- Which action should the nurse take first?
Answer: Assist the client into a high-Fowler's position and encourage deep breathing.
Repositioning the client to a high-Fowler's or orthopneic position is an immediate, independent nursing action that improves lung expansion and reduces the work of breathing. It should precede other interventions because it can produce rapid relief without risk. Choice D (focused lung assessment) is a strong competing option, but the nurse has already performed observation-level assessment — tripod positioning, pursed-lip breathing, and SpO2 reading — which is sufficient to justify an immediate independent intervention before conducting a deeper assessment. Choice A (increasing O2 to 6 L/min) risks suppressing the hypoxic respiratory drive in a COPD client and should not be the first action. Choice C (notifying the PHCP) is appropriate but follows an independent intervention and further assessment.
- Which instruction by the nurse provides the UAP with the best direction?
Answer: Make sure the client uses the incentive spirometer 10 times every hour while awake.
Effective delegation provides a specific, measurable, and achievable task with clear parameters. Instructing the UAP to have the client use the spirometer 10 times every hour while awake gives a concrete, verifiable target that the UAP can complete and report on without requiring nursing judgment. Choice B does not provide any clinical parameters and essentially delegates the decision of whether to perform the intervention to the client. Choice C requires the UAP to assess respiratory status, which is a nursing function outside UAP scope. Choice D is incorrect for an additional critical reason beyond scope: incentive spirometry requires slow, maximal inhalation to raise the piston — not exhalation. Instructing the client to blow into the device is fundamentally wrong technique and would provide no therapeutic benefit.
- The nurse should recognize these findings as indicators of:
Answer: Significant respiratory distress and increased work of breathing.
Nasal flaring, intercostal retractions, and expiratory grunting constitute the classic triad of significant respiratory distress in infants and require immediate nursing assessment and intervention. Nasal flaring indicates the infant is attempting to maximize airway diameter. Intercostal retractions reflect the use of accessory muscles as the infant struggles to generate sufficient negative pressure to move air. Expiratory grunting is a physiological response — the infant partially closes the glottis on exhalation to maintain positive end-expiratory pressure and prevent alveolar collapse. Together, these are never normal and always indicate significant work of breathing. Choices A, C, and D offer benign interpretations that would delay necessary intervention.
- Which action should the nurse take next?
Answer: Stop suctioning immediately and provide 100% oxygen.
When a client develops signs of physiological distress during suctioning — specifically tachycardia and a significant SpO2 drop — the nurse must stop the procedure immediately and administer 100% oxygen via the tracheostomy to restore oxygenation. Suctioning removes oxygen along with secretions, and continuing despite distress (A) risks inducing dangerous hypoxia or cardiac arrhythmia. This is the standard safety protocol: stop, oxygenate, allow the client to stabilize, and only resume suctioning if clinically necessary after recovery. Notifying the PHCP (C) may be appropriate if distress persists after oxygenation, but it is not the first action. Documenting and continuing (D) ignores a clinically significant and potentially life-threatening response.
- What is the priority nursing action?
Answer: Notify the primary health care provider immediately.
Chest tube drainage exceeding 100 mL/hour, particularly when it is bright red blood and represents a sudden increase from a stable baseline rate, is a critical indicator of potential post-operative hemorrhage — a medical emergency requiring immediate PHCP notification. Documenting and waiting (A) is dangerous; hemorrhage can progress rapidly to hemodynamic instability. Clamping the chest tube (B) is contraindicated post-thoracic surgery because it can cause tension pneumothorax by trapping air or blood in the pleural space — this is one of the most important safety principles in chest tube management. Coughing and deep breathing (D) are appropriate preventive measures but do not address a hemorrhage emergency and could worsen bleeding.
- Which action should the nurse take to ensure safe suctioning for this client?
Answer: Limit each suction pass to no more than 10 to 15 seconds.
Limiting each suctioning pass to no more than 10 to 15 seconds is the standard safety parameter to prevent hypoxia and mucosal trauma. The nurse should also pre-oxygenate before each pass and allow recovery time between passes. Applying continuous suction during insertion (B) is incorrect; suction should be applied intermittently only while withdrawing the catheter, not during insertion, to prevent mucosal damage and hypoxia. A suction pressure of 150 to 200 mmHg (C) is excessive for adults; the recommended range is 80 to 120 mmHg to prevent airway trauma. Instructing the client to hold their breath (D) is incorrect and counterproductive; clients are encouraged to cough during the procedure to help mobilize secretions.
- Based on the pink, frothy sputum and coarse crackles, which nursing hypothesis is the priority?
Answer: Impaired gas exchange related to pulmonary congestion.
Impaired gas exchange is the immediate life-threatening priority, evidenced by an SpO2 of 88%, RR of 28, and clinical signs of acute pulmonary edema. This is the hypothesis that, if left unaddressed, poses the greatest immediate risk to the client's survival. Risk for infection (B) is a secondary concern; fluid stasis may increase infection risk over time but is not immediately life-threatening. Anxiety (C) is real and warrants attention but is secondary to the physiological emergency. Decreased cardiac output (D) is the underlying pathophysiology driving the presentation, but impaired gas exchange is its most urgent and measurable consequence requiring immediate nursing action.
- Which action should the nurse take immediately?
Answer: Attempt to reinsert the tracheostomy tube using a spare obturator.
For a client with an established, mature tracheostomy stoma (a tract that has been in place for several weeks), the immediate priority when the tube is accidentally dislodged is to reinsert the tracheostomy tube using the obturator. The tract is well-formed and will remain patent long enough to allow reinsertion, which directly restores a secure airway. This is appropriate within LPN/VN scope for an established stoma per most facility protocols. Covering the stoma with an occlusive dressing (A) is appropriate only for a laryngectomy client where oral/nasal ventilation is no longer possible — it would obstruct this client's only functional airway. Supine positioning (B) does not address the dislodged tube and delays definitive airway management. BVM over the stoma (C) is a correct rescue action if reinsertion is unsuccessful, but reinsertion is the first-line response for an established stoma.
- Which action should the nurse take first?
Answer: Assess the client's airway for secretions and need for suctioning.
A high-pressure alarm indicates the ventilator is encountering increased resistance when delivering a breath to the client. The most common causes are secretion accumulation, the client biting the tube, bronchospasm, or the client breathing against the ventilator. Assessing the client's airway and suctioning as needed directly addresses the most frequent cause and prioritizes patient safety over equipment inspection. Choice A (checking for disconnections) describes the correct response to a low-pressure alarm, which indicates a loss of circuit integrity; it is not the priority action for a high-pressure alarm. Increasing oxygen (C) does not address the source of the resistance. Silencing the alarm without investigation (D) is a serious safety violation.
- Which instruction is most important to prevent a complication specific to this medication?
Answer: Rinse your mouth with water and spit it out after using the inhaler.
Fluticasone is an inhaled corticosteroid. Rinsing the mouth with water and spitting after each use is the most important instruction specific to this medication class because it prevents oral candidiasis (thrush) — a direct complication of corticosteroid deposition in the oropharynx. The stem asks for the instruction most important to prevent a medication-specific complication, making D the single best answer. Choice B (holding the breath for 10 seconds) is correct general MDI technique but is not specific to fluticasone or its complications. Choice A describes incorrect technique regardless of medication. Choice C overstates the required wait time between puffs of the same medication.
- Two hours later, the client's RR is 20, SpO2 is 95% on room air, and she states she can breathe much better now. The nurse determines the interventions were successful because:
Answer: The respiratory status has stabilized toward the client's baseline.
The primary treatment goal was to restore adequate oxygenation and ventilation. A return of RR to 20 breaths/min and SpO2 to 95% on room air — alongside the client's subjective report of improvement — represents measurable stabilization toward the client's admission baseline and confirms effective treatment. Choice A is not a valid success indicator in this scenario: the client's 'baseline' blood pressure was 150/90 mmHg on admission, which itself reflects poorly controlled hypertension; returning to that value is not a therapeutic goal. Choice B (no sputum) is a supportive secondary finding but not the primary outcome measure. Choice D (ADL performance) is an unrealistic short-term goal two hours into treatment of an acute pulmonary emergency.
- Which finding should the nurse identify as an expected therapeutic outcome of this medication?
Answer: Decreased wheezing and increased ease of breathing.
Albuterol is a short-acting beta-2 agonist bronchodilator. Its therapeutic mechanism is relaxation of bronchial smooth muscle, which widens the airways and directly produces decreased wheezing and improved airflow. This is the intended clinical goal of administering the medication. Choice A (tachycardia and nervousness) describes common side effects of beta-agonist stimulation — they may occur but are not the desired therapeutic outcome. Choice C (increased thick sputum) is not an expected effect of albuterol; mucolytics address secretion consistency. Choice D (hypotension and drowsiness) is not associated with albuterol; these findings would suggest an adverse reaction requiring evaluation.
- Which intervention should the nurse immediately implement to improve the client's respiratory status?
Answer: Place the client in a high-Fowler's position with the feet dangling.
High-Fowler's position with feet dangling is the priority independent nursing intervention for acute pulmonary edema. It simultaneously maximizes lung expansion by allowing full diaphragmatic excursion and reduces preload by promoting venous pooling in the dependent lower extremities — directly targeting the underlying pathophysiology. Administering an oral beta-blocker (B) is dangerous in the setting of acute decompensated heart failure; negative inotropic effects could worsen cardiac output. Vigorous chest physiotherapy (C) is inappropriate and potentially harmful during acute respiratory distress. Placing the client supine or lateral (D) would worsen venous return and further compromise the failing ventricle.
- The PHCP prescribes a STAT dose of IV furosemide. Which action is a priority for the nurse after administering the medication?
Answer: Monitor the client's hourly urine output and SpO2.
After administering a STAT dose of IV furosemide for acute pulmonary edema, the immediate priority is evaluating treatment effectiveness. Hourly urine output confirms the diuretic is working (fluid is being removed from the vascular space), while SpO2 monitoring confirms the primary clinical goal — improved gas exchange — is being met. Daily weight (A) is an important ongoing monitoring tool for heart failure but is not an immediate post-medication action. Diet teaching (C) is appropriate but is not a priority during an acute emergency. Documenting edema level (D) is relevant but reflects a chronic peripheral finding rather than the acute pulmonary emergency being treated.
- The nurse recognizes that the client's report of increased difficulty breathing while lying flat (orthopnea) is most likely caused by:
Answer: Increased venous return and fluid shifting into the lungs.
In left-sided heart failure, the supine position increases venous return to the right heart. The failing left ventricle cannot adequately pump this increased volume forward, causing a backup of fluid into the pulmonary circulation and alveoli — producing orthopnea. This is a classic and expected pathophysiological mechanism in decompensated heart failure. A pulmonary embolism (A) would cause sudden-onset dyspnea but is not position-dependent in the way orthopnea is. An adverse medication reaction (C) is not supported by the clinical picture. Accessory muscle use (D) is a compensatory response to the dyspnea, not its cause.
- The nurse should recognize that the client's confusion is most likely a clinical sign of:
Answer: Hypoxemia and decreased oxygen delivery to the brain.
In older adults, altered mental status — including new-onset confusion — is frequently the earliest and most prominent clinical sign of hypoxemia. The brain is highly sensitive to oxygen deprivation, and as SpO2 drops, cerebral oxygenation decreases, producing confusion before other classic respiratory symptoms become apparent. The concurrent drop in SpO2 from 96% to 90% directly supports this explanation. Age-related dementia (A) is a chronic, progressive condition and would not present as acute confusion over one hour. An adverse medication reaction (C) is possible but not supported without additional evidence; the SpO2 change provides a more compelling clinical explanation. Dehydration (D) could contribute to confusion but does not explain the concurrent SpO2 decline.
- Which assessment finding is the most critical indicator of worsening pulmonary edema?
Answer: The presence of pink, frothy sputum.
Pink, frothy sputum is pathognomonic for acute pulmonary edema — it signals that fluid under pressure is being forced from the pulmonary capillaries directly into the alveoli, severely impairing gas exchange. This is a high-priority, specific indicator of a life-threatening change in status. The blood pressure elevation (A) and tachycardia (C) are consistent with cardiovascular compensation but are non-specific findings that could have multiple causes. Peripheral edema (D) reflects systemic fluid retention, which is a chronic component of heart failure and is not an acute indicator of the current pulmonary crisis.
- Which action should the nurse perform first?
Answer: Check the client's SpO2 using a pulse oximeter.
The client is showing signs of acute respiratory deterioration — accessory muscle use, tachypnea, and subjective air hunger. The nurse must first collect focused data by measuring SpO2 to quantify the severity of gas exchange impairment before intervening or notifying the PHCP. This step takes seconds and immediately informs urgency. Administering the antibiotic (A) treats the underlying infection but does not address the acute respiratory deterioration. Incentive spirometry (C) is inappropriate during active respiratory distress. Preparing for a chest X-ray (D) is a dependent action that follows assessment and provider notification, not precedes them.
- Which instruction should the nurse reinforce?
Answer: Use a humidifier in your bedroom during the night.
A humidifier adds moisture to inspired air overnight, which directly addresses the goal of thinning secretions — making them less viscous and easier to mobilize. This is the most foundational teaching point for this specific goal because secretions must be adequately thinned before they can be effectively cleared. Choice B (deep breathing and coughing exercises) addresses expectoration — the mechanics of clearing secretions — but is less effective if the secretions remain thick; thinning comes first. Additionally, coughing every four hours is a reasonable preventive schedule but is not the primary intervention for thinning. Choice A (limiting fluids to 1 L/day) is directly contraindicated; adequate systemic hydration is essential for keeping pulmonary secretions thin. Choice C (cough suppressant at bedtime) is contraindicated for a productive cough; suppressing a productive cough causes secretion retention and increases the risk of infection.
- How should the nurse interpret this finding?
Answer: The system is functioning normally as the lung expands.
Tidaling — the rhythmic fluctuation of the water level in the water-seal chamber with each breath — is a normal and expected finding in a chest tube drainage system. It indicates the system is patent and the pleural space is communicating appropriately with the drainage unit. Importantly, cessation of tidaling is the concerning finding, as it may indicate either successful lung re-expansion (desired) or tube obstruction (undesired), requiring further assessment to differentiate. Obstruction (A) would stop tidaling, not cause it. An air leak (B) is identified by continuous bubbling in the water-seal chamber, not by tidaling. Suction pressure issues (D) are assessed in the suction control chamber, which is a separate component.
