ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 31 Questions
Question 1 of 5
The nurse is caring for a patient with chronic bronchitis who has a nursing diagnosis of impaired breathing pattern related to anxiety. Which of the following nursing actions is best to include in the plan of care?
Correct Answer: D
Rationale: Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.
Question 2 of 5
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen through a Venturi mask. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or nonrebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.
Question 3 of 5
The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which medication should the nurse administer first?
Correct Answer: B
Rationale: Salbutamol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. It is known as an asthma rescue medication. The other medications work more slowly.
Question 4 of 5
The nurse is caring for a patient in the emergency department who is experiencing an acute asthma attack. After listening to the patient's breath sounds, which of the following should the nurse take next?
Correct Answer: D
Rationale: The examiner can assess the degree of severity by measuring FEV1 or PEFR, identifying the degree of change in objective measurements, and evaluating the baseline pulse oximetry value. The length of time the attack has persisted is not as important as determining the patient's status at present. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. Initiating IV therapy is not a priority at this time.
Question 5 of 5
Which of the following actions by a patient who has asthma indicates a good understanding of the nurse's teaching about peak flow meter use?
Correct Answer: C
Rationale: Readings in the yellow zone indicate a decrease in peak flow; the patient should use short-acting β-adrenergic (SAB
A) medications. The best of three peak flow readings should be recorded. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings.