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A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
- A. Peak flow meter
- B. End-tidal CO2 monitor
- C. Chest tube
- D. Arterial blood gas
Correct Answer: A
Rationale: A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation. A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.
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A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
- A. Assessing the need to premedicate with an analgesic
- B. Placing the patient in low Fowler position
- C. Inserting the obturator into the outer cannula
- D. Maintaining aseptic technique
Correct Answer: D
Rationale: Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.
A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately?
- A. Tilt the patient's head forward.
- B. Begin ventilation using a manual resuscitation bag (Ambu bag).
- C. Place the mask tightly over the patient's nose and mouth.
- D. Pull the patient's jaw backward.
- E. Compress the bag twice the normal respiratory rate for the patient.
- F. Recommend that a sputum culture for cytology is obtained.
Correct Answer: B,C
Rationale: The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
- A. Place the patient in Fowler position.
- B. Encourage diaphragmatic breathing.
- C. Ask the patient to cough.
- D. Initiate oral suctioning of secretions.
Correct Answer: A
Rationale: Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
- A. Bronchial
- B. Bronchovesicular
- C. Vesicular
- D. Wheezing
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.