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A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?
- A. Instruct the client to wash their hands after contact with other people.
- B. Implement Droplet Precautions and don a surgical mask.
- C. Isolate the client from other clients with cystic fibrosis.
- D. Obtain blood, sputum, and urine culture specimens.
Correct Answer: C
Rationale: Burkholderia cepacia is spread through casual contact among cystic fibrosis clients, necessitating isolation from other CF clients. Hand washing is important but not the priority. Droplet precautions are not required, and cultures are secondary to preventing transmission.
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A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for tracheal deviation.
- C. Perform peak expiratory flow readings.
- D. Administer prescribed albuterol (Proventil) inhaler.
- E. Encourage diaphragmatic breathing.
Correct Answer: C,D
Rationale: Suprasternal retraction and wheezing indicate acute asthma exacerbation. Administering albuterol (a short-acting beta2 agonist) is appropriate for immediate relief, and peak flow readings help assess severity. Salmeterol is a long-acting medication, not for acute attacks. Tracheal deviation is unrelated, and diaphragmatic breathing is not a priority during an acute attack.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take? (Select all that apply.)
- A. Keep an intravenous line dedicated strictly to the infusion.
- B. Teach the client that this medication increases pulmonary pressures.
- C. Ensure that there is always a backup drug cassette available.
- D. Start a large-bore peripheral intravenous line.
- E. Use strict aseptic technique when using the drug delivery system.
Correct Answer: A,C,E
Rationale: Prostacyclin should be administered via a dedicated central venous catheter with strict aseptic technique to prevent infection. A backup cassette is essential due to risks of interruption. The medication decreases pulmonary pressures, and a central line, not peripheral, is used.
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.
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates 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.
- 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.
Correct Answer: C
Rationale: Long-acting beta2 agonist medications are used to prevent asthma attacks due to their long-acting nature. The client should take this medication daily for best effect. It is not a rescue medication, so it does not need to be carried at all times or used during an attack. Clients are not typically weaned off this medication as it is likely a daily maintenance therapy.
A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
- A. Review the client's pulmonary function test results.
- B. Review medications the client is currently taking.
- C. Assess how frequently the client uses a bronchodilator.
- D. Consider the report of the client with asthma phases.
Correct Answer: B
Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people due to increased production of leukotrienes when aspirin or NSAIDs suppress other inflammatory pathways. This is a high-priority action given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. Assessing bronchodilator use addresses interventions for attacks but not their cause. Considering asthma phases is not a priority action.