain to the client that he will not be allowed to smoke while receiving oxygen.
• Monitor the client's ability to tolerate removal of oxygen while eating.

ANS: A

Oxygen therapy is usually delivered by nasal cannula or mask unless the hypoxemia does not improve with these delivery devices. The client who is confused may not tolerate a face mask. Check the skin under the device and under the elastic band, especially around the ears, for areas of redness or skin breakdown. The confused client cannot receive instruction about the oxygen delivery device or not smoking.Which should be the priority intervention of a teaching plan to instruct a client about the proper use of an incentive spirometer?

• Instruct the client to exhale, put the mouthpiece in place, and take a breath for 5 to 10 seconds.
• Instruct the client to inhale with the mouthpiece in place, and then exhale for 5 seconds.
• Teach the client to exhale, put the mouthpiece in place, and take a breath for 20 seconds.
• Instruct the client to inhale, put the mouthpiece in place, and then cough briskly.

ANS: A

Incentive spirometry, also referred to as sustained maximal inspiration, is a type of bronchial hygiene used in pneumonia. Instruct the client to exhale fully, put the mouthpiece in place, and take a long, slow, deep breath for 3 to 5 seconds. Evaluate the technique and record the volume of air inspired. Teach the client to perform 5 to 10 breaths per session every hour while awake. The other sequences are incorrect regarding the use of an incentive spirometer.

Which statement indicates that the nurse understands the spread of severe acute respiratory syndrome (SARS)?

• "I will use gloves as my primary protection when I am in contact with the client."
• "I will use blood and body fluid precautions when I am in contact with the client."
• "I will use airborne and contact precautions when I am in contact with the client."
• "I will use a nonpermeable gown as my primary protection when I work with the client."

ANS: C

Use airborne and contact precautions with clients who are suspected to have SARS. Neither gowns nor gloves alone provide adequate protection for the nurse because they do not address airborne transmission. Blood and body fluid precautions should be used with disease processes spread through the splashing of body fluids on the caregiver. This does not apply to SARS.Which statement is correct about the care of a client with avian influenza?

• "The client will be placed on standard antibiotic agents, antiviral drugs, and contact isolation."
• "The client will be placed on airborne and contact isolation and will receive oxygen."
• "The client will be placed on oseltamivir (Tamiflu) and zanamivir (Relenza) to reduce complications of his infection."
• "The client's family members should be tested for evidence of the infectious process."

ANS: B

The client who is experiencing avian influenza should be on both airborne and contact isolation. Standard antibiotic agents would be ineffective with this disease process, as would be most of the standard antiviral medications commonly used for influenza. Human to human contact through family members is likely only in very close living arrangements.Which statement by the nurse indicates an accurate understanding of tuberculosis (TB) as a disease process?

• "The risk of transmitting TB will be reduced after the client has had drug therapy for 6 weeks."
• "A definitive diagnosis of TB can be made using a chest x-ray."
• "Conclusive evidence of TB can be found through physical examination of the chest."
• "The TB client can have a negative skin test if he is immunocompromised."

ANS: D

The tuberculin test (Mantoux test) result is the most commonly used reliable test of TB infection. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. The risk of transmitting the disease does not decrease after only 6 weeks on the medication. Conclusive evidence of TB is not provided through an examination of the chest or a chest x-ray.Only a sputum specimen will provide definitive evidence of the disease process. A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old, or anyone who is severely immunocompromised.The nurse is instructing a group of new nurses on the ventilator bundle approach to the prevention of ventilator-associated pneumonia (VAP).What intervention is emphasized in this approach?

• Keep the client's head of the bed elevated to 90 degrees.
• Change the ventilator circuit every 8-hour shift.
• Perform meticulous oral care at least every 24 hours.
• Continuously remove subglottic secretions.

ANS: D

The ventilator bundle for prevention of VAP recommended by the Centers for Disease Control and Prevention (CDC) consists of elevation of the head of the bed to between 30 and 45 degrees, continuous removal of subglottic secretions, changing the ventilator circuit no more than every 48 hours, and handwashing before and after client contact. Elevating the head of the bed 90 degrees, changing the ventilator circuit every 8 hours, and oral care every 24 hours are not considered to be part of the ventilator bundle approach.

Which is the nurse's best response when a client asks how the common cold is transmitted?

• "You can't transmit the cold to anyone who has had a full set of immunizations."
• "The cold can be spread only by physical contact with an infected person."
• "A cold is spread through droplets from sneezing or coughing and through secretions."
• "You are considered contagious until all symptoms have been gone for at least 24 hours."

ANS: C

The cold virus is easily spread from one person to another through nasal secretions, eye secretions, and droplets from sneezing or coughing.The common cold can be transmitted to anyone whether or not the person has had a full set of immunizations. A cold is spread through droplets, not merely through physical contact. The person with a cold is considered to be most contagious during the early part of the illness, especially for the first 2 to 3 days.Which client will the nurse caution to avoid taking over-the-counter decongestants for manifestations of a cold or flu?

• A young man with a latex allergy
• A middle-aged woman with hypertension
• A teenage woman who is taking oral contraceptives
• An older man who has had type 1 diabetes mellitus for 20 years

ANS: B

Most decongestants work by increasing blood vessel constriction. This action increases peripheral vascular resistance and blood pressure. The client who already has hypertension may develop dangerously high blood pressure when taking a decongestant. The client who has a latex allergy, taking oral contraceptives, or has type 1 diabetes would not be likely to be as affected by the decongestant in such a life-threatening manner as the client who is hypertensive.The client has a recurrence of a streptococcal infection. Which additional assessment would be performed so the nurse can assess for complications?

• Ophthalmoscopic examination
• Blood pressure in both arms
• Sputum specimen analysis
• Urinalysis

ANS: D

Persistent streptococcal infection commonly causes the complication of glomerular nephritis. A follow-up urinalysis after a streptococcal infection may show increased protein and the presence of blood, both of which are early manifestations of glomerular nephritis. Assessment of blood pressure in both arms, examination of the eyes, or a sputum specimen would not provide data needed to determine the presence of complications from a recurring streptococcal infection.What is a priority action to teach a client to prevent the spread of a cold?

• "Wash your hands after blowing your nose or sneezing."
• "Use boiling water to clean all dishes and utensils you have used."
• "Have family members wear masks until all cold symptoms subside."
• "Humidify the air in your home by running hot shower water to produce steam."

ANS: A

Cold viruses are shed in nasal and bronchial secretions. Handwashing after events that place viruses on the hands reduces the risk that the viruses will be spread directly or indirectly to others. Dishes need only to be washed in hot sudsy water. The mouth has more protective mechanisms to prevent viral infection than the nose or the conjunctiva of the eye. Masks worn by others have not been proven effective for preventing the spread of colds and may give family members a false sense of security. Humidifying the air promotes comfort but does not inhibit viral spread.