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A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
- A. A 66-year-old client with a pulse oximetry reading of 91%
- B. A 60-year-old client with a barrel chest and clubbed fingernails
- C. A 35-year-old client who has a longer expiratory phase than inspiratory phase
- D. A 37-year-old client with a heart rate of 120 beats/min
Correct Answer: D
Rationale: 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 91% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.
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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 lays on his or her side with knees bent.
- B. The client places his or her hands on his or her abdomen.
- C. The client lays in a prone position with his or her legs straight.
- D. The client places his or her hands above his or her head.
Correct Answer: B
Rationale: To perform diaphragmatic breathing correctly, the client should place their hands on their abdomen to feel the rise and fall of the diaphragm. This type of breathing cannot be performed effectively while lying on the side, in a prone position, or with hands above the head.
The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I will only use oxygen when I feel short of breath.
- B. I will store oxygen tanks in a warm, sunny area.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will smoke while wearing my oxygen via nasal cannula.
Correct Answer: C
Rationale: Using cotton balls to cushion oxygen tubing prevents pressure ulcers, indicating correct understanding. Continuous oxygen should be worn at all times, not only when short of breath. Smoking while using oxygen poses a fire risk, and oxygen tanks should be stored in a cool, well-ventilated area.
The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. Press down firmly on the canister to release one dose of medication. 2. Breathe in slowly and deeply. 3. Shake the whole unit vigorously three or four times. 4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 5. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. 6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
- A. 2,3,5,1,6,2
- B. 3,4,5,1,2,6
- C. 4,3,5,1,2,6
- D. 1,3,2,5,6,7,4
Correct Answer: C
Rationale: The correct order is: insert the inhaler into the spacer (4), shake the unit (3), place the mouthpiece in the mouth (5), release the medication (1), breathe in slowly and deeply (2), and hold the breath for 10 seconds (6).
A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, 'Will my children have cystic fibrosis?' How should the nurse respond?
- A. Your children will have cystic fibrosis and will also be carriers of the gene.
- B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
- C. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.
- D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
Correct Answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring both parents to be carriers for a child to have the disease. Testing the client and her partner is the most appropriate recommendation to assess risk. The other options are incorrect or irrelevant to the question.
The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. Take as deep a breath as possible. 2. Stand up (unless you have a physical disability). 3. Place the meter in your mouth, and close your lips around the mouthpiece. 4. Make sure the device reads zero or is at base level. 5. Blow out as hard and as fast as possible for 1 to 2 seconds. 6. Write down the value obtained. 7. Repeat the process two additional times, and record the highest number in your chart.
- A. 4,2,1,3,5,6,7
- B. 1,2,3,4,5,6,7
- C. 2,1,3,4,5,6,7
- D. 1,3,2,5,6,7,4
Correct Answer: A
Rationale: The correct order is: ensure the device is at zero (4), stand up (2), take a deep breath (1), place the meter in the mouth (3), blow out hard and fast (5), record the value (6), and repeat twice, recording the highest value (7).