Nokea
The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?
- A. A patient with a respiratory rate of 38.
- B. A patient with loud expiratory wheezes.
- C. A patient with jugular vein distension and peripheral edema.
- D. A patient who has a cough productive of thick, green mucus.
Correct Answer: A
Rationale: A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.
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The nurse is caring for a patient who is hospitalized with cystic fibrosis (CF) and is coughing up large quantities of thick green mucus. Which of the following treatments should the nurse include in the teaching plan?
- A. Antibiotic resistance.
- B. Inhaled bronchodilators.
- C. Oral corticosteroid therapy.
- D. Aerosolized amoxicillin.
Correct Answer: D
Rationale: The colour of the mucus and the patient's history of CF suggests Pseudomonas infection; an antibiotic is required. Oral corticosteroids and inhaled bronchodilators will not be effective in treating the respiratory infection; the effectiveness of bronchodilators has not been established for CF. Pseudomonas infections are usually responsive (not resistant) to TOBI.
The nurse is caring for a patient with cystic fibrosis (CF) who has blood glucose levels that are consistently 11-14 mmol/L. Which of the following nursing actions should the nurse plan to implement?
- A. Discuss the role of diet in blood glucose control.
- B. Educate the patient about administration of insulin.
- C. Give oral hypoglycemic medications before meals.
- D. Evaluate the patient's home use of pancreatic enzymes.
Correct Answer: B
Rationale: The glucose levels indicate that the patient has developed CF-related diabetes; insulin therapy will be required. Since the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF.
The nurse is teaching a patient about continuous home oxygen use and cautions the patient to take extra care to not run out of oxygen. Which of the following seasons should the nurse instruct the patient has the highest rate of oxygen evaporation?
- A. Spring.
- B. Summer.
- C. Fall.
- D. Winter.
Correct Answer: B
Rationale: During the summer, with liquid oxygen, evaporation is accelerated and may decrease reservoir duration to less than 1 week.
The nurse has completed patient teaching about the administration of salmeterol using a metered-dose inhaler (MDI). Which of the following actions by the patient indicates good understanding of the teaching?
- A. The patient attaches a spacer (aerochamber) before using the MDI.
- B. The patient coughs vigorously after using the inhaler.
- C. The patient floats the MDI in water to see if it is empty.
- D. The patient activates the inhaler at the onset of expiration.
Correct Answer: A
Rationale: Spacers can improve the delivery of medication to the lower airways. The other patient actions indicate a need for further teaching.
Which of the following findings by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
- A. Pulse oximetry reading of 91.9%.
- B. Absence of wheezes or crackles.
- C. Decreased use of accessory muscles.
- D. Respiratory rate of 22 breaths/minute.
Correct Answer: A
Rationale: For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.