Question

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Answer 1

Correct Answers:

Instruct the client to use pursed-lip breathing.

Rationale :

🔶Pursed-lip breathing is a cornerstone breathing technique for clients with chronic obstructive pulmonary disease (COPD).

🔶 It helps prolong exhalation, creating positive airway pressure that keeps the airways open longer and prevents alveolar collapse and air trapping, which are common in emphysema.

🔶This technique also helps reduce dyspnea and anxiety during exertion by improving ventilation efficiency.

🔶Clients are encouraged to inhale slowly through the nose and exhale through pursed lips, making it both a therapeutic and self-management strategy.

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Answer 2

Correct Answers:

"You may feel scared. Let's talk about what you are afraid of."

Rationale :

♥️ This response demonstrates the use of therapeutic communication by acknowledging the client’s emotional state without making assumptions or offering false reassurance.

♥️ It encourages the client to express her fears, which allows the nurse to provide emotional support and accurate information, enhancing trust.

♥️Reflecting feelings promotes psychological safety, especially for a client preparing for major surgery like a lobectomy.

♥️Unlike dismissive or minimizing statements, this approach is client-centered and promotes an open nurse-client relationship.

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Answer 3

Correct Answers:

Place in a prone position.

Rationale :

🔶 In clients with acute respiratory distress syndrome (ARDS), prone positioning is a key evidence-based intervention to improve oxygenation and ventilation-perfusion (V/Q) matching.

🔶It redistributes pulmonary blood flow and promotes alveolar recruitment, particularly in the posterior lungs, which are often collapsed due to fluid accumulation in ARDS.

🔶This positioning can significantly increase PaO₂ levels and reduce the need for high ventilator pressures.

🔶It is particularly used when conventional supine positioning does not maintain adequate oxygenation.

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Answer 4

Correct Answers:

Keep the drainage system below the level of the client's chest at all times.

Rationale :

📚A chest tube system relies on gravity-assisted drainage to remove air, blood, or fluid from the pleural space, thereby re-expanding the lung.

📚 Keeping the system below chest level prevents retrograde flow of contaminated drainage back into the chest cavity, which could lead to re-inflation of a pneumothorax or infection.

📚 This positioning maintains a one-way seal that is critical to patient safety.

📚 It is a non-negotiable part of chest tube transport and mobility protocol.

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Answer 5

Correct Answers:

"Use a bronchodilator I hour before eating."

Rationale :

✍️For clients with COPD, using a bronchodilator prior to meals helps open the airways, reduce dyspnea, and improve ventilation, making it easier to eat without becoming short of breath.

✍️COPD often leads to early satiety and fatigue during meals, so premedicating supports more adequate nutritional intake.

✍️Optimizing breathing beforehand allows for improved oxygenation during increased metabolic demand from eating.

✍️ This intervention supports nutritional status and energy balance, which are often compromised in COPD.

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Answer 6

Correct Answers:

Increased anteroposterior diameter of the chest

Rationale :

🔹Clients with COPD and emphysema commonly develop a barrel-shaped chest, which is reflected by an increased anteroposterior (AP) diameter.

🔹This change occurs over time due to chronic air trapping and lung hyperinflation, which alters chest wall structure.

🔹The AP diameter may approach or equal the transverse diameter in advanced stages of disease.

🔹This finding is a classic physical manifestation of emphysema and supports the diagnosis.

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Answer 7

Correct Answers:

Oral candidiasis

Rationale :

▩ Fluticasone is an inhaled corticosteroid, and one of its most common adverse effects is oropharyngeal candidiasis, or oral thrush.

▩ This occurs due to local immunosuppression of the oral mucosa, allowing fungal overgrowth.

▩ Clients should be taught to rinse their mouth thoroughly after inhalation to reduce this risk.

▩ White patches or soreness in the mouth should be reported promptly for antifungal treatment.

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Answer 8

Correct Answers:

Heparin

Rationale :

🍃In the event of a pulmonary embolism (PE), the priority pharmacologic intervention is anticoagulation, with heparin being the first-line agent.

🍃Heparin works by inhibiting thrombin and clot propagation, thereby reducing the risk of further embolization and allowing the body to naturally dissolve the clot.

🍃It is fast-acting and administered intravenously, making it ideal for acute management.

🍃 This treatment is followed by oral anticoagulants for long-term control.

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Answer 9

Correct Answers:

"Well discard his toothbrush and buy another:

Rationale :

✍️After treating streptococcal pharyngitis, it is essential to discard the child’s toothbrush to prevent re-exposure to group A Streptococcus bacteria.

✍️ Bacteria can survive on toothbrush bristles, posing a risk of reinfection.

✍️ This action reflects a good understanding of infection control and transmission prevention.

✍️ Replacing personal hygiene items like toothbrushes is a key part of post-illness care.

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Answer 10

Correct Answers:

Need for suctioning.

Rationale :

⪢ Following a total laryngectomy, the client will be unable to clear secretions through coughing due to removal of the vocal cords and altered airway anatomy.

⪢ The priority is ensuring a patent airway, and suctioning may be necessary to prevent airway obstruction from accumulating mucus.

⪢ Respiratory compromise is the most immediate postoperative risk in these clients.

⪢ Monitoring and intervening for ineffective airway clearance always takes precedence over pain, dressing, or IV integrity.

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RN ATI MedSurg Exam 1

No.

1 : A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

2 : A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

3 : A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

4 : A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

5 : A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

6 : A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

7 : A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

8 : A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

9 : A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

10 : A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the clients care?

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