290 Exam 2 Review

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

• A low arterial PCO2 level

• A hyperinflated chest noted on the chest x-ray

• Decreased oxygen saturation with mild exercise

• Pulmonary function tests that demonstrate in-

  creased vital capacity

• Pulmonary function tests that demonstrate increased vital capacity

Answer explanation

Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest X-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

Test-Taking Strategy: Focus on the subject, manifestations of COPD. Think about the pathophysiology associated with this disorder. Remember that hypercapnia, a hyperinflated chest, a flat diaphragm, oxygen desaturation on exercise, and decreased vital capacity are manifestations.

Reference: Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2023). Saunders Comprehensive Review for the Nclex-Rn examination (9th ed.). Elsevier.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

• Sitting up in bed

• Side-lying in bed

• Sitting in a recliner chair

• Sitting up and leaning on an overbed table

Answer explanation

Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike. Next, eliminate option 2 because this position will not enhance breathing.

Reference: Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2023). Saunders Comprehensive Review for the Nclex-Rn examination (9th ed.). Elsevier.

You are the nurse educating a patient on how to use incentive spirometry (IS). You know that there is a need for further teaching when a client makes which statement about IS?

• "I should try and use this about 10 times per hour"

• "I need to exhale into the mouthpiece to measure how well my lungs are working."

• "Hopefully this thing will help prevent pneumonia"

• "I know that this is used to help expand my lungs"

You are the nurse in an outpatient clinic, and a patient presents with fever, headache, and malaise. You suspect that which of the following interventions should be performed. Select all that apply.

• Teaching the patient about how to prevent the spread of infection.

• Informing the patient that they have a cold.

• Rapid influenza test.

• Advising the patient to stay home and rest.

Which of the following are characteristic manifestations of a cold? Select all that apply.

• Fever

• Nasal congestion

• Sore throat

• Headache

• Gradual onset

Which of the following are possible causes of atelectasis? Select all that apply

• Anesthesia

• Post-op pain

• Immobility

• Early ambulation

Hospital-Acquired Pneumonia (HAP) is defined as a pneumonia that occurs

• 12 hours or more after hospital admission and was not present a the time of admission

• 24 hours or more after hospital admission and was not present a the time of admission

• 36 hours or more after hospital admission and was not present a the time of admission

• 48 hours or more after hospital admission and was not present a the time of admission

The nurse is caring for a patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with an increase in respiratory rate from 26 to 44 breaths/min. Which action by the nurse would be the most appropriate?

• Have the patient perform huff coughing.

• Perform chest physiotherapy for 5 minutes.

• Teach the patient to use pursed-lip breathing.

• Instruct the patient in diaphragmatic breathing.

Answer explanation

Harding: Lewis's Medical Surgical Nursing 11e Online Chapter Review

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism?

• Loosening secretions so that they may be coughed up more easily

• Promoting maximal inhalation for better oxygenation of the lungs

• Preventing bronchial collapse and air trapping in the lungs during exhalation

• Increasing the respiratory rate and giving the patient control of respiratory patterns

Answer explanation

Harding: Lewis's Medical Surgical Nursing 11e Online Chapter Review

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding?

• Absence of dyspnea

• Improved mental status

• Effective and productive coughing

• PaO2 within normal range for the patient

Answer explanation

Harding: Lewis's Medical Surgical Nursing 11e Online Chapter Review

Focus on the subject: airway clearance