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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.
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A nurse is teaching a client with cystic fibrosis (CF). Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Drink fluids with meals to stay hydrated.
- B. Rest before meals to conserve energy.
- C. Eat six small meals a day.
- D. Eat high-fiber foods to promote gastric emptying.
- E. Increase carbohydrate intake for energy.
Correct Answer: A,B,C
Rationale: Fluids should be avoided with meals to prevent bloating, resting before meals conserves energy, and six small meals reduce bloating. High-fiber foods can cause gas, worsening shortness of breath, and excessive carbohydrates increase carbon dioxide production, risking acidosis.
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
- A. A 46-year-old with a 30-year history of smoking.
- B. A 52-year-old in a tripod position using accessory muscles to breathe.
- C. A 50-year-old with dependent edema and clubbed fingers.
- D. A 74-year-old with a chronic cough and thick, tenacious secretions.
Correct Answer: B
Rationale: A client in a tripod position using accessory muscles is in acute respiratory distress and requires immediate assessment to prevent respiratory failure. The other clients' symptoms, while concerning, do not indicate immediate distress.
A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.)
- A. What color is your sputum?
- B. Do you have any difficulty sleeping?
- C. How long does it take to perform your morning routine?
- D. Do you walk up stairs every day?
- E. Have you lost any weight lately?
Correct Answer: B,C,E
Rationale: Difficulty sleeping, prolonged morning routines, and weight loss indicate worsening dyspnea or fatigue, reflecting activity tolerance. Sputum color and stair climbing frequency are less directly related to activity tolerance.
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 client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
- A. When the tube drainage increases and warms to the touch.
- B. When the tube drainage decreases and becomes sanguineous.
- C. When the client experiences pain at the insertion site.
- D. When the tube becomes disconnected from the drainage system.
Correct Answer: D
Rationale: A disconnected chest tube allows air to enter the pleural space due to negative intrathoracic pressure, causing a pneumothorax. Warm drainage, sanguineous drainage, or pain at the insertion site do not directly increase pneumothorax risk.