Nokea
The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. Take as deep a breath as possible. 2. Stand up (unless you have a physical disability). 3. Place the meter in your mouth, and close your lips around the mouthpiece. 4. Make sure the device reads zero or is at base level. 5. Blow out as hard and as fast as possible for 1 to 2 seconds. 6. Write down the value obtained. 7. Repeat the process two additional times, and record the highest number in your chart.
- A. 4,2,1,3,5,6,7
- B. 1,2,3,4,5,6,7
- C. 2,1,3,4,5,6,7
- D. 1,3,2,5,6,7,4
Correct Answer: A
Rationale: The correct order is: ensure the device is at zero (4), stand up (2), take a deep breath (1), place the meter in the mouth (3), blow out hard and fast (5), record the value (6), and repeat twice, recording the highest value (7).
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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.
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 who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Strip the tubing to minimize clot formation and ensure patency.
- B. Secure tubing junctions with clamps to prevent accidental disconnections.
- C. Connect the chest tube to wall suction at the level prescribed by the provider.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct Answer: D
Rationale: Keeping padded clamps at the bedside ensures safety if the drainage system is interrupted. Stripping the tubing can cause harm, junctions should be taped not clamped, and suction levels are set per the device manufacturer, not the provider.
A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, 'What does this mean?' How should the nurse respond?
- A. Your children will be at high risk for the development of chronic obstructive pulmonary disease.
- B. I will contact a genetic counselor to discuss your condition.
- C. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.
- D. This is a recessive gene and should have no impact on your health.
Correct Answer: C
Rationale: AAT deficiency increases the risk of COPD, particularly in smokers. Clients with one allele produce enough AAT to prevent COPD unless exposed to irritants like smoke. The risk to children depends on the partner's AAT status, and contacting a genetic counselor is not the priority response.
A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip)
- A. Inflammation of the pleura
- B. Upper airway obstruction
- C. Pulmonary vascular edema
- D. Bronchospasm
Correct Answer: A
Rationale: A pleural friction rub, heard when the pleura is inflamed, is associated with inflammation of the pleura rubbing against the lung wall. Upper airway obstruction causes stridor, pulmonary edema causes crackles, and bronchospasm causes wheezing.