Question 1 of 6
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Which term would the nurse document for a patient who states, “It’s hard for me to breathe, and I feel short-winded all the time”?
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- ApneaApnea is the absence of breathing. The patient would be unable to indicate they are having difficulty breathing if they were apneic.
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- DyspneaDyspnea is difficulty breathing, and the patient may not have obvious symptoms.
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- StridorStridor is an abnormal lung sound heard when there is an obstruction in the upper airway. Children often experience stridor when they have croup.
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- DysphagiaDysphagia is difficulty swallowing. Patients with pharyngitis may experience dysphagia caused by inflammation associated with the infection.
Question 2 of 6
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Which nursing intervention addresses the problem statement potential for infection for the patient with a chronic respiratory condition?
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- Monitor pulse oximetry levels after exercise.Monitoring pulse oximetry levels after exercise addresses the problem statement altered gas exchange. The potential for infection is managed by avoiding crowds, getting vaccinees, and frequent handwashing for example.
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- Use a progressive exercise program.Using a progressive exercise program addresses the problem statement of altered activity level. The potential for infection is managed by avoiding crowds, getting vaccinees, and frequent handwashing for example.
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- Use oxygen as prescribed.Using oxygen as prescribed addresses the problem statement of altered activity level due to dyspnea. Using oxygen can reduce dyspnea. The potential for infection is managed by avoiding crowds, getting vaccinees, and frequent handwashing for example.
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- Give influenza and Pneumovax vaccines.The potential for infection is managed by avoiding crowds, getting vaccinees, and frequent handwashing for example.
Question 3 of 6
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The nurse is caring for a patient with a chronic respiratory disorder. Which nursing goal is appropriate to include in the plan of care? Select all that apply. One, some, or all responses may be correct.
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- Preventing infectionPatients with a chronic respiratory disorder are at increased risk for infection. The nurse would apply the goal of preventing infection for the patient.
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- Promoting oxygenationPatients with chronic respiratory disorders may have difficulty maintaining oxygenation. The nurse would include a goal promoting oxygenation.
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- Promoting rehabilitationPatients with chronic respiratory disorders may have difficulty maintaining self care or have periods of disability. Promoting rehabilitation is an appropriate nursing care goal.
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- Preventing further lung damagePatients with chronic respiratory disorders may suffer from progressive lung damage. An appropriate nursing goal is to prevent further lung damage.
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- Promoting adventitious breath soundsPatients with chronic respiratory disorders demonstrate adventitious breath sounds caused by abnormalities. The nurse would not promote adventitious breath sounds as part of the nursing care plan. The care goals would be to minimize adventitious breath sounds.
Question 4 of 6
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Which nursing intervention would improve the appetite for a 70-year-old patient with bacterial pneumonia?
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- Have the patient cough and deep breathe before meals.Coughing and deep breathing between meals is helpful to encourage expectoration. Appetite is adversely affected by foul tasing sputum, so oral care is important to improve appetite.
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- Offer the patient 1200 calories for each meal.The older patient with bacterial pneumonia may need additional calories; however, offering more food does not address the foul taste created by the infection. Oral care prior to meals promotes appetite.
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- Provide oral care prior to meals and snacks.The patient with bacterial pneumonia will often have a foul taste in their mouth, leading to a decreased appetite. Performing oral care will assist the patient to improve their appetite.
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- Encourage the patient to take at least 3 liters of fluid daily.The patient with bacterial pneumonia needs additional fluid to promote liquifying and expectorating secretions. However, encouraging fluid intake does not promote appetite. Performing oral care before meals promotes appetite for the patient.
Question 5 of 6
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Which patient may ask for three pillows for propping to facilitate breathing while sleeping or resting?
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- The patient with unpredictable asthma attacksAsthma is a chronic condition that causes narrowed airways. The patient with unpredictable attacks will need medication to reverse or prevent the narrowing of airways. These patients do not prop with multiple pillows to facilitate breathing.
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- The patient with intermittent dyspneaThe patient with intermittent dyspnea may occasionally need to be more upright when sleeping or resting but typically need additional interventions.
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- The patient with chronic orthopneaThe patient with orthopnea routinely needs multiple pillows to prop up on to breathe and must elevate the head of the bed when sleeping.
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- The patient with recently diagnosed tuberculosisThe patient with recently diagnosed tuberculosis will need interventions to manage severe coughing such as antitussives rather than multiple pillows to prop while sleeping or resting.
Question 6 of 6
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Which nursing intervention is appropriate to maintain hydration for the patient with a respiratory condition?
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- Encourage 3 liters of fluid intake daily.Unless contraindicated, the patient would be encouraged to take in 3 liters daily through oral or parenteral routes.
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- Humidify the patient’s environment.Humidifying the environment moisturizes the nasal passages and decreases fluid lost when breathing, however, the reduction of fluid loss is minimal and taking in fluids is more important to maintain hydration due to other ways fluids are lost such as with fever.
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- Provide antitussive medication.Antitussive medication reduces the patient’s cough but does not address hydration. Encouraging fluid intake of 3 liters per day will improve and maintain hydration.
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- Give supplements such as Pulmocare.Providing a supplement such as Pulmocare provides high fat and calories in a small quantity to improve nutritional intake for the patient. Supplements do not address hydration needs. Instead, the patient would be encouraged to take in 3 liters of fluid daily.
