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The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?
- A. Asthma
- B. Pneumonia
- C. Lung cancer
- D. COPD
Correct Answer: D
Rationale: Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with COPD.
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The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
- A. Resumption of the patients ADLs
- B. The familys willingness to care for the patient
- C. Nutritional status and fluid balance
- D. Signs and symptoms of respiratory complications
Correct Answer: D
Rationale: The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patients airway and breathing.
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
- A. Correct use of a ventilator
- B. Correct use of incentive spirometry
- C. Correct use of a mini-nebulizer
- D. Correct technique for rhythmic breathing
Correct Answer: B
Rationale: Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
- A. Bradycardia and frontal headache
- B. Dyspnea and substernal pain
- C. Peripheral cyanosis and restlessness
- D. Hypotension and tachycardia
Correct Answer: B
Rationale: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs?
- A. Non-rebreathing mask
- B. Nasal cannula
- C. Simple mask
- D. Partial-rebreathing mask
Correct Answer: B
Rationale: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patients respiratory status does not require a partial- or non-rebreathing mask.
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
- A. Cognition is decreased
- B. Daily arterial blood gases (ABGs) are necessary
- C. Slight tracheal bleeding is anticipated
- D. The cough reflex is depressed
Correct Answer: D
Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.