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100 Cards in this Set

  • Front
  • Back
The nurse teaches a parent of a toddler with leukemia about the health management of stomatitis after chemotherapy. Which statement by the parent indicates that the nurse's teaching has been effective?
"I can prepare my child's favorite foods like mashed potatoes and chocolate milk." Rationale: Mashed potatoes and chocolate milk will be nutritious, bland, and easy to chew, making this an appropriate selection for a child with stomatitis.
A patient with stage IV adenocarcinoma of the right lung has a respiratory rate of 20, heart rate of 92, circumoral cyanosis, and a small amount of pale yellow mucus during coughing. Which nursing diagnosis is indicated for the patien
impaired gas exchange Rationale: Stage IV adenocarcinoma indicates that the tumor has metastasized. Gas exchange becomes impaired as the amount of cancerous tissue increases. The findings listed are consistent with the diagnosis of impaired gas exchange.
Why should the nurse plan to place a patient with neutropenia in a private room?
to minimize exposure to infection Rationale: The greatest risk posed by neutropenia (low absolute neutrophil count) is infection. Placement in a private room along with strict asepsis, administration of antibiotics, and careful nutritional planning are key to reducing this risk.
What should the community health nurse recommend in response to a patient's inquiry about how to cope with anticipated alopecia related to scheduled chemotherapy?
Acquire a wig or hairpiece prior to hair loss to match original hair color. Rationale: Selecting the wig or hairpiece before the hair has begun to fall out makes it easier to match color and texture
Which intervention should be included in a care plan for a patient with multiple myeloma?
Promote good hydration. Rationale: Hypercalcemia is a common complication of multiple myeloma because the breakdown of bone releases calcium into the bloodstream. Maintaining hydration is most important.
Which behavior by a patient with an ileal conduit should alert the nurse to the need for additional teaching related to self-care? The patient
secures the face-plate of the appliance with tape. Rationale: Tape is used around the skin barrier, but it should never be used directly on the pouch.
Which dietary intervention should the nurse recommend for the family to implement in the care of a client with colorectal cancer who develops stomatitis related to chemotherapy?
increased fluid intake to maintain fluid and electrolyte balance and excretion of wastes Rationale: Dehydration is a substantial risk with both colorectal cancer and chemotherapy, and contributes to the fragility of the oral mucosa. Increased fluid intake is the highest priority in dietary planning.
Which intervention is important for a patient following an abdominal-perineal resection for rectal cancer? Encourage the patient to
lie in a sidelying position when in bed.
Rationale: A sidelying position in bed is the resting position least likely to be uncomfortable or irritating while the surgical wound is healing.
In assessing a patient one day following a mastectomy, the nurse should be aware that this patient is at greatest risk for developing which of the following?
pulmonary complications
Rationale: Pulmonary complications are a concern with any postsurgical patient. The concern is heightened after mastectomy because of the surgical location. Issues including pain, hematoma, and fluid accumulation can affect the patient's ability to clear the airway.
The nurse should encourage a patient receiving radiation therapy for Hodgkin's disease to follow which diet?
high-protein, high-carbohydrate, low-residue
Rationale: Radiation therapy affects the tissues of the gastrointestinal tract beginning at the oral cavity. Changes in taste sensation plus nausea, vomiting, anorexia, and diarrhea may occur, depending on the site. The diet should be highly nutritious (high in protein and carbohydrates) but not irritating to the affected tissues (low residue)
Which findings in a four year old with abdominal neuroblastoma indicate the development of distant metastasis?
periorbital edema and exophthalmus
Rationale: Among the findings listed, only this pair lists clinical manifestations of distant metastasis of a neuroblastoma.
A patient with lung cancer asks the nurse if there are any complementary or alternative treatments that can be used. Which is the nurse's best response? The nurse tells the patient,
"Describe the therapies you want to explore."
Rationale: This response is culturally sensitive and honors the patient's need for self-determination.
Early cancer of the prostate can be detected in a routine physical examination by which method?
rectal examination
Rationale: Digital rectal examination is recommended for all males age 40 and older, because it is a simple and very effective way of screening for prostate cancer.
Which nursing measure should be included in the immediate postoperative care plan of a patient following a right modified radical mastectomy?
Maintain continuous elevation of the right arm and hand on a pillow.
Rationale: Elevation of the arm on the affected side relieves pain after mastectomy.
Which laboratory finding, if abnormal, for a patient with cancer indicates that chemotherapy should be withheld?
bone marrow suppression
Rationale: Some degree of bone marrow suppression is expected with chemotherapy, but abnormal findings may indicate the need to limit or withhold the dose and increase measures to protect the patient from infection and injury.
A patient with a colostomy is being discharged. Which instruction should the nurse give the patient to help prevent skin breakdown?
Wash the area with mild soap and pat dry.
Rationale: Soap is mildly abrasive, and works well to clean residue around the stoma. The patient should dry the area by patting rather than rubbing, to avoid irritation and injury to the site.
Which sign should immediately alert the nurse to a potential problem in a patient following colostomy surgery for cancer of the colon?
The color of the stoma is dark red to black.
Rationale: Dark red or black coloring of the stoma may indicate an infection.
A patient with breast cancer asks the nurse why she is being treated with two different chemotherapy drugs instead of one. Which information should the nurse include in a response? Two drugs
increase the number of tumor cells destroyed.
Rationale: Combination (two-drug) chemotherapy uses drugs that target different phases of the cell cycle or have different chemical action, to increase the number of tumor cells attacked in each treatment cycle
Which patient statement should alert the nurse to assess the need for additional instruction regarding breast self-examination following surgery for breast cancer?
"The only good thing about my situation now is that I just need to examine one breast."
Rationale: Breast self-examination for the patient who has had breast cancer surgery should include examination of the chest wall where the breast was removed.
In planning teaching for parents of a child with osteogenic sarcoma who is receiving chemotherapy, the nurse will focus on the importance of early recognition of complications of myelosuppression. Which signs and symptoms should the nurse tell the parent to look for?
temperature elevation and gingival bleeding
Rationale: Myelosuppression (depressed bone marrow function) is common in chemotherapy, leading to a risk for infection (signaled by the elevation in temperature) and bleeding.
A woman has had a modified radical mastectomy. What is the nurse's rationale for placing a sign above her bed directing that blood samples are to be drawn and blood pressure is to be taken in the unaffected arm? These interventions may cause
increased risk for infection.
Rationale: Blood draws and blood pressure readings both require constriction of the arm, which places the patient at increased risk for infection.
The nurse counsels a family about available community resources to assist in the recovery of their father who has had a total laryngectomy for treatment of cancer. The nurse should consider the counseling effective if the family contacts which support group?
Lost Chord Club
Rationale: The Lost Chord Club is a support group for people who have had laryngectomies (removal of the larynx including the vocal chords).
A patient is receiving chemotherapy for treatment of leukemia. Which interventions should the nurse implement if the patient develops tumor lysis syndrome?
Increase the patient's fluids and assess for signs and symptoms of electrolyte imbalances.
Rationale: Tumor lysis syndrome arises when the contents of cells destroyed by chemotherapy or radiation are released into the body, causing electrolyte imbalances. Increasing fluids assists the kidneys in flushing the material.
A patient with cancer is receiving radiation therapy and is in a state of cachexia. Which instruction should the nurse include in the plan of care?
Eat six small meals per day and report any further weight loss.
Rationale: A patient in cachexia needs the best nutritional content possible. Small, frequent meals often work best to maintain weight for these patients.
The nurse is teaching cancer prevention to a group of parents. Which food should the nurse teach the parents to limit in their children's diet?
smoked meats
Rationale: Smoked meats contain nitrates and nitrites, which are associated with increased cancer risk
A patient with prostate cancer is scheduled to have a radical prostatectomy. Which response by the nurse would be best when the patient asks how the surgery will affect his sexual activity?
"The surgery may cause impotence and a penile prosthesis may be considered."
Rationale: Impotence is to be expected with radical prostatectomy. A penile prosthesis can enable the patient to achieve an erection.
Which disorder places a person at an increased risk for developing cancer?
Down syndrome
Rationale: Patients with Down syndrome are known to be at increased risk of leukemia.
During the admission physical of a three-year-old child with Wilms' tumor, the nurse should not perform which assessment technique?
palpation of the abdomen
Rationale: Palpation of the abdomen may cause cancer cells to migrate into nearby or even distant sites, if a Wilms' tumor is, in fact, present.
Which is the most appropriate instruction to give to the visitors of a patient receiving internal radiation therapy?
Maintain a distance of 6 feet from isotope source
Rationale: Visitors should be advised to remain 6 feet from the source of the radiation
When preparing a plan to meet the learning needs of a patient with cancer who is undergoing chemotherapy, the nurse should include which instruction?
Use the recommended antiemetic drug therapy.
Rationale: Antiemetic drugs are important to limit or reduce the nausea and vomiting common before, during, and after chemotherapy.
The home health nurse should instruct the family of a patient who has just had a bone marrow transplant to report all except which finding?
alopecia
Rationale : Alopecia is an expected result of the high-dose chemotherapy that must precede bone marrow transplant.
Which statement by a home care patient diagnosed with leukemia indicates the need for further teaching?
"I keep fresh cut flowers in my room."
Rationale: Fresh cut flowers and live plants pose a risk for bringing infectious material into the patient's home.
Which nursing measure should the nurse plan for a patient with thrombocytopenia resulting from cancer chemotherapy?
Apply pressure to the venipuncture sites for five minutes.
Rationale: Thrombocytopenia -- depletion of platelets -- places the patient at increased risk for bleeding. Applying pressure is an appropriate measure against this risk.
In assessing a patient who has oral lesions secondary to chemotherapy, the nurse should also assess for lesions in which part of the body?
perianal area
Rationale: The risk for infection is especially associated with pathogen entry sites such as the oral cavity, IV sites, and the perineum.
The nurse is giving instructions to a patient who is scheduled for a pacemaker implant. Which patient statement indicates an understanding of the procedure?
"A pacemaker delivers a stimulus to the heart to control heart rate."
Rationale: A pacemaker is designed to provide electric stimulus to the heart by generating a pulse.
Which findings should the nurse expect in a patient admitted with deep vein thrombophlebitis?
pain in the affected area and unilateral edema
Rationale: Primary signs of deep vein thrombophlebitis include pain in the affected area and unilateral edema.
Which is a goal of using morphine sulfate to treat acute myocardial infarction?
to decrease cardiac workload
Rationale: Morphine sulfate is the drug of choice for treating acute myocardial infarction because it reduces preload and thus decreases cardiac workload overall.
An older adult patient who is hospitalized with cardiac failure expresses feelings of powerlessness because of the complexity of the treatment. Which nursing action should be included in the plan of care?
Provide a choice of foods for the breakfast meal.
Rationale: Being allowed to choose what to have for breakfast from a list that contains appropriate choices can provide the patient with some sense of independence in a situation where there are many imposed restrictions.
A school-aged child who recently recovered from a viral illness presents with bruises on the extremities and trunk. Which condition would the nurse expect?
idiopathic thrombocytopenic purpura (ITP)
Rationale: Acute idiopathic thrombocytopenic purpura (ITP) occurs after certain childhood illnesses. Clinical manifestations of ITP include bruises, especially over bony prominences.
The nurse provides information regarding prevention of recurrence of rheumatic fever. Which statement made by the patient indicates that the nurse's instruction is effective?
"I understand that I will need to take precautions for the rest of my life."
Rationale: Rheumatic fever has lifelong consequences. The patient is at high risk for new infection and for worsening of problems related to the heart and joint damage.
Which symptom is most suggestive of acute left-sided heart failure?
exertional dyspnea
Rationale: This is suggestive of acute left-sided heart failure.
Which information should be included in the discharge plan for a patient receiving an angiotensin converting enzyme (ACE) inhibitor for blood pressure control? You may experience
cough.
Rationale: A cough is the most common side effect of an ACE inhibitor. It usually resolves within one to four days after therapy is begun, and the patient should be urged to continue taking the medication with this knowledge
The nurse is providing instruction to a patient with a medical history of long-term use
of sublingual nitroglycerin. Which comment made by the patient indicates that the nurse should provide the patient with additional instructions?
"I repeat the dosage every 30 minutes until the angina goes away."
Rationale: Dosage instructions for use of nitroglycerin indicate that the patient may take three tablets at 5-minute intervals. If pain is not relieved after the third tablet, the patient should call for emergency medical services.
The community-based nurse is counseling a patient who is taking 0.25 mg PO of digoxin (Lanoxin) daily. What statement by the patient indicates teaching was effective?
"I take my pulse."
Rationale: Digoxin (Lanoxin), a cardiac glycoside, slows the heart rate. Monitoring pulse is an effective way to ensure that the medication is working as expected and is not beginning to produce toxicity.
Which patient statement indicates that the nurse's teaching about precipitating factors of angina has been successful?
"I won't walk outside when it is very hot or very cold."
Rationale : A patient with angina should avoid exercising in an environment with temperature extremes.
The nurse is assessing a patient with an abdominal aortic aneurysm. Which clinical manifestation indicates a need for emergency measures?
severe back pain
Rationale: Severe back pain in a patient with an abdominal aortic aneurysm indicates impending rupture and the need to take emergency measures.
The nurse should expect to administer a combination of nitroglycerin IV (Tridal) and dopamine (Intropin) to a patient with which condition?
cardiogenic shock
Rationale: Nitroglycerin IV (Tridal) and dopamine (Intropin) is a combination given to patients with cardiogenic shock.
Which assessment data is indicative of iron deficiency anemia?
smooth, sore tongue
Rationale: A smooth, sore tongue is characteristic of a patient with long-term iron deficiency anemia.
Which finding leads the nurse to suspect that a patient has arterial, rather than venous, insufficiency?
hair loss on the toes, feet, and legs
Rationale: Diminished hair growth on extremities is a clinical manifestation of chronic arterial occlusive disease.
Which heart sound can be heard in a patient with pericarditis?
friction rub
Rationale: Friction rub is the classic sign of pericarditis.
A patient with atrial fibrillation has had a change in the dosage of digoxin (Lanoxin) from 0.125 mg to 0.25 mg PO daily. Which clinical manifestation is of primary concern to the nurse?
abdominal pain
Rationale: Abdominal pain in a patient whose digoxin dose has been increased may indicate early digoxin toxicity.
Bradydysrhythmias, sinoatrial arrest, and AV block may be treated with which drug?
atropine
Rationale : The findings listed are characteristic of third-degree atrioventricular block, for which atropine is the initial drug of choice.
The nurse is preparing a discharge plan for a patient with chronic arterial occlusive disease. Which instruction should the nurse include?
Maintain a daily walking program.
Rationale: A daily walking program provides an appropriate level of activity for patients with arterial occlusive disease.
Which assessment data would validate a nursing diagnosis of excess fluid volume relative to excess fluid/sodium retention secondary to right-sided heart failure?
pedal edema
Rationale: Pedal edema is a characteristic finding in patients with fluid volume excess.
When should the nurse begin Phase I rehabilitation of a patient who is recovering from a myocardial infarction?
as soon as the patient is hemodynamically stable
Rationale: Phase I rehabilitation after myocardial infarction begins when medical treatment has stabilized cardiac supply and demand.
Which patient-centered outcome indicates successful resolution of congestive heart failure (CHF)?
Pulmonary artery wedge pressure (PAWP) is 8 mm Hg.
Rationale: The normal value for pulmonary artery wedge pressure is 4-12 mm Hg.
Which physiological change in the cardiac system is expected in the older adult?
increased atrial irritability
Rationale: The aging heart may have an enlarged left atrium and increased atrial irritability.
Which direction is provided for a patient undergoing a Schilling test?
Collect all urine for a 24 hour period.
Rationale: The Schilling test requires that all urine produced over a 24-hour period is collected. Otherwise, the results are not useful.
Which laboratory result in a patient with cancer is indicative of disseminated intravascular coagulation(DIC)?
increased fibrin split products
Rationale: In DIC, normal hemostatic mechanisms are altered and many tiny clots form in the microcirculation. This condition will cause a finding of increased fibrin split products in the lab results.
Which is a possible complication of thrombolytic therapy in a patient following a myocardial infarction?
systemic bleeding
Rationale: Because thrombolytics act against clots, bleeding is a common risk of this treatment, and systemic involvement is a potentially serious complication
Which is a basic stress reduction technique for patients with coronary artery disease?
caring for a pet
Rationale: Research has shown that caring for a pet has a favorable effect on blood pressure and promotes relaxation.
Which physiological change associated with smoking increases the incidence of peripheral arterial disease?
increase in platelet aggregation
Rationale: Nicotine increases the risk of clots by increasing platelet aggregation. Clots are a key factor in peripheral arterial disease.
An older adult patient who is acutely ill is admitted with congestive heart failure. The patient settles down to sleep soon after admission. Three hours later, the patient awakens feeling restless, anxious, and breathless. Which initial action should the nurse take?
Sit the patient upright.
Rationale: The patient’s symptoms suggest orthopnea, difficulty breathing while lying down. An upright position will usually provide relief after 10 to 30 minutes.
What is a common side effect of digitalis?
nausea
Rationale: Nausea is a fairly common side effect of digitalis. If combined with several other clinical symptoms, it can be an early indicator of developing digitalis toxicity
Which clinical manifestation in a patient at risk for disseminated intravascular coagulation (DIC) requires immediate nursing action?
sudden heavy bleeding from nasal and oral mucosa
Rationale: Bleeding is the most common clinical manifestation of DIC, and profuse hemorrhage constitutes an emergency.
Which action by the patient with sickle cell anemia indicates the need for more teaching? The patient
Rationale : A patient with sickle cell anemia should be encouraged to maintain fluid intake. Dehydration is a common complication.
Which comment made by a patient who has hypertension indicates an understanding of the condition and recommendations for self-care?
"Weight loss could help my blood pressure to decrease."
Rationale: Obesity is a significant risk factor for high blood pressure, and weight control is a key step toward reducing blood pressure.
What causes the alteration in arterial blood gas values that occurs in a patient with lobar pneumonia?
Exudate infiltrates and fills the alveoli.
Rationale: Infiltration of the alveoli with fluid is characteristic of lobar pneumonia, and leads to a ventilation-perfusion mismatch and altered blood gas values.
Which statement best describes the administration of high concentrations of oxygen to a person with carbon dioxide retention due to chronic obstructive pulmonary disease (COPD)?
The respiratory drive will be reduced.
Rationale: Reduction of the respiratory drive occurs in this situation because blood oxygen levels have been raised, and as a result, the patient does not expel carbon dioxide.
Why does the nurse instruct a patient with pneumonia to drink fluids throughout the day?
Fluids promote hydration to loosen pulmonary secretions.
Rationale: Airway clearance is a key concern in pneumonia, and adequate fluid intake is a simple, effective step to liquify secretions. Retained secretions interfere with gas exchange and may slow recovery.
Which symptom should the nurse expect in a 20-month-old patient diagnosed with laryngotracheobronchitis?
predominant stridor on inspiration
Rationale: Stridor on inspiration is one of the defining features of laryngotracheobronchitis.
A postoperative patient with advanced emphysema becomes very short of breath while ambulating. Which action should the nurse implement to improve the patient's breathing pattern?
Instruct the patient to use pursed-lip breathing.
Rationale: Pursed-lip breathing improves control over the breathing pattern and is likely to ease shortness of breath for this patient.
What is the cause of the wheezing lung sound heard in children with asthma?
restricted air movement through narrowed airways
Rationale: Narrowed airways that restrict air movement are a defining aspect of asthma, and the cause of the wheezing lung sound.
The nurse hears air escaping from a laceration site of a patient with a perforated chest wound. What is the nurse's priority action? The nurse will
stop the flow of air coming through the wound.
Rationale: The nurse's first priority is to stop the air flow immediately.
A patient with asthma is using a metered dose inhaler (MDI) for the first time. Which action by the patient indicates the need for further patient education? The patient
places the inhaler in the mouth.
Rationale: Most inhalers without a spacer chamber are positioned one to two inches away from the mouth. The spacer is usually placed in the mouth. This patient may require further education.
Which is an indication that a chest tube drainage system connected to suction is not functioning properly?
occasional bubbles in the suction chamber
Rationale: Occasional bubbles in the suction chamber indicate that something may be wrong with the system.
How should the nurse be positioned when delivering the abdominal thrusts of the Heimlich maneuver to a conscious adult who is choking?
standing behind the person
Rationale: The proper position for delivering the Heimlich maneuver to a conscious adult is standing behind the person who is choking.
Which patient risk factors may indicate that the nurse should assign feeding responsibilities to a licensed practical nurse (LPN)?
vomiting with a decreased level of consciousness
Rationale: This patient requires the attention of a nurse trained at the level of LPN/LVN or above.
The goal for a patient with chronic obstructive pulmonary disease (COPD) is that the patient will have clear breath sounds. Which assessment indicates that the patient is working on this goal? The patient
drinks 2 to 3 L of fluid/day.
Rationale: Adequate hydration is one of the simple, effective ways for a patient with COPD to achieve clear breath sounds.
The nurse is assisting a patient with asthma in planning an exercise program. Which instruction should the nurse include as a priority in the teaching plan?
Use the beta agonist inhaler about 10 or 15 minutes before exercising.
Rationale: The patient should use the inhaler in anticipation, rather than waiting for troubling symptoms.
Which statement by the patient with moderate persistent asthma indicates the need for further patient teaching about medication?
"I only need to take the long-acting medication when I have respiratory problems."
Rationale: Long-acting medication for asthma is designed to alleviate symptoms and improve airway function. It needs to be taken regularly, not just on an as needed basis.
Which action should the nurse take to prevent obstruction of a tracheostomy tube by secretions
Humidify the air being inspired.
Rationale: It is important to humidify the air when a tracheostomy tube is being used.
Why may incentive spirometry be more effective than intermittent positive-pressure breathing (IPPB) in preventing or treating atelectasis? Incentive spirometry
maximizes the amount of air inhaled while maintaining relatively low airway pressure.
Rationale: A patient with atelectasis should be treated in a way that does not increase air pressure in the lung. Incentive spirometry enhances lung expansion, thus allowing maximum intake per inhalation. Intermittent positive-pressure breathing may be tried if first-line choices are not effective.
An adolescent with a fractured rib has very shallow breathing because of pain. The nurse should plan care to prevent which complication?
atelectasis
Rationale: Atelectasis or lung collapse may occur as the result of obstructed airways.
A patient's arterial blood gas values are pH 7.32, PaO2 70, PaCO2 50, and HCO3 27. These blood gas values are indicative of which condition?
respiratory acidosis
Rationale : The combination of pH < 7.4, a high PaCO2, and a slightly elevated HCO3 indicates respiratory acidosis.
The nurse teaches a client how to determine the amount of medication left in a CFC-based metered-dose inhaler (MDI). Which client statement indicates that the nurse's teaching was successful?
"If the canister floats, the MDI is empty."
Rationale: This correctly indicates that the CFC-based MDI is empty.
Which physiological change resulting from cigarette smoking increases the patient's risk for an upper respiratory infection?
ciliary paralysis
Rationale: The cilia are part of the body’s defenses against respiratory infection, and impairment of their function is a key effect of smoking.
Which complication might occur in a patient who is experiencing bronchospasms?
respiratory arrest
Rationale: Bronchospasm that becomes uncontrolled leads to status asthmaticus, an emergency that can develop into respiratory arrest.
Which nursing intervention is most effective in helping a patient with chronic obstructive pulmonary disease (COPD) to improve activity tolerance?
Establish a regular exercise routine.
Rationale: Activity intolerance is addressed by establishing a regular exercise program.
Assessment of a premature newborn reveals apical pulse 158, respirations 90, intercostal retraction, flaring of the nares, and pallor. Which is the most likely diagnosis?
respiratory distress syndrome
Rationale: Respiratory distress syndrome in a premature newborn is related to immature lung function. Among its clinical manifestations are rapid breathing, retractions, grunting, flaring of the nares, and pallor.
The nurse instructs a patient with pulmonary disease to drink 6 to 8 glasses of water a day, to use pursed-lip breathing prior to coughing, and to avoid cigarette smoke. The nurse's instructions are interventions based on which nursing diagnosis?
ineffective airway clearance
Rationale: All of the nurse's instructions in this case are related to improving airway clearance
What is the nurse's best response to a parent who expresses the intention of giving a stuffed animal to a child who has asthma? The nurse tells the parent that stuffed animals
collect dust that will precipitate symptoms of asthma.
Rationale: This is the primary reason that stuffed animals are not recommended for children with asthma.
Which statement made by a patient indicates a risk for the development of pneumonia?
"I missed three days of work last week because I had an upper respiratory infection."
Rationale: An upper respiratory infection that causes the patient to miss three days of work may be serious enough that pneumonia could develop as a complication.
What is the priority nursing action for a pediatric patient who suddenly becomes cyanotic in the recovery room?
Suction the nasopharynx.
Rationale: Cyanosis indicates obstruction of the airway. When it occurs in a child who is in the recovery room, the nurse's immediate response should be to suction the child.
Which is the most important assessment for a patient following a thoracotomy?
bilateral lung sounds
Rationale: Assessing bilateral lung sounds is the most important action for the nurse who is caring for a patient after a thoracotomy. Airway clearance is one of the critical concerns, because retained secretions can cause a variety of complications.
Which child in the emergency department should the triage nurse see first?
toddler with a croupy cough, drooling, and agitation
Rationale: The combination of a croupy cough, drooling, and agitation suggests that this child has epiglottitis, which is rapidly progressive and serious.
The patient with a history of emphysema is talking to the nurse about plans for a future vacation. Which vacation destination would be ill-advised for this patient?
ski resort
Rationale: A ski resort is not a good choice for a patient with emphysema because of the cold temperatures and possibly high altitude (increasing the chance of hypoxia).
A patient with asthma asks the nurse to explain the reason for using a Cromolyn-containing inhalant before exercising. Which is the nurse's best response?
"Cromolyn helps you tolerate activity."
Rationale: Cromolyn inhalers deliver an anti-inflammatory drug that keeps the airway from narrowing in response to exercise or cold.
Which nursing measure is most important to optimize gas exchange for the patient who is on a ventilator?
Frequently reposition the patient.
Rationale: Immobility has negative effects on the pulmonary system, so repositioning is a key intervention to optimize gas exchange for a patient who is on a ventilator.
Which is the most beneficial nursing instruction for the patient who has an upper respiratory tract infection?
Increase the humidity in the home.
Rationale: Increasing humidity usually helps to liquify secretions