MANAGEMENT OF CARDIAC DISORDERS

Review of Anatomy & Physiology of the Heart

SEATWORK: ANATOMY OF THE

HUMAN HEART
Illustrate and Label the structures of the heart
Using a diagram, trace the blood circulation of oxygenated and deoxygenated blood.
Illustrate and trace the conduction pathway of the heart
What are the events of a cardiac cycle? Explain each phase.
What is the Frank-Starling’s law of the heart. Explain.
HEART ANATOMY AND PHYSIOLOGY

HEART CIRCULATION

CORONARY ARTERIES
CONDUCTION SYSTEM

Cardiac Conduction System

is a series of pathways that conduct electrical impulses through the heart, stimulate
depolarization and resulting muscle contraction of the chambers in a specific
sequence, and initiate the pumping action of the heart.
Special Electrophysiologic Properties of Cardiac Cells
Automaticity- the ability to initiate an electrical impulse
Excitability- the ability of a cell to respond to a stimulus
Conductivity- the ability to transmit impulses from one cell to another.
The Components of the Cardiac Conduction System
Sinoatrial (SA): natural pacemaker;
concentration of cells responsible for initiating the conduction impulses in the healthy heart
located in right atrium at juncture with superior vena cave; rate 60 to 100 beats per minute (bpm)
Internodal pathways:
carry impulse from SA node to AV node through both right and the left atria: impulse initiates
process of depolarization in both atria;
depolarization results in myocardial contraction of both atria.
Atrioventricular (AV) node:
located at the base of the atrial septum; slows the impulse; allows atria to fully empty before
initiating depolarization when SA node is not functioning
can initiate an impulse at the rate of 40 to 60 beats per minute.
Bundle of His: short branch of conductive cells connecting the AV node to the bundle
branches at the intraventricular septum.
 Bundle branches: right (RBB) and left (LBB) split off on either side of intraventricular
septum carry impulse to purkinje fibers.
Purkinje fibers: diffuse network of conduction pathways are the terminal branches of
the conduction system conduct impulses rapidly throughout the ventricles
initiate rapid depolarization wave throughout the myocardium and resulting
ventricular contraction; when the SA and AV nodes fail can initiate impulses at
the rate 20 to 40 beats per minute.
CARDIAC ACTION POTENTIAL
DEPOLARIZATION – electrical activation of a cell caused by the influx of sodium into the
cell while potassium exits the cell.
REPOLARIZATION – return of the cell to the resting state caused by re-entry of potassium
into the cell while sodium exits.
REFRACTORY PERIODS:
A.EFFECTIVE REFRACTORY PERIOD: phase in which cells are incapable of depolarizing
B. RELATIVE REFRACTORY PERIOD: phase in which cells require a stronger than normal
stimulus to depolarize.

EVENTS OF A CARDIAC CYCLE

⮚ Blood flows from vena cava/pulmonary vain into ATRIA

⮚ Blood flows through AV valves INTO VENTRICLES (70%).
⮚ Contraction of closed ventricles increases pressure
⮚ Ventricular ejection phase – blood forced out
⮚ Semilunar valves open, blood goes to aorta and pulmonary trunk

⮚ ALSO CALLED ISOVOLUMENTRIC RELAXATION

⮚ Ventricles relax, ventricular pressure becomes LOW
⮚ Semilunar valves close, aorta and pulmonary trunk backflows
⮚ TOTAL CARDIAC CYCLE TIME = 0.8 seconds
⮚ Atrial systole (contraction) = 0.1 second
⮚ Ventricular systole (contraction) = 0.3 seconds
⮚ Quiescent period (relaxation) = 0.4 seconds
Cardiac Output (CO):
volume of blood in liters ejected by the heart each minute
indicator of pump function of the heart; normal adult CO is 4 to 8 L/min;
CO is measured directly by pulmonary artery (e.g., Swan-Ganz) in a critical care setting;
clinical indicators of decreased CO include signs of decreased tissue perfusion including change
in level of consciousness (early), cyanosis (late).
CARDIAC OUTPUT- BLOOD PUMPING
OF THE HEART: GENERAL CONCEPTS
STROKE VOLUME : the amount of blood ejected with each heartbeat
CARDIAC OUTPUT: amount of blood pumped by the ventricles in liters per minute
PRELOAD: degree of stretch of the cardiac muscle fibers at the end of diastole.
CONTRACTILITY: ability of the cardiac muscle to shorten in response to an electric impulse.
AFTERLOAD: the resistance to ejection of blood from the ventricle.

CARDIAC OUTPUT- BLOOD PUMPING

OF THE HEART: GENERAL CONCEPTS
CARDIAC OUTPUT- BLOOD PUMPING
OF THE HEART: VARIABLE CONCEPTS
CARDIAC OUTPUT: blood amount pumped per minute
CO (ml/min) = HR (beats/min) x SV (ml/beat)
Normal CO = 75 beats/min x 70 ml/beat = 5.25 L/min
 CARDIAC OUTPUT- BLOOD PUMPING
OF THE HEART: VARIABLE CONCEPTS

HEART RATE: cardiac cycles per minute

Normal range is 60-100 bpm
TACHYCARDIA is greater than 100 bpm
BRADYCARDIA is less than 60 bpm
Sympathetic system increases HR
Parasympathetic system decreases HR

CARDIAC OUTPUT- BLOOD PUMPING

OF THE HEART: BLOOD PRESSURE

Control is neural (central and peripheral) and hormonal

Baroreceptors in the carotid and aorta
Hormones – ADH, aldosterone, epinephrine can increase blood pressure

REGULATION OF STROKE VOLUME (SV)

END DIASTOLIC VOLUME (EDV) total collected in ventricle at the end of diastole;
determined by length of diastole and venous pressure (-120ml)
END SYSTOLIC VOLUME (ESV) – Blood left over in ventricle at the end of contraction (not
pumped out); determined by force of ventricle contraction and arterial blood pressure (-50
ml)

REGULATION OF STROKE VOLUME (SV)

STROKE VOLUME (ml/beat) = EDV (ml/beat) – ESV (ml/beat)

Normal SV = 120 ml/beat – 50 ml/beat = 70 ml/beat
MEAN ARTERIAL PRESSURE
Defined as the average arterial pressure during a single cardiac cycle.
As blood is pumped out of left ventricle into the arteries, pressure is generated. It is considered
as the PERFUSION PRESSURE seen by organs in the body.
MAP that is >60 mmHg is enough to sustain the organs of the average person
MAP that is < 60 mmHg, then the organs are not being adequately perfused and they will
become ISCHEMIC

MEAN ARTERIAL PRESSURE

EJECTION FRACTION
 EJECTION FRACTION
FRANK-STARLING’S LAW OF THE HEART
Critical factor for stroke volume is “degree of stretch of cardiac muscle cells.”
The more the heart fills, the stronger the force of contraction; The more stretch, the more
contraction force
Increased EDV = more contraction force
Slow heart rate = more time to fill
Exercise = more venous blood return
 FRANK-STARLING’S LAW OF THE HEART

REGULATION OF HEART RATE

1. AUTONOMIC REGULATION OF HEART RATE
SYMPATHETIC NERVOUS SYSTEM – norepinephrine increases heart rate
(maintains stroke volume which leads to increased cardiac output)
PARASYMPATHETIC – acetylcholine (Ach) decreases heart rate
VAGAL TONE –parasympathetic inhibition of inherent rate of SA node, allowing
normal HR.
BARORECEPTROS/PRESSORECEPTORS – monitor changes in blood pressure and
allow reflex activity with the ANS
REGULATION OF HEART RATE
2. HORMONAL AND CHEMICAL REGULATION OF THE HEART
EPINEPHRINE – hormone released by adrenal medulla during stress, increases heart
rate
THYROXINE – hormone released by thyroid, increases heart rate in large quantities,
amplifies effect of epiephrine
CA++, K+, NA+ - very important
Hyperkalemia – KCl as lethal injection
Hypokalemia – arrhythmias
Hypocalcemia – depresses heart function
Hypercalcemia – increases contraction phase
REGULATION OF HEART RATE
2. HORMONAL AND CHEMICAL REGULATION OF THE HEART
Hypernatremia – block Na+ transport and muscle contraction
3. Other factors affecting heart rate (HR)
*** EXERCISE – lowers resting heart rate (40-60)
HEAT – increases heart rate significantly
 COLD – decreases heart rate significantly

CARDIAC DIAGNOSTICS

Cardiac enzymes
◦CK-MB (creatine kinase, myocardial muscle)
◦Lactate dehydrogenase (LDH)
◦Troponin

CK-MB

 An elevation in value indicates myocardial damage.

 An elevation occurs within hours and peaks at 18 hours following an acute ischemic attack.

 Normal value is 0% to 5% of total; total CK is 26 to 174 units/L.

Lactate dehydrogenase (LDH)

◦ Elevations in LDH levels occur 24 hours following myocardial infarction and peak in 48 to 72 hours.

◦ bNormally, LDH1 is lower than LDH2; when the serum concentration of LDH1 is higher than LDH2, the
pattern is indicated as “flipped,” signifying myocardial necrosis.

◦ The normal value of LDH in conventional units is 140 to 280 international units/L.

Troponin

◦Troponin is composed of three proteins—troponin C, cardiac troponin I, and cardiac troponin T.

◦Troponin I especially has a high affinity for myocardial injury; it rises within 3 hours and persists for up
to 7 to 10 days.

◦ Normal values are low, with troponin I being lower than 0.6 ng/mL and troponin T normally ranging
from 0 to 0.2 ng/mL; thus, any rise can indicate myocardial cell damage.

Myoglobin

◦Myoglobin is an oxygen-binding protein found in cardiac and skeletal muscle.

◦The level rises within 2 hours after cell death, with a rapid decline in the level after 7 hours.

Complete blood count

 The RBC count decreases in RHD and infective endocarditis and increases in conditions
characterized by inadequate tissue oxygenation.

 The WBC count increases in infectious and inflammatory diseases of the heart and after MI
because large numbers are needed to dispose of the necrotic tissue resulting from the
infarction.

 An elevated Hct can result from vascular volume depletion.

 Decreases in Hb and Hct can indicate anemia

Blood coagulation factors

◦An increase in coagulation factors can occur during and after MI, which places the client at greater risk
for thrombophlebitis and extension of clots in the coronary arteries

Serum lipids

◦The lipid profile measures serum cholesterol, triglyceride, and lipoprotein levels.
◦The lipid profile is used to assess the risk of developing CAD.

◦The desirable range for serum cholesterol is lower than 200 mg/dL, with low-density lipoprotein
cholesterol lower than 130 mg/dL and high-density lipoprotein cholesterol at 30 to 70

mg/dL.

◦Lipoprotein-a or Lp(a), a modified form of LDL, increases atherosclerotic plaques and increases clots;
value should be less than 30 mg/dL

Highly sensitive C- reactive protein (hsCRP)

◦ Detects an inflammatory process such as that associated with the development of atherothrombosis; a
level less than 1 mg/dL is considered low risk and a level over 3 mg/dL places the client at high risk for
heart disease.

Electrolytes

 POTASSIUM
 SODIUM
 CALCIUM

Potassium

◦Hypokalemia causes increased cardiac electrical instability, ventricular dysrhythmias, and increased risk

of digoxin toxicity.

◦flattening and inversion of the T wave, the appearance of a U wave, and ST depression

◦Hyperkalemia causes asystole and ventricular dysrhythmias.

◦tall peaked T waves, widened QRS complexes, prolonged PR intervals, or flat P waves

Sodium

 The serum sodium level decreases with the use of diuretics.

 The serum sodium level decreases in heart failure, indicating water excess.
Calcium

◦ Hypocalcemia:

◦ ventricular dysrhythmias

◦ prolonged ST and QT intervals

◦ cardiac arrest

◦ Hypercalcemia:

◦ shortened ST segment and widened T wave

◦ atrioventricular block

◦ tachycardia or bradycardia

◦ digitalis hypersensitivity

◦ cardiac arrest

Other Blood Tests

◦ BUN: elevated in heart disorders that adversely affect renal circulation, such as heart failure and
cardiogenic shock

◦ Blood glucose: An acute cardiac episode can elevate the blood glucose level.

◦ B-type natriuretic peptide (BNP): released in response to atrial and ventricular stretch; it serves as a
marker for CHF

◦ BNP levels should be lower than 100 pg/mL; the higher the level, the more severe the CHF

Chest X-ray

◦to determine the size, silhouette, and position of the heart

◦Specific pathological changes are difficult to determine on x-rays, but anatomical changes can be seen.

◦Nursing Actions:

◦ Prepare the client for radiography, explaining the purpose and procedure.

◦ Remove jewelry.

◦Ensure that the client is not pregnant.

Electrocardiography

◦records the electrical activity of the heart and is useful for detecting cardiac dysrhythmias, location and
extent of MI, and cardiac hypertrophy and for evaluation of the effectiveness of cardiac medications

◦Nursing Actions:

◦ Determine the client’s ability to lie still; advise the client to lie still, breathe normally, and refrain from
talking during the test.

◦ Reassure the client that an electrical shock will not occur.

◦ Document any cardiac medications the client is taking.

ECG BASICS

Holter Monitoring

◦ client wears a Holter monitor and an ECG tracing is recorded continuously over a period of 24 hours or
more while the client performs his or her ADL

◦ identifies dysrhythmias if they occur and evaluates the effectiveness of antidysrhythmics or pacemaker
therapy

◦Nursing actions:

◦Instruct the client to resume normal daily activities and to maintain a diary documenting activities and
any symptoms that may develop for correlation with the electrocardiographic tracing.

◦Instruct the client to avoid tub baths or showers because they will interfere with the
electrocardiographic recorder.

Echocardiography

◦ noninvasive procedure is based on the principles of ultrasound and evaluates structural and functional
changes in the heart

◦ Heart chamber size is measured, ejection fraction is calculated, and flow gradient across the valves is

determined.
◦ Transesophageal echocardiography may be performed in which the echocardiogram is done through
the esophagus; this is an invasive exam and requires pre- and postprocedure preparation and care
similar to endoscopy procedures.

Stress Test

◦ noninvasive test, studies the heart during activity and detects and evaluates CAD

◦ Treadmill testing most commonly used mode

◦ may be used with myocardial radionuclide testing (perfusion imaging), at which point the procedure
becomes invasive because a radionuclide must be injected

◦IV infusion of dipyridamole (Persantine), dobutamine hydrochloride, or adenosine (Adenocard) is given

to dilate the coronary arteries and simulate the effect of exercise

◦An informed consent is required if a radionuclide is injected.

Pre-procedure

 Consent Obtain an informed consent if required.

 Rest Provide adequate rest the night before the procedure.
 Meal Instruct the client to eat a light meal 1 to 2 hours before the procedure.
 Stimulants Instruct the client to avoid smoking, alcohol, and caffeine before the procedure.
 Medications Withhold theophylline (12 hours); CCB and b-blockers (24 hours)

Other Pre -procedure Interventions

 Instruct the client to wear nonconstrictive, comfortable clothing and supportive rubbersoled
 shoes for the exercise stress test.
 Instruct the client to notify the physician if any chest pain, dizziness, or shortness of breath
occurs during the procedure

Post-procedure Interventions

◦Instruct the client to avoid taking a hot bath or shower for at least 1 to 2 hours.
Cardiac catheterization

◦An invasive test involving insertion of a catheter into the heart and surrounding vessels

◦Obtains information about the structure and performance of the heart chambers and valves and the
coronary circulation

Pre-procedure

Consent Secure informed consent.

NPO

Withhold solid food for 6 to 8 hours and liquids for 4 hours as prescribed to prevent vomiting and
aspiration during the procedure.

Allergies

Assess for allergies to seafood, iodine, or radiopaque dyes; if allergic, the client may be premedicated
with antihistamines and corticosteroids to prevent a reaction.

Measurements

Document the client’s height and weight because these data will be needed to determine the amount of
dye to be administered.

Baseline

Document baseline vital signs and note the quality and presence of peripheral pulses for postprocedure
comparison.

Lidocaine

Inform the client that a local anesthetic will be administered before catheter insertion.

Lay still

Inform the client that he or she may feel fatigued because of the need to lie still and quiet on a hard
table for up
Sensations

Inform the client that he or she may feel a fluttery feeling as the catheter passes through the

heart, a flushed, warm feeling when the dye is injected, a desire to cough, and palpitations

caused by heart irritability.

Insertion

Prepare the insertion site by shaving and cleaning with an antiseptic solution if prescribed.

Sedatives

Administer pre-procedure medications such as sedatives if prescribed.

IV line

Insert an IV line if prescribed.

Close monitoring

Monitor VS and cardiac rhythm for dysrhythmias at least q 30 mins x 2 h initially.

Complications

Assess for chest pain and, if dysrhythmias or chest pain occurs, notify the physician.

Complications

Monitor peripheral pulses and the color, warmth, and sensation of the extremity distal to the insertion
site at least q 30 mins x 2 h initially.

Notify

Notify the physician if the client complains of numbness and tingling, if the extremity becomes cool,
pale, or cyanotic, or if loss of the peripheral pulses occurs.

Bleeding
Monitor the pressure dressing for bleeding or hematoma formation.

Pressure

Apply a sandbag or compression device (if prescribed) to the insertion site to provide additional
pressure if required.

Complications

Keep extremity extended for 4 to 6 hours, as prescribed, keeping the leg straight to prevent arterial
occlusion.

CBR x 6 to 12 h, as prescribed; however, the client may turn from side to side.

◦ If the antecubital vessel was used, immobilize the arm with an armboard or sling.

◦ Encourage fluid intake, if not contraindicated, to promote renal excretion of the dye and to replace
fluid loss caused by the osmotic diuretic effect of the dye.

◦ Monitor for N/V, rash, or other signs of hypersensitivity to the dye.

Cardiac Dysrhythmias

Cardiac Dysrhythmias
⮚ These are disturbances in regular heart rate and/or rhythm due to change in electrical
conduction or automaticity.
⮚ Maybe detected by change in pulse, abnormality on auscultation of heart rate, or
ECG abnormality.
⮚ Continuous cardiac monitoring is indicated for potentially life-threatening
dysrhythmias.
Causes of Cardiac Dysrhythmias
• Disturbance of Automaticity.
❑ This may involve a speeding up or slowing down of areas of automaticity
such as sinus node, the atrioventricular node, or the myocardium.
❑ Abnormal beats may arise through this mechanism from the atria, the AV
junction, or the ventricles.
• Disturbance in Conduction
❑ Conduction may be either too rapid or too slow. The mechanism of
reentry depends on the presence of slowed conduction.
• Combinations of Altered Automaticity and Conduction.
❑ A simple example would be a premature atrial contraction with first-
degree AV block or atrial tachycardia.
Bioelectrical Conduction System
Systematic Evaluation of Cardiac Rhythm
Rate
Equals how fast the heart is depolarizing. The atria and ventricles depolarize at the same
time, but each can depolarize at a different rate.
Normal: 60 – 100/min
Bradycardia: <60/min
Tachycardia: >100/min
Rhythm
Rhythmicity refers to the regularity of the heart beats.
P waves used to establish ATRIAL RHYTHMICITY
R waves used to establish VENTRICUALR RHYTHMICITY

P waves
Represents the impulse initiated in the SA node and the spread through the atria.
An indication of ATRIAL DEPOLARIZATION
P waves
A change in the form of the P wave can indicate that the impulse did not come from the
SA node, but rather from an abnormal pace making site, such as the atria or AV
node.
Amplitude of <3mm, duration of 0.06 – 0.11 sec
PR interval
It measures the time it takes for the impulse to depolarize the atria, travel to the AV node,
and then dwell there briefly before entering the bundle of His.
Changes in conduction through the AV node are the most common cause of changes in
PR interval.
PR interval
Measured from the beginning of P wave to ventricular (QRS) complex
Normal: 0.12- 0.20 sec
Significance: can show evidence of non-SA node generated impulse or impulse delay
Q Wave
First negative deflection on the strip; may not be seen in all leads
Represent septal depolarization and normally lasts 0.03 sec or less
QRS complex
A set of three distinct waveforms that are indicative of VENTRICULAR
DEPOLARIZATION
Represents the time necessary for the impulse to spread through the bundle of his and its
branches to right and left ventricles
Measured from beginning of QRS to end of QRS
QRS complex
A set of three distinct waveforms that are indicative of VENTRICULAR
DEPOLARIZATION
If there is a delay or interruption in conduction in either bundle branch, the QRS will
widen in a manner typical for either right or left bundle branch.
 If the depolarization occurs below the bundle branches, the QRS complex will be
widened and notched or slurred because a different sequence of conduction will
ensue.
Normal: 0.06 – 0.12 sec
Significance: important indicator of ventricular myocardial cell activity.
QT interval
Time it takes for impulse to spread through ventricles and for repolarization to occur
Measured from beginning of QRS to end of t wave
Normal QT intervals are based on heart rate: the slower the heart rate, the longer the
normal QT; the faster the heart rate, the shorter the normal QT.
QT interval
Normal 0.32 – 0.44 sec
Significance: indicator of the time the heart needs for the depolarization-repolarization
cycle. An abnormal duration may indicate myocardial problem.
ST segment
Connects the QRS complex to the T wave.
Usually isoelectric or flat.
Elevation suggests infarction or injury; depression suggests ischemia or effect of
medication.

T wave
Represents VENTRICULAR REPOLARIZATION
Changes in amplitude can indicate electrical disturbances resulting from electrolyte
imbalance or myocardial infarction.
Significance: a critical relative refractory period during which myocardial cells are
vulnerable to extra stimuli.
T wave
Represents VENTRICULAR REPOLARIZATION
Changes in amplitude can indicate electrical disturbances resulting from electrolyte
imbalance or myocardial infarction.
Significance: a critical relative refractory period during which myocardial cells are
vulnerable to extra stimuli.
U wave
Seen in Hypokalemia and MI
Sometimes a normal finding; therefore a diagnosis of pathology should be dependent on
more specific indications.
Uncertain, but may be due to repolarization of the Purkinje system.
Remember the following points when monitoring patients
❑ A prominent P wave should be displayed if organized atrial activity is present.
Leads that show the P wave clearly should be chosen.
❑ The QRS amplitude should be sufficient to properly trigger the rate meter.
❑ The patient’s precordium must be taken exposed so that defibrillation paddles can be
readily used if necessary.
❑ Monitoring is for rhythm interpretation only. One should not try to read ST
abnormalities or attempt more elaborate ECG interpretation.
 ❑ Artifacts should be noted: a straight line will show if the electrodes is loose, or a
bizarre, wavy baseline resembling ventricular fibrillation may appear if an electrode
is loose or the patient moves.

Normal Sinus Rhythm

The most important rhythm, without a thorough understanding of what is normal,

abnormal cannot be understood.
Upright, small rounded P waves are present in lead II
P waves precede each QRS complex
Both the atrial rate ad the ventricular rate are the same
Rhythm is essentially regular
PR interval : lasts 0.12 – 0.20 seconds
QRS complex: lasts 0.12 seconds or less
Clinical significance: signifies a functioning SA node conduction system; signifies a
normal functioning electrical system.

Seatwork:

1. Illustrate the normal ECG pattern.

2. Identify the placement of chest and limb leads in ECG.

MANAGEMENT OF CARDIAC DISORDERS

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS

RISK FACTORS
▪ NON-MODIFIABLE – age, gender, race, heredity
▪ MODIFIABLE – stress, diet, exercise, sedentary lifestyle, smoking, alcohol, hypertension,
hyperlipidemia, DM, obesity, type A personality, contraceptive pills

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS

COMMON CLINICAL MANIFESTATIONS:
▪ DYSPNEA
▪ Exertional
▪ Orthopneal
▪ paroxysmal nocturnal dyspnea
▪ Cheyne-stokes

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS

COMMON CLINICAL MANIFESTATIONS:
▪ CHEST PAIN
 ▪ Pressure, fullness, burning tightness
▪ Knife-like/stabbing
▪ Crushing or searing chest pain
▪ Radiating to back, neck, jaw, shoulders, one or both arms

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS

COMMON CLINICAL MANIFESTATIONS:
▪ EDEMA
▪ Ascites
▪ Hydrothorax
▪ Anasarca
▪ Bilateral pedal edema

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS

Assessment of CLIENTS WITH CARDIOVASCULAR DISORDERS
COMMON CLINICAL MANIFESTATIONS:
▪ PALPITATIONS
▪ HEMOPTYSIS
▪ FATIGUE
▪ SYNCOPE AND FAINTING
▪ CYANOSIS
▪ ABDOMINAL PAIN
▪ CLUBBING OF FINGERS
▪ JAUNDICE

ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
▪ PHYSICAL EXAMINATION
ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
▪ PHYSICAL EXAMINATION
ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
▪ AUSCULTATION
S1 – due to closure of the AV (mitral/tricuspid) valves
▪ Timing: beginning of the systole
▪ Loudest at the apex
S2 – due to closure of the semilunar (pulmonic/aortic) valves
▪ Timing: diastole
▪ Loudest at the base
S3 – Ventricular Diastolic Gallop – vibration resulting from resistance to rapid ventricular
filling secondary to poor compliance
▪ Timing – early diastole
▪ Location – apex (LV) or LLSB (RV) PITCH: faint and low pitch
 ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
▪ AUSCULTATION
▪ S4 – ATRIAL Diastolic Gallop – vibration resulting from resistance to late ventricular
filling during atrial asystole
▪ Timing – late diastole (before S1)
▪ Location – apex (LV) or LLSB (RV) PITCH: low (use bell)
▪ HEART MURMURS – sounds other than the typical “lub-dub”; typically caused by
disruption in flow
▪ INCOMPETENT VALVE – swishing sound just after the normal lub-dub; valve
does not completely close, some regurgitations of blood
▪ STENOTIC VALVE – high pitch swishing sound when blood should be flowing
through valve, narrowing of outlet in the open state

ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
HEART MURMURS
ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
▪ AUSCULTATION
▪ PERICARDIAL FRICTION RUB
▪ It is an extra heart sound originating from the pericardial sac
▪ Mechanism: originates from the pericardial sac as it moves
▪ Timing: with each heartbeat
▪ Location: over pericardium; upright position, leaning forward
▪ Pitch: high pitch and scratchy. Sound like sandpaper being rubbed together
▪ Significance: inflammation, infection, infiltration

ASSESSMENT:
COMMON CLINICAL MANIFESTATIONS:
PERICARDIAL FRICTION RUB
ASSESSMENT:
CLASSIFICATIONS OF CLIENTS WITH DISEASES OF THE HEART (FUNCTIONAL
CAPACITY)
⮚ CLASS I – patients with cardiac disease but without resulting limitations of physical
activity
⮚ CLASS II – patients with cardiac disease resulting to slight limitation of physical activity
⮚ CLASS III – patients with cardiac disease resulting in marked limitation of physical
activity. They are comfortable at rest.
⮚ CLASS IV – patients with cardiac disease resulting in inability to carry on any physical
activity without discomfort
 FUNCTIONAL CAPACITY
DIAGNOSTIC ASSESSMENT
• BLOOD STUDIES
⮚ RBC count – women – 4.2-5.4M/mm3; men – 4.7-6.1M/mm3
⮚ HEMOGLOBIN – women -12-16g/dl; men – 13-18 g/dl
⮚ HEMATOCRIT – women 36-42 %; men – 42-48%
⮚ RBC INDICES – MCV (mean corpuscular volume); MCH (mean corpuscular
hemoglobin); MCHC (mean corpuscular hemoglobin concentration)
⮚ PLATELET COUNT

DIAGNOSTIC ASSESSMENT
• BLOOD STUDIES
⮚ WBC count / differential count – 5000-10000/mm3
⮚ GRANULOCYTES:
⮚ NEUTROPHILS – 55-70%
⮚ EOSINOPHILS – 1-4%
⮚ BASOPHILS – 0.5-1.0%
⮚ AGRANULOCYTES:
⮚ LYMPHOCYTES – 20-40%
⮚ MONOCYTES – 2-8%
PLATELETS – 150000-450000/mm3

DIAGNOSTIC ASSESSMENT
B. COAGULATION SCREENING TEST
⮚ BLEEDING TIME – measures the ability to stop bleeding after small puncture wound.
⮚ NORMAL VALUE – 2.75-8 mins
⮚ PARTIAL THROMBOPLASTIN TIME - used to identify deficiency of coagulation
factors, prothrombin and fibrinogen; monitors heparin therapy.
⮚ NORMAL VALUE – 60-70 Seconds
⮚ PROTHROMBIN TIME – determines activity and interaction of the PT group clotting
factors; used to determine dosages of oral anti-coagulant
⮚ NORMAL VALUE – 12-14 seconds

DIAGNOSTIC ASSESSMENT
C. ERYTHROCYTE SEDIMENTATION RATE (ESR)
⮚ -it is a measurement of the rate at which RBCs settle out of anticoagulated blood in an hour
⮚ It is elevated in infectious heart disorders or myocardial infarction
⮚ Non specific inflammatory test
⮚ NORMAL VALUES: men: 15-20 mm/hr; women: 20-30 mm/hr
 DIAGNOSTIC ASSESSMENT
D. CARDIAC PROTEINS AND ENZYMES
• CK-MB (creatine-kinase)
Most cardiac specific enzymes
Accurate indicator of myocardial damage
Elevates in MI within 4 hours, peaks in 18 hours and then declines until 3 days
Normal value: 0-7 U/L or males 50-35 mu/ml; females 50-250 mu/ml

DIAGNOSTIC ASSESSMENT
D. CARDIAC PROTEINS AND ENZYMES
2. Lactic Dehydrogenase (LDH)
⮚ An established marker for the late diagnosis of myocardial infarction
⮚ Elevates in MI in 24 hours, peaks in 48-72 hours returns to normal in 10-14 days.
⮚ Normal value is 70-200 IU/L (100-225 mu/ml)

DIAGNOSTIC ASSESSMENT
D. CARDIAC PROTEINS AND ENZYMES
3. Myoglobin
⮚ Rises within 1-3 hours
⮚ Peaks in 4-12 hours
⮚ Returns to normal in a day
⮚ Not used alone as a cardiac marker
⮚ Muscular and renal disease can also have elevated myoglobin
⮚ NORMAL VALUE: 0-85 ng/ml

DIAGNOSTIC ASSESSMENT
D. CARDIAC PROTEINS AND ENZYMES
4. TROPONIN I and T
⮚ I is usually utilized for MI
⮚ Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks.
⮚ Early and late diagnosis can be made with troponin; NO IM injections before blood
sample!
⮚ Normal value TROP I - <0.6 ng/ml
TROP T –<0.4 ng/ml

DIAGNOSTIC ASSESSMENT
D. CARDIAC PROTEINS AND ENZYMES
4. SERUM LIPIDS
 ⮚ Lipid profile measures SERUM CHOLESTEROL, TRIGLYCERIDES and
LIPOPROTEIN LEVELS
⮚ Cholesterol = 200 mg/dl
⮚ TRIGLYCERIDES = 40-150 mg/dl
⮚ LDL = 130 mg/dl
⮚ HDL = 30-70 mg/dl
⮚ NPO post midnight (usually 12 hours)

NON INVASIVE PROCEUDRES

A. CARDIAC MONITORING/ ELECTROCARDIOGRAPHY

NON INVASIVE PROCEUDRES

B. HOLTER MONITORING
⮚ A non invasive test in which the client wears a Holter monitor and an ECG tracing
recorded continuously over a period of 24 hours
⮚ Instruct the client to resume normal activities and maintain a diary of activities and any
symptoms that may develop

HOLTER MONITOR

NON INVASIVE PROCEUDRES

C. CARDIAC STRESS TEST
⮚ Non invasive test that studies the heart during activity and detects and evaluates CAD
⮚ Exercise test, pharmacologic test and emotional tests
⮚ TREADMILL testing is the most commonly used
⮚ Used to determine CAD, chest pain causes drug effects and dysrhythmias in exercise

NON INVASIVE PROCEUDRES

C. CARDIAC STRESS TEST
⮚ PRE-TEST:
⮚ Consent may be required, adequate rest, eat a light meal or fast for 4 hours and avoid
smoking, alcohol and caffeine

NON INVASIVE PROCEUDRES

C. CARDIAC STRESS TEST
⮚ DURING TEST
⮚ Secure electrodes to appropriate location on chest, obtain baseline BP and ECG tracing,
instruct client to exercise as instructed and report any pain, weakness and SOB, monitor BP
and ECG continuously.
 NON INVASIVE PROCEUDRES
C. CARDIAC STRESS TEST
⮚ POST TEST
⮚ Instruct client to notify the physician if any chest pain, dizziness or shortness of breath
occurs.
⮚ Instruct the client to avoid taking a hot shower for 10-12 hours after test

NON INVASIVE PROCEUDRES

D. PHARMACOLOGIC STRESS TEST
⮚ USE OF DIPYRIDAMOLE
⮚ Maximally dilates coronary artery
⮚ Side effect: flushing of face
⮚ PRE-TEST: 4 hours fasting, avoid alcohol, caffeine
⮚ POST TEST: report symptoms of chest pain

NON INVASIVE PROCEUDRES

E. ECHOCARDIOGRAM
⮚ Non invasive test that studies the structural and functional changes of the heart with the use
of ultrasound.
⮚ CLIENT PREP: instruct the patient to remail still during the test, secure electrodes for
simultaneous ECG tracing, explain that there will be no pain or electrical shock; lubricant
is placed on the skin which will be cool.

NON INVASIVE PROCEUDRES

E. PHONOCARDIOGRAM
⮚ A graphic recording of heart sound with simultaneous ECG
⮚ A plot of high fidelity recording of the sounds and murmurs made by the heart
⮚ Provides a recording of all the sounds made by the heart during a cardiac cycle.

INVASIVE PROCEUDRES
A. CARDIAC CATHETERIZATION (CORONARY
ANGIOGRAPHY/ARTERIOGRAPHY)
⮚ Insertion of a catheter into the heart and surrounding vessels
⮚ Is an invasive procedure during which physician INJECTS a dye into the coronary arteries
and immediately takes a series of x-ray films to assess the structures of the arteries.
⮚ Determines the structure and performance of the heart valves and surrounding vessels.
⮚ Used to diagnose CAD, assess coronary artery patency and determines extent of
atherosclerosis

INVASIVE PROCEUDRES

INVASIVE PROCEUDRES

INVASIVE PROCEUDRES
A. CARDIAC CATHETERIZATION (CORONARY ANGIOGRAPHY/ARTE-
RIOGRAPHY)
⮚ PRE-TEST: fasting for hours; check for allergies (iodine, seafood); provide medications to
allay anxiety
⮚ INTRA-TEST: inform patient of a fluttery feeling as the catheter passes through the heart;
inform the patient that a feeling of warmth and metallic taste may occur when the dye is
administered.
⮚ POST-TEST: monitor VS and cardiac rhythm.
⮚ Monitor peripheral pulses, color and warmth and sensation of extremity distal to the
insertion site.
⮚ Maintain sandbag to the insertion site if required to maintain pressure.
⮚ Monitor for bleeding and hematoma formation

INVASIVE PROCEUDRES
B. NUCLEAR CARDIOLOGY
⮚ Are safe methods of evaluating left ventricular muscle function and coronary artery blood
distribution.
⮚ CLIENT PREPARATION: obtain written consent, explain procedure, instruct client that
fasting may be required for a short period before exam, assess for iodine allergy.
⮚ POST PROCEDURE: encourage client to drink fluids to facilitate the excretion of contrast
material, assess venipuncture site for bleeding or hematoma

INVASIVE PROCEUDRES
B. NUCLEAR CARDIOLOGY

INVASIVE PROCEUDRES
B. TYPES OF NUCLEAR CARDIOLOGY
⮚ MULTIGATED ACQUISITION (MUGA) or Cardiac Blood Pool Scan
⮚ Provides information on wall motion during systole and diastole, cardiac valves, and
ejection fraction

INVASIVE PROCEUDRES
B. TYPES OF NUCLEAR CARDIOLOGY
SINGLE PHOTON EMISSION COMPUTED
TOMOGRAPHY (SPECT)
⮚ Used to evaluate the myocardium at risk of infarction and to determine infarction size

INVASIVE PROCEUDRES
B. TYPES OF NUCLEAR CARDIOLOGY
POSITRON EMISSION TOMOGRAPHY (PET) Scanning
⮚ Uses two isotopes to distinguish viable and nonviable myocardial tissue

INVASIVE PROCEUDRES
B. TYPES OF NUCLEAR CARDIOLOGY
PERFUSION IMAGING WITH EXERCISE TESTING
⮚ Determines whether the coronary blood flow changes with increased activity
⮚ Used to diagnose CAD, determine the prognosis in already diagnosed CAD, assesses the
physiologic significance of a known coronary lesion, and assess the effectiveness of
various therapeutic modalities such as coronary artery bypass surgery, percutaneous
coronary intervention, or thrombolytic therapy.

INVASIVE PROCEUDRES
B. TYPES OF NUCLEAR CARDIOLOGY
PERFUSION IMAGING WITH EXERCISE TESTING

HEMODYNAMICS MONITORING
A. CENTRAL VENOUS PRESSURE
⮚ Reflects the pressure of the blood in the right atrium
⮚ Engorgement is estimated by the venous column that can be observed as it rises from an
imagined angle at the point of manubrium (angle of Louis)
⮚ With normal physiologic condition, the jugular venous column rises no higher than 2-3 cm
above the clavicle with the client in a sitting position at 45 degree angle.

HEMODYNAMICS MONITORING
A. CENTRAL VENOUS PRESSURE
⮚ Measurement of:
⮚ Cardiac efficiency
⮚ Blood volume
⮚ Peripheral resistance

⮚ RIGHT VENTRICULAR PRESSURE – a catheter is passed from a cutdown in the

antecubital, subclavian jugular or basilica vein to the right atrium and attached to a
prescribed manomenter or transducer

HEMODYNAMICS MONITORING
A. CENTRAL VENOUS PRESSURE
⮚ NORMAL VALUE – 2-8 cm H20 or 2-6 mmHg

⮚ DECREASE indicates decreased circulating volume; INCREASE indicates increase blood

volume or right sided heart failure

HEMODYNAMICS MONITORING
A. CENTRAL VENOUS PRESSURE
To Measure: patient should be flat with zero point of
manometer at the same level of the RA which corresponds to the mid-axillary line of the
patient or
approx. 5 cm below the sternum.
 Fluctuations follow patients respiratory function and will
fall on inspiration and rise on expiration due to changes
in intrapulmonary pressure.
Reading should be obtained
at the highest point of fluctuation.

HEMODYNAMICS MONITORING
B. PULMONARY ARTERY PRESSURE (PAP)
⮚ Appropriate for critically ill clients requiring more accurate assessments of the left
heart pressure
⮚ SWAN-GANZ CATHETER/PULMONARY ARTERY CATHETER is used
⮚ CLIENT PREPARATION:
⮚ Consent, insertion under sterile technique, at bedside, sterile drapes may cover face, assist
client flat or slight T position as tolerated
HEMODYNAMICS MONITORING
B. PULMONARY ARTERY PRESSURE (PAP)
CARDIAC DISORDERS:
CORONARY ARTERY DISEASE

CORONARY ARTERY DISEASE

Results from the focal narrowing of the large and medium sized coronary arteries due to the
deposition of atheromatous plaque in the vessel wall.
CORONARY ARTERY DISEASE
PREDISPOSING FACTORS
CORONARY ARTERY DISEASE
CORONARY ARTERY DISEASE
SEX: Male
RACE: Africans, African Americans, Pacific Islanders
Smoking
Obesity
Hyperlipidemia
Sedentary lifestyle
Diabetes Mellitus
Hypothyroidism
Diet: increased saturated fats
Type A personality
CORONARY ARTERY DISEASE
Chest pain
Dyspnea
Tachycardia
Palpitations
Diaphoresis
CORONARY ARTERY DISEASE
Percutaneous Transluminal Coronary Angioplasty and Intravascular Stenting (PTCA)
Mechanical dilation of the coronary vessel wall by compressing the atheromatous plaque.
It is recommended for clients with single vessel coronary artery disease
CORONARY ARTERY DISEASE
Prosthetic intravascular cylindric stent maintain good luminal geometry after balloon deflation
and withdrawal.
Intravascular stenting is done to prevent restenosis after PTCA
CORONARY ARTERY BY PASS GRAFT

CORONARY ARTERY BY PASS GRAFT

For SAPHENOUS VEIN SITE:
Wear support stockings 4-6 weeks post op
Apply pressure dressing or sand bag on the site
Keep leg elevated when sitting
CORONARY ARTERY DISEASE
OBJECTIVES OF CABG
Revascularize myocardium
To prevent angina
 Increase survival rate
Done to single occluded vessels
If there is 2 or more occluded blood vessels, CABG is done

CORONARY ARTERY DISEASE

Nitroglycerin is the drug of choice for relief of pain from acute ischemic attacks
Instruct to avoid over fatigue
Plan regular activity program
Antilipemic agents - STATINS
CORONARY ARTERY DISEASE
Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium
resulting to myocardial ischemia
Chest pain is relieved by rest or nitroglycerine due to temporary myocardial ischemia
ANGINA PECTORIS
STABLE
Pain less than 15 minutes, recurrence is less frequent, has known cause
UNSTABLE
Pain is more than 15 minutes but less than 30 minutes, recurrence is more frequent and
the intensity of pain increases.
VARIANT ANGINA (PRINZMETAL’S ANGINA)
Longer in duration and may even occur at rest. Results from CORONARY
VASOSPASM.
ANGINA DECUBITUS
Paroxysmal chest pain that occur when the client sits or stands.
ANGINA PECTORIS
Sex: male
Race: Africans, African-Americans, Pacific Islanders
Smoking
Obesity
Hyperlipidemia
Sedentary lifestyle
Diabetes Mellitus
Hypertension
CAD: Atherosclerosis
Thromboangitis Obliterans
ANGINA PECTORIS
EXCESSIVE PHYSICAL EXERTION: heavy exercise, sexual activity
EXPOSURE TO COLD ENVIRONMENT: vasoconstriction
EXTREME EMOTIONAL RESPONSE: fear, anxiety, excitement, strong emotions
EXCESSIVE INTAKE OF FOODS or heavy meal
ANGINA PECTORIS
LEVINE’S SIGN: initial sign that shows the hand clutching the chest
CHEST PAIN: characterized by sharp stabbing pain located at the substerna usually
radiates from neck, back, arms, shoulder and jaw muscles, usually relieved by rest or
after taking nitroglycerin (NTG)
Dyspnea
Tachycardia
Palpitations
diaphoresis
ANGINA PECTORIS
HISTORY TAKING AND PHYSICAL EXAM
ECG: may reveal ST segment depression, T wave inversion during chest pain
Stress test/ treadmill test: reveal abnormal ECG during exercise
Increase serum lipid levels
Serum cholesterol and uric acid is also increased
ANGINA PECTORIS
DRUG THERAPY: if cholesterol is elevated
NITRATES: drug of choice/ NITROGLYCERINE (SL, tab, patch, ointment, spray)
Beta-adrenergic blocking agents
Calcium-channel blockers
Ace-inhibitors
MODIFICATION of diet and other risk factors
SURGERY:
CORONARY ARTERY BYPASS GRAFT
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

ANGINA PECTORIS
Enforce complete bed rest
Give prompt pain relievers with nitrates or narcotic analgesics as ordered
Administer medications as ordered
ANGINA PECTORIS
When given in small doses will act as a venodilator, but in large doses will act as
vasodilator
HOW TO GIVE PRN?
Give 1st does of NTG SL 3-5 minutes; 2nd dose of NTG if pain persists after 1st dose with
interval of 3-5 minutes, Give 3rd and last dose of NTG if pain still persists at 3-5
minutes intervals
ANGINA PECTORIS
NITROGLYCERINE Tablets (sublingual)
Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate
the drug
Change stock every 6 months
Offer sips of water before giving sublingual nitrates. WHY?
Relax for 15 minutes after taking a tablet to prevent dizziness
Monitor side effects: orthostatic hypotension, flushed face, transient headache and
dizziness (frequent side effect)
Instruct the client to rise slowly from sitting position
Assist or supervise in ambulation

ANGINA PECTORIS
NITROGYLYCERINE TRANSDERMAL PATCH
Nitropatch is applied once a day, usually in the morning
 Avoid placing near hairy areas. Why?
Avoid rotating transdermal patches Why?
Avoid placing near microwave ovens or during defibrillation Why?
ANGINA PECTORIS
Beta Blockers: decreases myocardial oxygen demand by decreasing heart rate, cardiac
output and BP
What are your Beta Blockers?
Assess PR, withhold if decreased
Administer with food Why?
PROPANOLOL is NEVER GIVEN
with RESPI-COPD cases, Why?
With DM cases Why?
Side effects: hypotension, nausea, vomiting, depression, fatigue
ANGINA PECTORIS
CALCIUM CHANNEL BLOCKERS relaxes smooth cardiac muscle, reduces coronary
vasospasm
What are your CCBs?
Assess HR and BP
Administer 1 hour before meal and 2 hours after meal (Food delays absorption)
ANGINA PECTORIS
Administer oxygen inhalation
Place client on semi to high fowler’s position
Monitor strictly v/s, I/O, cardiopulmonary status and ECG tracing
Instruct decrease saturated fats, sodium and caffeine
Provide client health teachings and discharge planning
Avoidance of 4Es
Prevent complication (myocardial infarction)
Instruct the client to take medication before indulging into physical exertion to
achieve the maximum therapeutic effect of the drug
ANGINA PECTORIS
Provide client health teachings and discharge planning
Reduce stress and anxiety; relaxation techniques and guided imagery
Avoid overexertion and smoking
Avoid extremes of temperature
Dress warmly in cold weather
Participate in regular exercise program
Space exercise periods and allow for rest periods
Emphasize importance of follow up care
Instruct the client to notify physician immediately if pain occurs and persists despite
rest and medication therapy.
DESCRIPTION
Death of myocardial cells from inadequate oxygenation often caused by sudden blockage of
a coronary artery
Characterized by localized formation of necrosis (tissue destruction) with subsequent
healing by scar formation and fibrosis
Also called heart attack
Terminal stage of CAD characterized by malocclusion, necrosis and scarring
MYOCARDIAL INFARCTION
TRANSMURAL MYOCARDIAL INFARCTION: most dangerous type characterized by
occlusion of both right and left coronary artery
SUBENDOCARDIAL MYOCARDIAL INFARCTION: characterized by occlusion of
either right or left coronary artery
MYOCARDIAL INFARCTION
6-8 HOURS because of majority of death occurs due to arrhythmia leading to premature
ventricular contractions

An elevation in ST segment in 2 contiguous leads is a key diagnostic indicator for MI.

The appearance of abnormal Q waves is another indication of MI.
MYOCARDIAL INFARCTION
SEX: male
RACE: black,
African Americans
Smoking
Obesity
CAD: Atherosclerosis
Thrombus formation
Genetic predisposition
Hyperlipidemia
MYOCARDIAL INFARCTION
CHEST PAIN:
EXCRUCIATING: visceral, viselike pain with sudden onset located at substernal
and rarely in precordial
Usually radiates from neck, back, shoulders, arms, jaw and abdominal muscles
(abdominal ischemia): severe crushing
Not usually relieved by rest or by nitroglycerine
Nausea and vomiting
Dyspnea
Increased blood pressure and pulse with gradual drop in blood pressure (initial sign)
MYOCARDIAL INFARCTION
Hyperthermia: elevated temperature
Skin: cool, clammy, ashen
Mild restlessness and apprehension
Occasional findings: pericardial friction rub, rales upon auscultation, s4 or atrial gallop
MYOCARDIAL INFARCTION
CARDIAC ENZYMES
CK-MB elevated
Creatinine phosphokinase (CPK): elevated
Lactate dehydrogenase: increased
Serum glutamic pyruvate transaminase (SGPT): increased
Serum glutamic oxalacetic transaminase (SGOT): increased
TROPONIN TEST: increased
ECG tracing reveals: ST segment elevation, T wave inversion, widening QRS complexes
(indicates that there is arrhythmia in MI), pathologic Q wave
Serum cholesterol and uric acid are both increased
CBC: increased WBC
MYOCARDIAL INFARCTION
GOAL: decrease myocardial oxygen demand
DECREASE MYOCARDIAL WORKLOAD (rest the heart!)
Establish a patent IV line
Administer narcotic analgesic (drug of choice): Morphine sulfate IV why?
Side effects: HYPOTENSION/ RESPIRATORY DEPRESSION
ANTIDOTE : ?
SIDE EFFECT OF ANTIDOTE: ?
MYOCARDIAL INFARCTION
Administer oxygen low flow 2-3 lpm: to prevent respiratory arrest or dyspnea and prevent
arrhythmias
Enforce CBR in semi fowlers position without bathroom privileges (use bedside commode):
Why?
Instruct client to avoid forms of Valsalva maneuver: Why?
Place client on semi fowler’s position
Monitor strictly VS, I/O, ECG tracing and hemodynamic procedures
Perform complete lung and cardiovascular assessment
Monitor urinary output and report output of less than 30 ml/ hr: Why?
MYOCARDIAL INFARCTION
Provide a full liquid diet with gradual increase to soft diet: low in saturated fats, Na and
caffeine
Maintain quiet environment
Administer stool softeners as ordered to facilitate bowel evacuation and prevent straining
Relieve anxiety associated with CCU environment
Administer medications as ordered:
Vasodilators: Nitroglycerin (NTG), Isosorbide Dinitrate (ISDN)
Anti- Arrhythmic agents: What are they?
B-blockers
ACE inhibitors
MYOCARDIAL INFARCTION
Administer medications as ordered:
Calcium Channel blockers
Thrombolytics/ Fibrinoltyic agents: What are they?
Side effects: ?
Nursing interventions: ?
ANTICOAGULANTS : What are they?
ANTIPLATELET AGGREGATES: What are they?
MYOCARDIAL INFARCTION
Provide client teaching and discharge planning concerning:
Effects of MI healing process and treatment
Medication regimen including time name purpose schedule dosage side effects of the
medicines
 Dietary restrictions: low SODIUM, low CHOLESTEROL, avoidance of coffee
Encourage client to take 20-30 cc/week of wine, whisky and brandy to induce
vasodilation
Avoidance of modifiable risk factors
PREVENT COMPLICATIONS:
ARRYHTMIAS: caused by premature ventricular contractions
CARDIOGENIC SHOCK: late sign is oliguria
LEFT CONGESTIVE HEART FAILURE
MYOCARDIAL INFARCTION
PREVENT COMPLICATIONS:
THROMBOPHLEBITIS: positive homan’s sign
STROKE/ CVA
DRESSLER’S SYNDROME (POST MI syndrome): client is resistant to
pharmacologic agents: administer 150000-450000 units of streptokinase
as ordered
Emphasize importance of participation in progressive activity program
Resumption of ADLs particularly in sexual intercourse is 4-6 weeks post cardiac
rehab, post CABG and instruct to:
Make sex as an appetizer rather than a dessert
Instruct client to assume a non weight bearing position
Client can resume sexual intercourse if can climb or use the staircase
MYOCARDIAL INFARCTION
Need to report the ff s/sx:
Increased persistent chest pain
Dyspnea
Weakness
Fatigue
Persistent palpitations
Light headedness
MYOCARDIAL INFARCTION
Enrollment of client in cardiac rehabilitation program
For strict compliance to all medication regimen and importance of follow up care
DESCRIPTION
Is a shock state which results from profound left ventricular failure usually from
massive MI.
It results to low cardiac output, thereby systemic hypoperfusion
SIGNS AND SYMPTOMS:
Decreased systolic BP
Oliguria
Cold, clammy skin weak pulse
Cyanosis
Mental lethargy
confusion
CARDIOGENIC SHOCK
HOMEWORK:
WHAT IS COUNTERPULSATION?
Illustrate and explain the mechanism behind the INTRA-AORTIC BALLOON PUMP
What are its indications? Contraindications? Nursing interventions pre- and post
procedure?
CARDIOGENIC SHOCK
Perform hemodynamic monitoring
Administer oxygen therapy
Correct HYPOVOLEMIA. How?
PHARMACOLOGY:
Inotropic agents: ?
Sodium Bicarbonate: to relieve lactic acidosis
Monitor hourly urine output, LOC and arrhythmias
Provide psychosocial support
CARDIOGENIC SHOCK
Decrease pulmonary edema
Auscultate lung fields for crackles and wheezes
Note for dyspnea, cough, hemoptysis and orthopnea
Monitor ABG for hypoxia and metabolic acidosis
Place in fowler’s position to reduce venous return
CARDIOGENIC SHOCK
Decrease pulmonary edema
Administer during therapy as ordered:
MORPHINE SULFATE: to reduce venous return
AMINOPHYLLINE: why?
VASODILATORS: to reduce venous return
DESCRIPTION
⮚ Is the inflammation of the pericardium which occurs approximately 1-6
weeks after AMI.
⮚ Results in antigen-antibody response. The necrotic tissues play the role of an
antigen, which trigger antibody formation. INFLAMMATORY PROCESS
FOLLOWS.
⮚ CONSTRICTIVE PERICARDITIS is a condition in which a chronic
inflammatory thickening of the pericardium compresses the heart so that it is
unable to fill normally during diastole.
DESCRIPTION
DESCRIPTION
PERICARDITIS
⮚ Pain in the anterior chest, aggravated by coughing, yawning, swallowing,
twisting and turning the torso, relieved by upright, leaning forward position.
⮚ Pericardial friction rub – scratchy, grating or crackling sound
⮚ Dyspnea
⮚ Fever, sweating, chills
⮚ Joint pains
⮚ arrhythmias
PERICARDITIS
⮚ Elevate HOB, place pillow on the overbed table so that the patient can lean
on it.
⮚ Bed rets
⮚ Administer pharmacotherapy:
⮚ ASA and corticosteroids: why? (to suppress the inflammatory process)
⮚ Assist in pericardiocentesis if cardiac tamponade is present
PERICARDITIS
⮚ ASPIRATION OF BLOOD OR FLUID FROM PERICARDIAL SAC
DESCRIPTION
⮚ Also known as pericardial tamponade, is an emergency condition in which
fluid accumulates in the pericardium
⮚ If the fluid significantly elevates the pressure on the heart it will prevent the
heart’s ventricles from filling properly.
DESCRIPTION
⮚ This in turn leads to a low stroke volume.
⮚ The end result is ineffective pumping of blood, shock and often death.
CARDIAC TAMPONADE
⮚ Chest trauma (blunt or penetrating)
⮚ Myocardial ruptured
⮚ Cancer
⮚ Pericarditis
⮚ Cardiac surgery (first 24-48 hours)
⮚ Thrombolytic therapy
CARDIAC TAMPONADE
CARDIAC TAMPONADE
⮚ BECK’S TRIAD
⮚ Hypotension
⮚ Jugular vein distension
⮚ Muffled heart sounds
⮚ PULSUS PARADOXUS (drop of at least 10mmHg in arterial BP on
inspiration)
⮚ Tachycardia
⮚ Breathlessness
⮚ Decrease in LOC

CARDIAC TAMPONADE
⮚ Administer oxygen
⮚ Elevate HOB, place pillow on the overbed table so that the patient can lean
on it
⮚ Bed rest
⮚ Administer anti-inflammatory medicines
⮚ Assist in pericardiocentesis and thoracotomy

CARDIAC TAMPONADE
CARDIAC TAMPONADE
PREDISPOSING FACTORS
⮚ Inability of the heart to pump blood towards systemic circulation
⮚ LEFT SIDED HEART FAILURE
⮚ 90% mitral valve stenosis
⮚ RHD – inflammation of mitral valve
⮚ Anti-streptolysin O (ASO) titer - 300 todd units
⮚ Penicillin, PASA, steroids
⮚ Aging

LEFT SIDED HEART FAILURE

LEFT SIDED HEART FAILURE
⮚ Chest x-ray – cardiomegaly
⮚ PAP – pulmonary arterial pressure
⮚ Measures pressure in right ventricle
⮚ Reveals cardiac status
⮚ PCWP – pulmonary capillary wedge pressure
⮚ Measures end systolic and end diastolic pressure
⮚ Done through cardiac catheterization (swan-ganz catheter)
⮚ Echocardiogram – reveals enlarged chamber
⮚ Arterial blood gases – increased PCO2, decreased PO2

PREDISPOSING FACTORS
⮚ Increased pressure of blood backing up from a failing left ventricle
⮚ Further back up of fluid and pressure into the pulmonary arteries causing
pulmonary congestion, pulmonary edema, pulmonary hypertension
⮚ DECREASED EJECTION FRACTION of left ventricle due to muscle
weakness or increased afterload
⮚ DIASTOLIC DYSFUNCTION due to decreased compliance of the left
ventricle.

PREDISPOSING FACTORS
⮚ Decreased stroke volume
⮚ Decreased cardiac output
⮚ Decreased preload due to less filling because of stiffness of ventricles
⮚ Decreased blood flow and oxygenation to chemoreceptors and body tissues
⮚ DECREASED PERFUSION
LEFT SIDED HEART FAILURE
LEFT SIDED HEART FAILURE
LEFT SIDED HEART FAILURE
⮚ PULMONARY s/sx related:
⮚ PULMONARY EDEMA/CONGESTION
⮚ Dyspnea, paroxysmal nocturnal dyspnea, 2-3 pillows orthopnea
⮚ Productive cough (blood tinged)
⮚ Rales/ crackles
⮚ Bronchial wheezing
⮚ Frothy salivation
LEFT SIDED HEART FAILURE
⮚ PULMONARY s/sx related:
⮚ PULSUS ALTERANS – a unique pattern during which the amplitude of the
pulse changes or alternates in size with a stable heart rhythm. Common in
severe left ventricular dysfunction.
⮚ Anorexia, body malaise
⮚ Point of Maximal Impulse (PMI) displaced laterally, cardiomegaly
⮚ S3 (ventricular gallop)
DESCRIPTION
⮚ PREDISPOSING FACTORS
⮚ Tricuspid valve stenosis
⮚ COPD
⮚ Pulmonary embolism (characterized by chest pain and dyspnea)
⮚ Pulmonic stenosis
⮚ Left sided heart failure
RIGHT SIDED HEART FAILURE
⮚ Chest X-ray – cardiomegaly
⮚ Central venous pressure – ELEVATED
⮚ Echocardiogram – reveals enlarged heart chamber
⮚ Muffled heart sounds – cardiomyopathy
⮚ CYANOTIC HEART DISEASES
⮚ TETRALOGY OF FALLOT (TOF) – “tet spells” – cyanosis
with hypoxemia
⮚ Tricuspid valve stenosis
⮚ Transposition of aorta
⮚ ACYANOTIC – PATENT DUCTUS ARTERIOSUS

RIGHT SIDED HEART FAILURE

⮚ Jugular vein distention
⮚ Pitting edema
⮚ Ascites
⮚ Weight gain
⮚ Hepatosplenomegaly
⮚ Jaundice
⮚ Pruritus/urticarial
⮚ Esophageal varices
⮚ Anorexia
⮚ Generalized body malaise
RIGHT SIDED HEART FAILURE
RIGHT SIDED HEART FAILURE
⮚ GOAL: increase myocardial contraction/ increase cardiac output
⮚ ADMINISTER MEDICATIONS
⮚ CARDIAC GLYCOSIDES – DIGOXIN
⮚ LOOP DIURETICS – why?
⮚ BRONCHODILATORS – why?
⮚ NARCOTIC ANALGESICS – why?
⮚ NITROGLYCERINE – WHY?
⮚ ANTI-ARRHYTHMIC AGENTS – why?
 ⮚ BETA BLOCKERS – debatable therefore give low dose

RIGHT SIDED HEART FAILURE

⮚ GOAL: increase myocardial contraction/ increase cardiac output
⮚ ADMINISTER O2 inhalation at 3-4 lpm via nc as ordered
⮚ High Fowler’s, 2-3 pillows – why?
⮚ Restrict sodium and fluids – why?
⮚ Monitor strictly VS, IO and breath sounds
⮚ Weight patient daily and assess for pitting edema
⮚ Abdominal girth daily and notify MD

RIGHT SIDED HEART FAILURE

⮚ GOAL: increase myocardial contraction/ increase cardiac output
⮚ Provide meticulous skin care
⮚ Provide a dietary intake which is low in saturated fats and caffeine
⮚ Health teachings and discharge planning:
⮚ PREVENT COMPLICATIONS: arrhythmia, shock,
thrombophlebitis, MI
⮚ Regular adherence to medications
⮚ Diet modifications
⮚ Importance of follow-up care

valves of the heart control theflow

of blood through the heart into the
PA and aorta by opening and
closing in response to the blood
pressure changes as the heart
contracts and relaxes through the
cardiac cycle

• When valves do not close

completely, blood flows backward
through the valve, a condition called
regurgitation. When valves do not
open completely, a condition called
stenosis, the flow of blood through
the valve is reduced.

ENDOCARDITIS MYOCARDITIS PERICARDITIS

-Microbial (bacterial)
Risks:
-prosthetic valves
 -Hx congenital HD

Myocarditis
-Microbial (viral)
-Acute systemic
infections
-Toxins (e.g.
anthracyclines,
ethanol, radiation)

Pericarditis

-Microbial (viral)
-AMI
-Conn. Tissued/o
-Neoplasm
-Trauma
-S/p pericardectomy

RHEUMATIC

FEVER

• multisystem disease resulting from an autoimmune

reaction to infection with group A streptococci (GAS)

occurs most often

in school-age

children (5 to 14),

F>M

RISK

FACTORS:

• Malnutrition
• Overcrowding

• Poor hygiene

• Lower

socioeconomic

status

Clinical

Manifestations

• MAJOR Manifestations

• Carditis

• Polyarthritis

• Sydenham’s Chorea

• Erythema marginatum

• Subcutaneous nodules

Clinical Manifestations

Carditis -systolic or diastolic murmur

-prolonged PR and QT

-signs of CHF

Polyarthritis

-pain and limited movements of 2 or more joints

-swollen, red, warm, tender joints

Sydenham’s Chorea

-purposeless, involuntary, rapid movements

associated with muscle weakness, involuntary

facial grimace, speech disturbance and emotional

lability

Erythema marginatum

-nonpruritic pink, macular

rash with pale central areas

Subcutaneous nodules

-firm, painless nodules over the scalp,

extensor surface of joints, and vertebral

column

•Throat

culture

•ESR,WBC

and diff

• CRP

PHARMACOLOGIC MANAGEMENT

• Antimicrobial therapy

• Penicillin

• Salicylates or NSAIDs

• Prevention of recurrent episodes

Nursing Management
Reducing Fever

-Administer Penicillin and Salicylates/NSAIDs

-Evaluate response

Maintaining Adequate Cardiac Output

-Assess for s/sx of carditis (e.g. chest pain,

palpitations)

-WOF 2nd Degree-HeartBlock

Maintaining Activity

-Bed rest

-Provide ROME

LIST OF VALVULARDISEASES

•Mitral Valve

•Prolapse

•Regurgitation

•Stenosis

•Aortic Valve

•Regurgitation

•Stenosis
CONDITION LOCATION TIMING

condition location Timing

Mitral Stenosis Apex Diastolic
Mitral Regurgitation Systolic
Aortic Stenosis 2nd ICS, Right Systolic
Aortic Regurgitation diastolic

DIAGNOSTICS

• Doppler

echocardiography

• Transesophageal

echocardiography

Surgical Management of Valvular

Heart Diseases

• Valvuloplasty

• Commisurotomy

• Annuloplasty

• Chordoplasty

• Leaflet Repair

• Valvular Replacement

• Tissue Valves

• Xenografts, Homografts, and

autografts
• Mechanical Valves

Pharmacological

Management

• ACE Inhibitors

• Angiotensin blockers

• ß-blockers

• Antiplatelet agents

• Anticoagulants

• Antibiotics

Nursing

Management

• Health education:

• diagnosis, the

progressive nature, and

treatment plan

• teach to report new

symptoms or changein

symptoms

• risk for infection (esp.

post-surgical)

Nursing

Management
• Assessment and

monitoring of the ff:

• S/Sx

• Dysrhythmias

• Other symptoms e.g.

dizziness, syncope,

increased weakness

Peri-operative

Management

• assess for S/sx of HFand

emboli

• focus on recovery from

anesthesia and

hemodynamic stability

• assist pt create an activity-

rest plan

Aneurysm

pathologic dilatation of a segment of a blood vessel

According to Layers

• True aneurysm involves all three layers of the

vessel wall

• Pseudoaneurysm: the intimal and medial layers

are disrupted and the dilatation is lined by

adventitia only and, at times, by perivascular clot

According to GrossAppearance

• fusiform aneurysm affects the entire

circumference of a segment of thevessel,

resulting in a diffusely dilatedartery

• saccular aneurysm involves only a portion of

the circumference, resulting in an outpouching

of the vessel wall

According to Location

Etiology

• Atherosclerosis (most common)

• Risks:

• Caucasians

• M>F

• Elderly

Diagnosis

• CXR

• CTA

• Transesophageal echocardiography (TEE) –for TAA*

Peri-Operative Nursing

Management

• Pre-op: Assess and monitor s/sx of impending rupture

• Severe, constant pain

• Falling BP and Hct

• Post-op: Monitor pulmonary, cardiovascular, renal, and neurologic status

• Arterial occlusion

• Hemorrhage

• Infection

Elastic arteries- Largest arteries

Muscular arteries - Medium-sized

Arterioles Microscopic (15–300 μm in diameter)

Capillaries Microscopic; smallest blood vessels (5–10 μm in diameter)

Postcapillary venules Microscopic (10–50 μm in diameter)

Muscular venules Microscopic (50–200 μm in diameter)

Veins Range from 0.5 mm to 3 cm in diameter

FUNCTIONS

• Transport blood to

the tissues and

back

• Carry blood

away from the

heart

• Exchanges

between tissues

and blood

• Return blood

toward the heart

Physiology of
Blood Flow

FLOW RATE ≡ ΔP/R

1. Pressure gradient

2. Laminar flow vs

Turbulent flow

Hydrostatic

pressure exerted by

the blood against

the blood vessel

walls

• determined by

cardiac output,

blood volume, and

vascular resistance

Raynaud’s

Phenomenon

• a syndrome of intermittent

arteriolar vasoconstriction that

results in coldness, pain, and

pallor of the fingertips or toes

NAME ORIGIN
•named after the

French physician

Maurice Raynaud,

who described

the condition in

1862

PRIMARY SECONDARY

ETIOLOGIES

(COLD HAND)

• Cryoglobulinemia

• Obstruction (e.g. emboli)

• Lupus/other connective tissue dse

• Diabetes/drugs

• Hematologic conditions

• Atherosclerosis/arterial conditions

• Neurologic conditions

• Don’t know (Idiopathic)

DIAGNOSIS

• Clinical symptoms must last at least 2 years

•Rule out other disorders, e.g.

• Carpal tunnel syndrome

• Thromboangiitis obliterans (Buerger’s Dse)

• Vasospastic d/o
Management

• Avoid stimuli

• CCB

• Nursing:

• Caution against

handling sharp objects

• Educate regarding

side effects of CCB

(e.g. postural

hypotension)

Buerger’s Disease

•characterized by recurring inflammation

of the intermediate and small arteries

and veins of the lower and upper

extremities

Etiology and

Risk Factors

•autoimmune

vasculitis

•men 20 to 35

years

•heavy smoking or

chewing of
tobacco

COMMON

FINDINGS

• intermittent claudication

• ischemic pain at rest

• pain more severe at night

• cool, numb, or tingling

sensation

• diminished pulses in the distal

extremities

• extremities that are cool and

red in the dependent position

• development of ulcerations in

the extremities

Diagnosis

•Duplex

ultrasonography

•Contrast

angiography

Medical-Surgical Management

•minimizing infection

•conservative débridement of necrotic tissue

• Above the Knee Amputation (AKA)

Nursing

Management

• Pain management

• Lifestyle changes

• Post-operative nursing

management for

amputation

Varicosities

Varicosities

• abnormally dilated,

tortuous, superficial

veins caused by

incompetent venous

valves

• commonly occurs in

the lower extremities,

the saphenous veins,

or the lower trunk,

but it can occur

elsewhere in the

body, such as the

esophagus

RISK FACTORS
•F>M

•occupations

requiring

prolonged

standing

•familial factors

MANIFESTATIONS

• IF SYMPTOMATIC,

• Dull aches

• Muscle cramps

• Increased muscle fatigue

in the lower legs

• Ankle edema

• Feeling of heaviness of

the legs

• Nocturnal cramps

Prevention

• Avoid activities that cause

venous stasis

• Changing position frequently

• Elevating the legs when they

are tired

• Getting up to walk for several

mins hourly

• Use of graduated

compression stockings

• Weight reduction plan for

overweight patients

Medical

Management

•Ligation and

Stripping

•Thermal Ablation

•Sclerotherapy

DIAGNOSTICS

Laboratory

Studies

• Arterial Blood Gas

•Sputum Analysis

•Thoracentesis

ABG Pre-procedure

Perform Allen’s test before drawing radial artery specimens.

Have the client rest for 30 minutes before specimen collection

to ensure accurate measurement of body oxygenation.

Do not turn off oxygen unless the ABG sample is prescribed to

be drawn with the client breathing room air.

ABG Post-procedure

Hemolysis Transport the specimen to the laboratory within 15 minutes.

Pressure Apply pressure to the puncture site for 5 to 10 minutes or longer if the client is receiving

anticoagulant therapy or has a bleeding disorder.

FiO2 Note the oxygen and type of ventilation that the client is receiving on the

laboratory form.

Body Temp Note the client’s temperature on the laboratory form.

Ice Place the specimen on ice.

Sputum

Analysis Pre

procedure

Interventions

• Determine specific

purpose of collection

and check with

institutional policy for

appropriate method for

collection of a

specimen.

• Obtain an early

morning sterile

specimen from

suctioning or

expectoration after a

respiratory treatment if

a treatment is

prescribed.

Sputum Analysis Pre-procedure

Interventions

Antibiotic therapy Always collect the specimen before the

client begins antibiotic therapy.

Breathing pattern Instruct the client to take several deep breaths and then

cough deeply to obtain sputum.

Amount Obtain 15 mL of sputum.

Rinse Instruct the client to rinse the mouth with water before collection.

Sputum Analysis Post-

procedure Interventions
If a culture of

sputum is

prescribed,

transport the

specimen to

the laboratory

immediately.

Assist the

client with

mouth care.

Thoracentesis

Pre-procedure

•Obtain informed

consent and vital

signs.

•Prepare the client

for ultrasound or

chest radiograph,

if prescribed,

before procedure.

Thoracentesis

Pre-procedure

• Assess results of

coagulation studies.
•Client is positioned

sitting upright, with

the arms and

shoulders supported

by a table at the

bedside during the

procedure

Thoracentesis

Pre-procedure

• If the client cannot sit

up, the client is placed

lying in bed toward the

unaffected side, with

the head of the bed

elevated.

• Instruct the client not to

cough, breathe

• deeply, or move during

the procedure.

Imaging Tests

•Chest X-ray

•CT Scan

•PET Scan

•MRI

•Pulmonary

Angiography

•V/Q Scan
Xray Preparation

Remove all

jewelry and other

metal objects from

the chest area.

Assess the client’s

ability to inhale

and hold his or

her breath.

X-ray Postprocedure

•Help the client get dressed.

Other Tests

•Bronchoscopy

•Pulmonary

Function Tests

•Lung Biopsy

BRONCHOSCOPY

Direct visual

examination of the
larynx, trachea,

and bronchi with a

fiberoptic

bronchoscope

BRONCHOSCOPY PREPARATION

Consent Obtain informed consent.

Maintain NPO status for the client from midnight

before the procedure. Aspiration

Baseline Obtain vital signs.

Bleeding Assess the results of coagulation studies.

BRONCHOSCOPY

PREPARATION

Remove dentures

and eyeglasses.

Prepare suction

equipment.

Establish IV access as

necessary and administer

medication for sedation

as prescribed.

Have emergency

resuscitation

equipment readily

available.

BRONCHOSCOPY POST-

PROCEDURE

Sputum Have an emesis basin readily available for the client to expectorate

sputum.

Aspiration Maintain NPO status until the gag reflex returns.

Airway Assess for the return of the gag reflex.

Lung Expansion Maintain the client in a semi-Fowler’s position.

Stability Monitor vital signs.

BRONCHOSCOPY POST-

PROCEDURE

Complications Notify the physician if fever, DOB, or other signs of complications

occur following the procedure.

Complications

Monitor for complications, such as bronchospasm or bronchial perforation,

indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia,

and pneumothorax.

Respirations Monitor respiratory status, particularly if sedation

has been administered.

Airway bleeding Monitor for bloody sputum.

PULMONARY

FUNCTION

TESTS

Tests used to evaluate

lung mechanics (e.g.

FEV1, FVC, MVV)

through spirometric

measurements, lung

volumes and

capacities.

PRE-PROCEDURE

Light meal only Instruct the client to refrain from smoking or eating a heavy meal for

4 to 6 hours before the test.

Sealed

Mouthpiece Remove dentures.

Comfort Instruct the client to void before the procedure and to wear

loose clothing.

Pre-bronchodilators Consult with the physician regarding holding bronchodilators before

testing.

Respiratory Depression Determine whether an analgesic that may depress the respiratory function is

being administered.

POST-

PROCEDURE

•Client may resume

normal diet and

any

bronchodilators

and respiratory

treatments that

were held before

the procedure.

LUNG

BIOPSY

A transbronchial

biopsy and a

transbronchial needle
aspiration may be

performed to obtain

tissue for analysis by

culture or cytological

examination

BRONCHIAL BIOPSY PRE-

PROCEDURE

Obtain

informed

consent.

Maintain NPO

status of the

client before

the

procedure.

Inform the client that

LA will be used but a

sensation of

pressure during

needle insertion and

aspiration may be

felt.
3

Administer

analgesics

and sedatives

as prescribed.

BRONCHIAL BIOPSY POST-

PROCEDURE

Monitor vital signs.

Apply a dressing to the biopsy site and monitor for drainage or bleeding.

Monitor for signs of respiratory distress and notify the physician if they occur.

Monitor for signs of pneumothorax and air emboli and notify the physician if they

occur.

Prepare the client for chest radiography if prescribed.

RHINITIS

• group of disorders

characterized by

inflammation and irritation

of the mucous membranes

of the nose

• Allergic

• Non-allergic

ETIOLOGY

• ALLERGIC RHINITIS

• Foods (e.g. peanuts, walnuts,

brazil nuts, wheat, shellfish,

soy, cow’s milk, and eggs)

• Medications (e.g. penicillin,

sulfa medications, aspirin)

• Environmental particles

ETIOLOGY

•NON-ALLERGIC RHINITIS

•Common colds

MANIFESTATIONS

• Rhinorrhea

• Nasal congestion

• Nasal discharge

• Sneezing
• Pruritus of the nose, roof

of the mouth, throat, eyes,

and ears

• Headache*

PHARMACOLOGIC

MANAGEMENT

• Antihistamines

• Corticosteroid nasal sprays

• Decongestants

• Mast cell stabilizers

NURSING

MANAGEMENT

Patient education

RHINOSINUSITIS

RHINOSINUSITIS (for.

SINUSITIS)

• Inflammation of the

paranasal sinuses and nasal

cavity

• Bacterial or viral
• Acute (less than 4 weeks)

• Subacute (4 to 12 weeks)

• Chronic (more than 12

weeks)

PATHOPHYSIOLOGY

MANIFESTATIONS •purulent nasal drainage (anterior,

posterior, or both) accompanied

by nasal obstruction

• facial pain–pressure–fullness

• cloudy or colored nasal

discharge congestion, blockage,

or stuffiness

• localized or diffuse headache

COMPLICATIONS • Osteomyelitis

• Mucocele (cyst of the

paranasal sinuses)

• Sinus thrombosis

• Meningitis

•Brain abscess

• Severe orbital cellulitis

PHARMACOLOGIC
MANAGEMENT

• Nasal saline lavage and

decongestants

• Oral corticosteroids

• Antibiotics:

• DOC: Amoxicillin

• Alternatives: trimethoprim-

sulfamethoxazole,

macrolides, quinolones

• Cephalosporins

NURSING

MANAGEMENT:

PATIENT TEACHING

• Humidification of air at home

• Warm compress

• Avoid swimming, diving, and air

travel

• Smoking cessation (immediate)

• Proper use of sprays and antibiotics

PHARYNGITIS

“sore throat”
PHARYNGITIS: ETIOLOGIES

• ACUTE

•VIRAL: adenovirus,

influenza virus,

Epstein-Barr virus,

herpes simplex virus

•BACTERIAL: GAS

(Strep throat)

•CHRONIC

• OCCUPATIONAL:

• dusty surroundings

• excessive use of voice

• suffer from chronic cough

• SOCIAL: habitual alcohol and

tobacco use

MANIFESTATIONS

• Fiery-red pharyngeal membrane and tonsils

• Lymphoid follicles that are swollen and flecked with white-purple exudate

• Enlarged and tender cervical lymph nodes

• (-) cough

• Fever (higher than 38.3’C

• malaise
Manifestations

• constant sense of

irritation or fullness in the

throat

• mucus that collects in the

throat and can be

expelled by coughing

• dysphagia

• Intermittent postnasal

drip

PHARMACOLOGIC

MANAGEMENT

• Erythromycin,

Cephalosporins,

Macrolides

• Aspirin

• Acetaminophen
NURSING MANAGEMENT

• Liquid to soft diet

• Cool beverages, warm liquids,

and flavored frozen desserts

• Increase fluid intake (at least 2

to 3 L/day)

• Warm saline gargles or throat

irrigations

• Mouth care

• Replace toothbrush and avoid

sharing utensils

Tonsillitis

Sites of Infection

• Palatine tonsils

• Lingual tonsils

• Pharyngeal tonsils

(Adenoiditis)

Etiologies

• GABHS

• Epstein-Barr virus

•Cytomegalovirus

• NOTE: Children>Adults
Manifestations

•Sore throat

•Fever

•Snoring

•Dysphagia

• Adenoiditis:

• mouth-breathing

• Earache

• draining ears

• frequent head colds

• foul-smelling breath

• voice impairment,

• noisy respiration

Surgical

Management

•Tonsillectomy

•Adenoidectomy

Pharmacologic Management

POST OPERATIVE NURSING

CARE
• Turn head to the side to

allow drainage

• Do not remove the oral

airway until (+) gag and

swallowing reflexes

• Ice collar to the neck

• Ice cream or cold foods

LARYNGITIS

ETIOLOGIES

• voice abuse

• exposure to dust,

chemicals, smoke, and

other pollutants

• URI

• isolated infection

• gastroesophageal reflux

MANIFESTATIONS • hoarseness or aphonia

• severe cough

• “tickle” in the throat that is made worse by cold

air or cold liquids

MANAGEMENT

•resting the voice

•avoiding irritants

(including smoking)

•inhaling cool steam or

an aerosol

EPISTAXIS

MANAGEMENT

• Sit upright with the head tilted

forward, pinch the soft outer

portion of the nose against the

midline septum for 5 or 10

minutes continuously

• Application of nasal

decongestants

• Cauterization + Surgicel or

Gelfoam

• Nasal pack impregnated with

petrolatum jelly or antibiotic

ointment

NURSING TEACHING
•Avoid:

•forceful nose blowing

•Straining

•high altitudes

•nasal trauma

(including nose

picking)

NASAL

OBSTRUCTION

ETIOLOGIES •deviation of the

nasal septum

•hypertrophy of the

turbinate bones

•pressure of nasal

polyps

ETIOLOGIES •deviation of the

nasal septum

•hypertrophy of the

turbinate bones

•pressure of nasal

polyps
ETIOLOGIES

•deviation of the

nasal septum

•hypertrophy of

the turbinate

bones

•pressure of nasal

polyps

PHYSIOLOGIC EFFECTS

• Sleep deprivation

• Mouth breathing

• dryness of the oral mucosa

• persistent dry, cracked lips

•Chronic infection

MANAGEMENT

•SURGICAL:

•Functional rhinoplasty

•NURSING:

•Post-op care

•Elevate HOB
•Frequent oral hygiene

NASAL FRACTURE

TRAUMA

Torn mucous membranes

hematoma

infection abscess

necrosis

MANAGEMENT • Nasal packing

• Cold compress

• Rhinoplasty

MANAGEMENT

•Nasal packing

•Cold compress

•Rhinoplasty

Pneumonia

Pneumonia
inflammation of the lung parenchyma secondary to infection

Etiologies

• Streptococcus pneumoniae

• Staphylococcus aureus

• Klebsiella species

• Pseudomonas organisms

• E. coli

• Legionella pneumophila

• H. influenzae

Etiologies

• Parainfluenza viruses

• Respiratory syncytial viruses

• Rhinoviruses

• Adenovirus

• Varicella, rubella, rubeola

• Pneumocystis jiroveci

• Aspergillus fumigatus

CLASSIFICATIONS

•Community-acquired (CAP)

•Typical

•Atypical

•Healthcare-associated
•Pneumonia in the immunocompromised

•Aspiration pneumonia

MANIFESTATIONS

•Chills

•Rising fever (38.5°C to 40.5°C)

•Pleuritic pain

•Tachypnea

•Rhonchi and wheezes

•Use of accessory muscles

for breathing

•Mental status changes

•Sputum production

DIAGNOSIS

• CXR:

• lobar or segmental consolidation

• pulmonary infiltrates

• pleural effusions

• Blood and Sputum culture

• Gram Staining

• Elevated WBC count and ESR

Medical

Management

MEDICAL

MANAGEMENT

•Antibiotics

•respiratory fluoroquinolone (Moxifloxacin,

Gemifloxacin, or Levofloxacin)

•beta-lactam agent (Cefpodoxime or

Cefuroxime)

MEDICAL

MANAGEMENT

•Supportive

treatment: (viral pneumonia)

• Hydration

• Antipyretics

• Antitussive medications

• Antihistamines

• Nasal decongestants

MEDICAL

MANAGEMENT

•Bed rest
•Oxygen therapy

MEDICAL

MANAGEMENT

•Respiratory

support:

•high FiO2

•endotracheal intubation

•mechanical ventilation

MEDICAL MANAGEMENT

•Treatment of atelectasis, pleural

effusion, shock, respiratory

failure, or superinfection is

instituted, if needed

• Pneumococcal

vaccination (if high risk)

NURSING

MANAGEMENT

Nursing Focus

Improving

Airway Patency
1

Promoting Rest

and Conserving

Energy

Promoting Fluid Intake

and Maintaining

Nutrition

Promoting

Patients’

Knowledge

Monitoring and

Preventing Potential

Complications

Acute Respiratory

Distress Syndrome

Definition

•Severe form of acute lung injury (ALI)

Definition
•clinical syndrome characterized by a

sudden and progressive pulmonary

edema, increasing bilateral infiltrates on

chest x-ray, refractory hypoxemia, and the

absence of an elevated left atrial pressure

Pathophy

ANATOMIC

ALTERATIONS

Interstitial and intra-alveolar edema and hemorrhage

Alveolar consolidation

Intraalveolar hyaline membrane formation

Pulmonary surfactant deficiency or abnormality

Atelectasis

CLINICAL COURSE

RADIOLOGIC FINDINGS

•Increased opacity

•“white lungs”

•“ground-glass” appearance
MANAGEMENT

•Invasive Mechanical

Ventilation

•Fluid management

•Pharmacologic Therapy

MECHANICAL

VENTILATION

•Use of PEEP

•Use of low tidal volume, high

respiratory rates

•Inverse ratio ventilation

•Prone ventilation

PHARMACOLOGIC TREATMENT*

•Glucocorticoids

•Surfactant replacement

•Anti-inflammatory
•Sedatives

Pulmonary Embolism

Definition

• obstruction of one or more pulmonary

arteries by a thrombus (or thrombi)

usually originating in the deep veins of

the legs, the right side of the heart, or,

rarely, an upper extremity, which

becomes dislodged and is carried to the

pulmonary vasculature

PREDISPOSING FACTORS

Stasis

VIRCHOW’S

TRIAD

Predisposing Factors

•Stasis and prolonged

immobilization.

•Concurrent phlebitis.

•Heart failure and stroke.

•Injury to vessel wall.

•Coagulation disorders and hypercoagulable

state.

•Malignancy.

•Advancing age, estrogen therapy, and oral

contraceptives.

•Fracture of long bones.

•Obesity.

Pulmonary vascular

obstruction

Pulmonary

infarction

Alveolar atelectasis Alveolar

consolidation

Bronchospasm

DIAGNOSIS

• Thoracic imaging: V/Q

scan

• Pulmonary angiography*

• D-Dimer assay

• ABG levels
• Chest x-ray

*gold standard

MANAGEMENT

•O2

administration

•Establish IV

access

•Vasopressors

•Inotropic agents

•ECG monitoring

•Small doses of

IV morphine

•Mechanical

ventilation

MANAGEMENT

•Anticoagulants

•subcutaneous low molecular weight heparin (LMWH)

•IV or subcutaneous unfractionated heparin (UFH)

•Thrombolytics

•Streptokinase
•Tissue Plasminogen Activator (TPA)

SURGICAL INTERVENTION

•Intraluminal filter insertion

•Embolectomy, either by open surgical embolectomy

or catheter embolectomy with fragmentation

Intraluminal

Filter

Insertion

Open

Embolectomy

PULMONARY

TUBERCULOSIS

DEFINITION

◦an infectious disease

primarily affecting

the lung

parenchyma, most

often caused by

Mycobacterium
tuberculosis

clinical classification

Primary TB: occurs soon

after the initial infection

with tubercle bacilli

Postprimary TB: results from

endogenous reactivation of latent

infection, usually localized to the apical

and posterior segments of the upper

lobes

Disseminated TB:

extrapulmonary TB, miliary

TB

Anatomic alteration

Alveolar

consolidation

Alveolar-capillary

membrane

destruction

Caseous

tubercles or

granulomas

Cavity
formation

Fibrosis and

secondary

calcifications of the

lung parenchyma

Distortion and

dilation of the

bronchi

Increased

bronchial

secretions

route of transmission

AIRBORNE DROPLET INGESTION OF

UNPASTEURIZED

MILK

DIRECT

INOCULATION

THROUGH THE SKIN

CONSTITUTIONAL SYMPTOMS

◦Fatigue

◦Anorexia
◦weight loss

◦low-grade fever

◦night sweats

◦acute febrile illness

◦Chills

◦flulike symptoms

PULMONARY SYMPTOMS

Cough:

• insidious onset

• progressing in

frequency

• mucoid or

mucopurulent

sputum

Hemoptysis Chest pain and

dyspnea

• suggest

extensive

involvement

o Mantoux test
o Acid-fast staining

o Sputum cultures

o CXR

Mantoux test

Most widely used tuberculin

test

Consists of intradermal

injection of a small amount of

PPD of the tuberculin bacillus

Skin is observed for

induration after 48 hours and

72 hours

<5 mm = negative result

o 5 to 9 mm = suspicious, retesting required

o ≥10 mm = positive result

sputum culture

o Necessary to differentiate M. tuberculosis

from other acid-fast organisms (e.g. M. avium,

M. kansasii)

o Can also identify drug-resistant bacilli and

their sensitivity to antibiotic therapy

Radiologic findings

Increased opacity

Ghon nodule and complex

Cavity formation

Cavity lesion containing an air-fluid level

Pleural effusion

Calcification and fibrosis

Retraction of lung segments or lobe

Pharmacological

o Rifampicin

o Isoniazid

o Pyrazinamide

o Ethambutol

o Streptomycin

RIPES STRATEGY

INH and R are first-line

agents prescribed for the

entire 9 mos

INH is the most effective

first-line anti-TB agent

NURSING

MANAGEMENT

Improving Breathing

Pattern

Preventing Transmission of

Infection

Improving Nutritional

Status

BRONCHIAL

ASTHMA

Description

chronic inflammatory disorder of the

airways that causes varying degrees of

obstruction in the airways

marked by airway inflammation and

hyperresponsiveness to a variety of stimuli

or triggers

Triggers

Description

causes recurrent episodes of wheezing,

breathlessness, chest tightness, and

coughing associated with airflow

obstruction that may resolve

spontaneously

often reversible with

treatment

Pathogenesis

The allergic reaction in the airways can result in an

immediate reaction with obstruction occurring, and it

can result in a late bronchial obstructive reaction several

hours after the initial exposure to the precipitant.

Mast cell release of histamine leads to a

bronchoconstrictive process, bronchospasm, and

obstruction.

Pathophysiology
Status asthmaticus

• a severe life-threatening asthma episode that is

refractory to treatment and may result in

pneumothorax, acute cor pulmonale, or respiratory

arrest

Assessment

Dyspnea Wheezing Breathlessness

Chest tightness Cough

Diagnostics •Pulmonary function tests (Spirometry)

Diagnostics

Peak Expiratory Flow Rate (PEFR)

Diagnostics

• Bronchoprovocation Testing aka Methacholine

Challenge Test

• Exercise challenges: Exercise is used to

identify the occurrence of exercise-induced

bronchospasm

Assessment:

Acute Asthma

Attacks
•progressively worsening symptoms

•decrease in expiratory airflow

(speaks in short phrases)

•evidence of air trapping

•hypoxemia

Assessment:

Acute Asthma

Attacks

•Restlessness, apprehension, and

diaphoresis

•Sputum: none to clear and

gelatinous,

•Auscultation: crackles to wheezes to

diminished

PRIORITY

NURSING ACTIONS

1. Assess airway patency and respiratory status.

2. Administer humidified oxygen by NC or SFM.

3. Administer rescue medications.

4. Initiate an intravenous (IV) line.

5. Prepare for CXR if prescribed.

6. Prepare to obtain ABG if prescribed.

Rescue
Medications

• Short-acting b2 agonists (for bronchodilation)

• Anticholinergics (for relief of acute

bronchospasm)

• Systemic corticosteroids (for anti-

inflammatory action to treat reversible airflow

obstruction)

Acute

Respiratory

Failure

•Invasive Mechanical Ventilation

•Heliox administration

•Close monitoring

•Bronchodilator and ICS

Preventive

Medications

• Corticosteroids (for anti-inflammatory action)

• Antiallergic medications (to prevent an adverse response on exposure to an allergen)

• Long-acting b2 agonists (for long-acting bronchodilation)

• Leukotriene modifiers (to prevent bronchospasm and inflammatory cell infiltration)

• Mast cell stabilizers (blocks binding of IgE to mast cells to inhibit inflammation)

Other Interventions

•Chest physiotherapy

•Allergen control

•Increase fluid intake

•Flu vaccinations (6 months and older)

CHRONIC

OBSTRUCTIVE

PULMONARY DISEASE

Description

•Disease of progressive airflow

limitation, associated with an abnormal

inflammatory response of the lungs

that is not completely reversible

•Leads to pulmonary insufficiency,

pulmonary hypertension, and cor

pulmonale.

RISK FACTORS
•Cigarette smoking (primary risk factor)

•Environmental air pollution

•Host factors

•genetic predisposition (α1-

antitrypsin deficiency)

•abnormal lung development

•accelerated aging

Forms

Assessment

• Cough and exertional dyspnea, orthopnea

• Wheezing and crackles, prolonged exp.

• Sputum production

• Weight loss

• Barrel chest (emphysema)

Assessment

•Use of accessory muscles for breathing

•Cardiac dysrhythmias

•Congestion and hyperinflation

•Respiratory acidosis and hypoxemia

Interventions

•Fowler’s position and leaning forward

•Allow activity as tolerated.

•Administer bronchodilators, ICS, and mucolytics as prescribed.

•Administer antibiotics for infection if prescribed.

Interventions

Low FiO2

(1 to 2 L/min) as prescribed

Monitor VS inc. SpO2

Provide respiratory treatments and CPT

Diaphragmatic or abdominal breathing techniques and

pursed-lip breathing techniques.

Assess sputum characteristics

Air

Entrainment

Mask

Air

Entrainment

Mask

Interventions
• Suction PRN

• Monitor weight; small frequent meals

• high-calorie, high-protein diet with

supplements

• Encourage fluid intake up to 3000 mL/day,

unless contraindicated

Pulmonary

Rehabilitation

•Physical conditioning

•Breathing exercises

•Activity pacing

•Self-care activities

•Patient education

Non-Invasive Ventilation (NIV)

•Use of masks (nasal, oro-nasal) to

ventilate the lungs

•GOAL: normalize arterial pH and return

PaCO2

to pre-exacerbation levels

•For stable hemodynamics only

Quiz 2
A client with copd is experiencing dyspnea and has low Pao2 level. The nurse plan to administer oxygen
as ordered

- High oxygen concentration may inhibit the hypoxic stimulus to breath

Which of the following findings would most likely indicate the presence of respiratory infection in client
with asthma

- Cough productive of yellow sputum

Which of the following is priority goal with copd

- Maintain functional ability

Which of the following is priority goal for client with copd

- 76 years old grandmother

Which of the following is primary reason to teach pursed lip breathing to client copd

- Promote carbon dioxide elimination

Which of the following outcome would be appropriate for client with copd who has been discharged
from home

-client agrees to call the physician if dyspnea on exertion increases

A client with copd report steady weight loss and being too tired from just breathing to eat. Which of the
following nursing diagnosis would most appropriate

-imbalanced nutrition: less than body requirement related to fatigue

The nurse obtain s sputum specimen from client with suspected tuberculosis for laboratory study .
Which of the laboratory technique is most commonly identify tubercle bacilli in sputum

-acid fast staining

Which of the following physical assessment findings would the nurse expect to find client with copd

-increased anteropostero chest diameter

A client with acute asthma is prescribed short term corticosteroid therapy which is rationale use of
steroids in client with asthma

-corticosteroids have anti-inflammatory effect

A 34 year old female with history of asthma is admitted to e. r. The nurse notes the client is dyspenic
with respiratory rate 35 breaths/ min. nasal flaring use of accessory muscle

- Administer bronchodilator as prescribes

The client with tuberculosis to be discharge home with community health nurse follow up

-teaching client about disease and its treatment

When instructing client on how decrease the risk of COPD the nurse should be emphasize which
following behavior

-abstain from cigarette smoking

Which the following diet would most appropriate client with copd

-high calorie, high protein diet

Which of the following health promotion activities should the nurse include as discharge plan for client
asthma

-incorporate physical exercise as tolerated into daily routine

When performing postural drainage which of the following factors promote the movement of secretions
from the lower to upper respiratory tract

- Force of gravity

The public health is making follow up care for client with tuberculosis who does not regularly take his
medications
-ask the spouse of client to supervise the daily administration of the medication

The nurse teaching a client who has been diagnosed tuberculosis on how to avoid spreading disease to
the family members

-I should always cover mouth and nose when sneezing

The nurse administer theophylline to a client with copd. To evaluate effectiveness of this medication

-relaxation of bronchial smooth muscles

What is the rationale that supports multi drug treatment for client with tuberculosis

- Multiple drugs reduces development of resistant strains of bacteria.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following
problems is a priority when the nurse develops a nursing plan of care?

Ineffective coughing and deep breathing.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest
discomfort. What should the nurse do first?
1. Elevate the head of the bed 30 to 45 degrees.

A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia.
While obtaining the client's health history, the nurse learns that the client has osteoarthritis,
follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would
most likely be a predisposing factor for the diagnosis of pneumonia?
1. Age.

Which of the following is significant data to gather from a client who has been diagnosed with
pneumonia? Select all that apply.
1. Quality of breath sounds.

3. Occurence of chest pain.

5. Color of nail beds.
A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic
tests must be completed before antibiotic therapy begins?

Sputum culture

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor
which of the following laboratory values?

Serum creatinine

A client with pneumonia has a temperature of 102.6 ° F (39.2 ° C), is diaphoretic, and has a
productive cough. The nurse should include which of the following measures in the plan of
care?
Frequent linen changes

Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The
nurse should determine the effectiveness of bed rest by assessing the client's:
1. Decreased cellular demand for oxygen.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

Decreased oxygenation on the blood

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for

Moderate pain that worsens on inspiration.

Which of the following measures would most likely be successful in reducing pleuritic chest pain
in a client with pneumonia?
4. Teach the client to splint the rib cage when coughing.

The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse
should evaluate the outcome of administering the drug by assessing which of the following?
Select all that apply.
1. Decreased pain when breathing.
Decreased temp
Which of the following mental status changes may occur when a client with pneumonia is first
experiencing hypoxia?

Irritability

The client with pneumonia develops mild constipation, and the nurse administers docusate sodium
(Colace) as ordered. This drug works by:
1. Softening the stool.

Which of the following is an expected outcome for an elderly client following treatment for
bacterial pneumonia
2. The ability to perform activities of daily living without dyspnea.

The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order
should the nurse explain the steps to the client?
1. "Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)."
2. "Relax your neck and shoulder muscles."
3. "Pucker your lips as if you were going to whistle."
4. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two,
three, four)."

2,1,3,4

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease
(COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should:

Assess vital signs

When developing a discharge plan to manage the care of a client with chronic obstructive
pulmonary disease (COPD), the nurse should advise the the client to expect to:
1. Develop respiratory infections easily.

Which of the following indicates that the client with chronic obstructive pulmonary disease
(COPD) who has been discharged to home understands his care plan?
he client agrees to call the physician if dyspnea on exertion increases.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −,
36 mEq/ L. The nurse should assess the client for?

Flushed skin

When teaching a client with chronic obstructive pulmonary disease to conserve energy, the
nurse should teach the client to lift objects:
-2. While exhaling through pursed lips.

The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for
signs and symptoms of right-sided heart failure. Which of the following signs and symptoms
should be included in the teaching plan?
-peripheral edema

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of
chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract
infection. Which of the following findings would be expected?
Coarse crackles

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough
effectively. Which of the following instructions should be included?
1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation

A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action
by the client indicates to the nurse that he needs further instruction regarding its use? Select all
that apply.
1. Activation of the MDI is not coordinated with inspiration. 2. The client inspires rapidly when
using the MDI.
3. The client holds his breath for 3 seconds after inhaling with the MDI.
4. The client shakes the MDI after use. 5. The client performs puffs in rapid succession.

A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2
58; HCO3 26. Which of the following orders should the nurse perform first?
1. Albuterol (P

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a
corticosteroid. Which of the following client actions indicates that he is using the MDI correctly?
Select all that apply.
1. The inhaler is held upright.
. The mouth is rinsed with water following administration.

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4
hours. The nurse instructs the client to report adverse effects. Which of the following are
potential adverse effects of metaproterenol? 1. Irregular heartbeat.

A client who has been taking flunisolide (AeroBid), two inhalations a day, for treatment of
asthma.has painful, white patches in his mouth. Which response by the nurse would be most
appropriate?
You have developed a fungal infection from your medication. It will need to be treated with an
antifungal agent."

Which of the following is an appropriate expected outcome for an adult client with well-controlled
asthma?

Breath sounds are clear

The nurse should teach the client with asthma that which of the following is one of the most common
precipitating factors of an acute asthma attack?

Viral respiratory infections.

Medsurg quiz

1.

A school nurse is educatirig students on modifiable risk factors for 2 points coronary artery
disease (CAD) Which modifiable risk factors should the nurse include in the presentation?
SELECT ALL THAT APPLY
Dm 
HTN
Age
Family history
Sedentary lifestyle
Obesity

2. An adult man rushes himself to the hospital because of severe, chest pain. He is diaphoretic
and in severe distress. Which of the following must you do first?
Administer Nitroglycerin sublingual STAT

Administer chewable Aspirin 165 mg STAT

OGet a 12-lead ECG tracing

Prepare the patient for defibrillation.

Establish a peripheral IV line

3.

Among the following cardiac biomarkers, which is the quickest to

rise or increase in a patient with Myocardial infarction?

CK MB

Troponin I

LDH

Homocysteine

Tringlycerides

4. Consumption of a heavy meal can predispose a patient to

myocardial ischemia secondary to blood shunting

Correct

Incorrect

5. Which of the following blood vessels can be grafted to bypass an obstructed coronary artery?
Select all that apply.

1 point

saphenous veins

Dinternal mammary artery

brachial artery

cephalic vein

1 point

6. A nurse, assessing a client hospitalized following a myocardial infarction (MI), obtains the
following vital signs blood pressure (BP) 78/38 mm Hg, heart rate (HR) 128 respiratory rate
(RR) 32 For which life. threatening complication should the nurse carefully monitor the client?

pulmonary embolism

cardiac tamponade

cardiomyopathy
Cardiogenic shock

7. What term is used to describe a white blood cell (WBC) count that is 1 point

above normal values?

polycythemia

neutropenia

leukopenia

leukocytosis

8. Following a Cardiac Catheterization procedure, which of the

following is/are CORRECT nursing action(s)?

Monitor for nausea, vomiting, and alterations in vital signs

OPlace the patient on complete bed rest for 6 hours

None of these

Olf the antecubital vessel was used as an access point, apply arm sling

All of these

9.If Purkinje system is damaged conduction of the electrical impulse is impaired through the

AV node
Bundle of His

Atria

Ventricles

10. A nurse is instructing a client diagnosed with coronary artery disease about care at home The
nurse determines that teaching is

effective when the client states. SELECT ALL THAT APPLY.

A nurse is instructing a client diagnosed with coronary artery disease about care at home The
nurse determines that teaching is effective

when the client states SELECT ALL THAT APPLY

should carry my nitroglycern in my front pants pocket so it is handy

"If I have chest pain, I stop activity and place one nitroglycerin tablet

under my tongue

"I should always take three nitroglycerin tablets Satiates apart

1 plan to avoid being around people when they are smoking

I plan on wa king n most days of theseos for at east 20 minutes

?11. A nurse should anticipate instructing a client scheduled for a coronary artery bypass graft to:
SELECT ALL THAT APPLY.

discontinue taking aspirin prior to surgery

Operform postoperative cardiac rehabilitation exercises and stress management strategies.

Owash with an antimicrobial soap the evening prior to surgery.

Oshave the chest and legs and then shower to remove the hair. Oresume normal activities when
discharged from the hospital

Dexpect close monitoring after surgery, several intravenous (IV) lines, a

urinary catheter, endotracheal tube, and chest tubes.

12. Which of the following can most definitively diagnose CAD?

Coagulation studies

Cardiac catheterization

12-lead ECG

2D-Echocardiography

Arterial Blood Gas

Pulmonary Function Test

13. Respiratory depression is a serious adverse effect of Morphine

sulphate. Which of the following manifestations will indicate that the

patient is about to go to respiratory arrest?

Hypopnea and/or Hypoventilation

Crackles and/or Rhonchil

Snoring sounds

OSudden increase in BP

Jerking movements of the leg

Because the patient will be under local anesthesia

14. Your patient is scheduled for Cardiac Catheterization tomorrow. As part of your pre-
procedure interventions, you place the patient on NPO 6 hours before the test. Why?

Because the patient will be under local anesthesia

Because the surgeon says so

Because the patient will be under sedation during the test 

Because the patient will be asked to eat during the test

15. Blood for cardiac enzymes and serum laboratory tests are drawn on a diabetic client admitted
to an emergency department (ED) 5 hours after beginning to experience chest pressure. A nurse
reviews the following laboratory results. Which serum laboratory findings should the nurse
report to a primary healthcare provider (HCP) immediately due to the possibility that the chent
may be experiencing a myocardial infarction (MI)? SELECT ALL THAT APPLY

BUN
PTINR
CK-MB
CK
Platelets
Troponin T
Hgb

16. A pistent is brought into the ER with chest pam The physician m having difficulty
confirming the patient's diagnosis through an ECG Blood results show an elevated level of CK-
MB What can the physician suspect after reviewing the blood work?

gastroesophageal reflux

valvular stenosis

myocardial infarction

pulmonary ombolism

17. The nurse is caring for a patient with stable angina Which assensmont finding would be
consistent with this medical diagnosis?

Persistent ECG changes

Increasing nocturnal pain

Correlation between activity levels of pa

Evidence of impained cardiac outout such as weak peripheral pulses

18. How would you prepare a patient for an exercise stress test?

instruct to wear shoes with rubber soles.

Advise to wear thick clothes

Maintain on NPO for at least 6 hours:

Ensure a Chost X ray film is available prior to the test

?19. Which of the following ECG changes can be seen in patients with

ischemic heart diseases? Select all that apply

Twave depression

T wave inversion:

ST segment elevation

deep wave

20. A diet high in sodium can significantly reduce a person's blood

pressure

Correct

Incorrect

21. Which of the following enzymes is most accurate and reliable in diagnosing Myocardial
Infarction?

Myoglobin

Homocysteine

CK MB

Troponin I

C-Reactive Protein

Central Venous Pressure

1. What term is used to described a red blood cell (rbc) count that is  below normal values?

leukocytosis

anemia

Opolycythemia
leukopenia

23. What are the drug therapy targets for angina treatment?

Decrease heart rate, increase activation of RAAS system

Increase cardiac output, decrease body fluid volume

Improve myocardial perfusion, reduce metabolic demand

Vasodilation, dilation of large veins results in decreased pre-load and

decreased blood pressure.

24. Which of the following diagnostic tests can confirm if hyperlipidemia 1 is a risk factor for a
patient's CAD?

Total Cholesterol levels

OSGOT, SGPT

OLDH

OFasting Blood Sugar

25. Your patient is scheduled for Cardiac Catheterization tomorrow As part of your assessment,
you confirmed the presence of allergies to seafood Which medication will you expect to
administer?

Salbutamol

Diphenhydramine

Dobutamine

Epinephrine

26. Which of the following medications is administered to induce coronary arterial dilation?

Salbutamol

Nitroglycerin

Metoprolol
Epinephrine

Naloxone

27. Blood tests such as lipid levels must be the first diagnostic test to be performed in a patent
with acute chest pain

Correct

Incorrect

28. The nurse instruct the patient about modifiable risk factors for coronary artery disease (CAD)
Which statements indicate that teaching has been effective? (Check all that apply)

1 should drink alcohol because this prevents heart disease

Obesity is a risk factor that I can change to reduce the onset of heart disease

There is not much that can be done to prevent heart disease

Restricting my activity reduces the onset of heart disease

I should stop smoking to reduce my risk of heart disease

29. A nurse is teaching a client about precautions with warfarin (Coumadin) therapy. The client
should be instructed to avoid which over the counter medication?

Histamine blockers

Laxatives containing magnesium salts

Cough medicines with guadinessin

Non steroidal anti-inflammatory drugs (NSAIDs)

30. A nurse is taking care of a patient with Angina Pectoris What specific drug can be used to
manage chest pain immediately? No acronym or abbreviation

Answer nitroglycerin

31. An informed consent is required prior to Cardiac Catheterization

This statement is INCORRECT

This statement is CORRECT

32. A person who initially comes to the ER due to a complaint of chest pain can go to cardiac
arrest at any point in time especially without immediate and proper medical intervention

Correct

Incorrect

33. A nurse is teaching a client newly diagnosed with chronic stable angina Which instructions
should the nurse incorporate in the teaching session on measures to prevent future angina?
SELECT ALL THAT APPLY

Maintain complete bed rest without bathroom privileges

Wear a Facemask when outdoors in cold weather

Take nitroglycent before a stressful situation even though pain is not present

Perform most exertional ar fivities in the morning

Avoid straining at stool

Eliminate tobacco use

34. The location of the coronary obstruction can be identified by which

of the following test?

12-lead ECG

WBC count with differential

CK-MB levels

Troponin I

OC-Reactive Protein

Chest X-ray

35. Which of the following statements is/are TRUE regarding Ischemic

Heart Diseases?

1. Coronary Atherosclerosis is caused by a ruptured blood vessel

2 12-lead ECG is a mainstay in the diagnosis of these conditions

3 WBC with differential does not diagnose IHD

4. Cardiac enzymes rise secondary to schemia and/or infarction

12.4

1,2

1234

2,4

3 only

3,4

36. Clrent Bong is diagnosed with class II heart failure according to the New York Heart
Association Functional Classification has been taught about the initial treatment plan for this
disease You determine that the chent needs additional teaching if he states that the treatment plan
includes

Odiuretics

a low sodium diet

home oxygen therapy

CACE inhibitors

37. You are the incoming Recovery Room Nurse. The circulating nurse and the OR team are
transporting a SIP CABG patient to the PACU. Which of the following assessments should you
give priority to this patient?

circulation

airway

breathing

Painscale

38. What is the primary reason for administering morphine to a client with mi?

Decrease oxygen demand on the client's heart

Decrease the client's anxiety

to decrease the client's pain

To sedate the client

39. Prior to a stress test the NOD must instruct the client to avoid taking a hot ball or shower for
at least 1 to 2 hours

This is NOT the responsibility of the muse

This action is CORRECT

This actions INCORRECT

40. A client with a myocardial infarction is admitted to the cardiac unit The nurse can best
determine the effectiveness of the client's ventricular contractions by

observing anxiety levels

evaluating enzyme levels

monitoring urinary output hourly

assessing breath sounds frequently

41. During examination of a patient's extremites you press firmly for a tpoint brief period on a
tingemail You observe that it takes about 5 seconds for the color to relium to the nel bed. This
finding is most consistent with which of the following?

reduction in cardiac output of poor peripharat perfusion

presence of a disorder causing systemic hypertension

presence of a disorder causing chronic hypoxemia. 

reduction in vandus ridurn to the right side of the heart

42. A patient with angina pectoris is being discharged home with nitroglycerine tablets Which of
the following instructions does the nurse include in the teaching?

When your chest pain begins, lie down, and place one tablet under. your tongue. If the pain
continues, take two tablets in 5 minutes" 

'Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital"
"Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital"

"Place one Nitroglycerine tablet under the tongue every five minutes for unrelieved pain for a
maximum of three doses Go to the hospital if the pain is unrelieved

43. Which of the following is TRUE or CORRECT regarding the chost pain experienced by the
patient with Myocardial Infarction?

1 may radiate to the jaw, back, and left arm

unrelieved by rest or nitroglycerin

3 rolioved only by opioids

4 lasts 10 minutes

5 lasts 30 minutes or longer

1,3
134
125
2,4
1,2,3
1,2,3,5

44. To enhance the porculaneous absorption of nitroglycerine ointment it would be MOST

important for the nurse to select a site that is

muscular

Onear the heart

non-hairy

over bony prominence

45. A chent diagnosed with chronic stable angina, telephones a clinic nuise. The client reports a
headache lasting for several days after taking one dose of isosorbide mononitrate (imdure) The
client also reports symptoms of orthostatic hypotension and palpitations which is the nurse's best
action?

Recommend that the client make an appointment with the health care provider

Have the client resime the dose to take it later in the day when the client is more active
instruct the chent to take two paracetamol 300 mg tablets when taking the imdur dose

tenen the cent mas the headaches subside over time   with  continue medication use

In a client with status asthmaticus, which of the following should the nurse monitor the client for early
manifestation?

Respiratory acidosis

The primary structural alteration in pulmonary emphysema is:

Distended ineffective alveoli related to chronic bronchial obstruction.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic
episodes. Which of the following positions least likely alleviate dyspnea?

Sitting up and leaning on a table or lying supine with feet elevated

The community health nurse is conducting an educational session with community members regarding
the signs and symptoms associated with TB. Which of the following is least likely a sign and symptom?

Headache

The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which
items when performing this care?"

Particulate respirator, gown and gloves

The nurse instructs a client to use the pursed-lip method of breathing and determines that the client
understands if the client states that its primary purpose is to promote which outcome?

Promote carbon dioxide elimination.

Which of the following medications has a bronchodilation effect?

Long-acting B2 agonists

When dealing with patients with asthma attack immediate intervention is necessary because the
continuing and progressive dyspnea leads to increased anxiety, aggravating the situation. The nurse is to
administer aminophylline to a client with acute asthma attack. When asked why the drug is being
administered, the nurse's BEST reply would be:

"It will relax smooth muscle of the bronchial airway."

The nurse is instructing a client with emphysema about measures that will enhance the effectiveness of
breathing during dyspneic periods. Which position should the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

What is the leading risk factor of COPD?

Cigarette smoking

Which of the following cues is an indication of an acute asthma attack?

Patient speaks in short phrases.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been
receiving medication for 2 wks. The nurse determines that the client has understood the information if
the client makes which statement?

"I should not be contagious after 2-3 wks of medication therapy."

Status asthmaticus is refractory to treatment and may result in:

Pneumothorax.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated
for tuberculosis. Which instruction is least likely to be included in the list?

Avoid contact with other individuals, except family members, for at least 6 months.

In the Provincial Clinic, the nurse administers Mantoux skin test to a client today. The nurse tells the
client to be back in the clinic to have the results read after:

48-72 hrs

Which of the following is a priority nursing action in an acute asthma attack?

Assess airway patency and respiratory status

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which findings would the
nurse expect to note on assessment of this client?

A hyperinflated chest noted on the chest x-ray

The oxygen delivery system is prescribed for a client with COPD. Which oxygen device would the nurse
prepare for the client?

venturi mask

QUIZLET

A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining
a comprehensive health history or full physical examination is unnecessary until the
acute distress has resolved. Brief questioning and a focused physical assessment
should be done rapidly to help determine the cause of the distress and suggest
treatment. Checking for allergies is important, but it is not appropriate to complete the
entire admission database at this time. The initial respiratory assessment must be
completed before any diagnostic tests or interventions can be ordered.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler's position with the left arm extended
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the
pleural space is easier. The other positions would increase the work of breathing for the
patient and make it more difficult for the health care provider performing the
thoracentesis

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg;
PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic
acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal
retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would
not be caused by acidosis.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse document this
finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are
high-pitched sounds. They can be heard during the expiratory or inspiratory phase of
the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural
friction rubs are grating sounds that are usually heard during both inspiration and
expiration
The nurse palpates the posterior chest while the patient says "99" and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the patient repeats a word or phrase such as "99." After noting absent
fremitus, the nurse should then auscultate the lungs to assess for the presence or
absence of breath sounds. Absent fremitus may be noted with pneumothorax or
atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors,
thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing
is an appropriate intervention for atelectasis, but the nurse needs to first assess breath
sounds. Fremitus is decreased if the hand is farther from the lung or the lung is
hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for
fremitus because of the presence of large muscles and breast tissue.
A patient with a chronic cough has a bronchoscopy. After the procedure, which
intervention by the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus.
ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local
anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse
should monitor for the return of these reflexes before allowing the patient to take oral
fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient
does not need to be on bed rest, and the head of the bed does not need to be in the
high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of
heart failure. When auscultating the patient's lungs, which finding would the nurse most
likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are
continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles
are a series of long-duration, discontinuous, low-pitched sounds during inspiration.
Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
While caring for a patient with respiratory disease, the nurse observes that the patient's
SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the
priority action of the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
ANS: C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs
supplemental oxygen when exercising. The other actions are also important, but the first
action should be to correct the hypoxemia.
The nurse teaches a patient about pulmonary function testing (PFT). Which statement,
if made by the patient, indicates teaching was effective?
a. "I will use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I should inhale deeply and blow out as hard as I can during the test."
d. "My blood pressure and pulse will be checked every 15 minutes after the test."
ANS: C
For PFT, the patient should inhale deeply and exhale as long, hard, and fast as
possible. The other actions are not needed with PFT. The administration of inhaled
bronchodilators should be avoided 6 hours before the procedure.
The nurse observes a student who is listening to a patient's lungs who is having no
problems with breathing. Which action by the student indicates a need to review
respiratory assessment skills?
a. The student starts at the apices of the lungs and moves to the bases.
b. The student compares breath sounds from side to side avoiding bony areas.
c. The student places the stethoscope over the posterior chest and listens during
inspiration.
d. The student instructs the patient to breathe slowly and a little more deeply than
normal through the mouth.
ANS: C
Listening only during inspiration indicates the student needs a review of respiratory
assessment skills. At each placement of the stethoscope, listen to at least one cycle of
inspiration and expiration. During chest auscultation, instruct the patient to breathe
slowly and a little deeper than normal through the mouth. Auscultation should proceed
from the lung apices to the bases, comparing opposite areas of the chest, unless the
patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7).
Place the stethoscope over lung tissue, not over bony prominences.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was
hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of
89% to 90%). In planning for discharge, which action by the nurse will be most effective
in improving compliance with discharge teaching?
a. Start giving the patient discharge teaching on the day of admission.
b. Have the patient repeat the instructions immediately after teaching.
c. Accomplish the patient teaching just before the scheduled discharge.
d. Arrange for the patient's caregiver to be present during the teaching.
ANS: D
Hypoxemia interferes with the patient's ability to learn and retain information, so having
the patient's caregiver present will increase the likelihood that discharge instructions will
be followed. Having the patient repeat the instructions will indicate that the information
is understood at the time, but it does not guarantee retention of the information.
Because the patient is likely to be distracted just before discharge, giving discharge
instructions just before discharge is not ideal. The patient is likely to be anxious and
even more hypoxemic than usual on the day of admission, so teaching about discharge
should be postponed.
A patient is admitted to the emergency department complaining of sudden onset
shortness of breath and is diagnosed with a possible pulmonary embolus. How should
the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Start an IV so contrast media may be given.
b. Ensure that the patient has been NPO for at least 6 hours.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to undress to the waist and remove any metal objects.
ANS: A
Spiral computed tomography (CT) scans are the most commonly used test to diagnose
pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered
but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray
includes undressing and removing any metal. Bronchoscopy is used to detect changes
in the bronchial tree, not to assess for vascular changes, and the patient should be NPO
6 to 12 hours before the procedure. Positron emission tomography (PET) scans are
most useful in determining the presence of malignancy, and a radioactive glucose
preparation is used.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which
statement indicates that the patient may need teaching regarding medication use?
a. "I have not had any acute asthma attacks during the last year."
b. "I became short of breath an hour before coming to the hospital."
c. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain."
d. "I've been using my albuterol inhaler more frequently over the last 4 days."
ANS: D
The increased need for a rapid-acting bronchodilator should alert the patient that an
acute attack may be imminent and that a change in therapy may be needed. The patient
should be taught to contact a health care provider if this occurs. The other data do not
indicate any need for additional teaching.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan.
Which information obtained by the nurse is a priority to communicate to the health care
provider before the CT?
a. Allergy to shellfish
b. Apical pulse of 104
c. Respiratory rate of 30
d. Oxygen saturation of 90%
ANS: A
Because iodine-based contrast media is used during a spiral CT, the patient may need
to have the CT scan without contrast or be premedicated before injection of the contrast
media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need
for further assessment or intervention but do not indicate a need to modify the CT
procedure.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding
would require immediate action?
a. The bicarbonate level (HCO3-) is 31 mEq/L.
b. The arterial oxygen saturation (SaO2) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D
All the values are abnormal, but the low PaO2 indicates that the patient is at the point
on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause
a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse
should intervene immediately to improve the patient's oxygenation.
When assessing the respiratory system of an older patient, which finding indicates that
the nurse should take immediate action?
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral crackles at lung bases
ANS: D
Crackles in the lower half of the lungs indicate that the patient may have an acute
problem such as heart failure. The nurse should immediately accomplish further
assessments, such as oxygen saturation, and notify the health care provider. A barrel-
shaped chest, hyperresonance to percussion, and a weak cough effort are associated
with aging. Further evaluation may be needed, but immediate action is not indicated. An
older patient has a less forceful cough and fewer and less functional cilia. Mucous
membranes tend to be drier.
A patient in metabolic alkalosis is admitted to the emergency department, and pulse
oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse
take next?
a. Administer bicarbonate.
b. Complete a head-to-toe assessment.
c. Place the patient on high-flow oxygen.
d. Obtain repeat arterial blood gases (ABGs).
ANS: C
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation
curve will decrease the amount of oxygen delivered to tissues, so high oxygen
concentrations should be given. Bicarbonate would worsen the patient's condition. A
head-to-toe assessment and repeat ABGs may be implemented. However, the priority
intervention is to give high-flow oxygen.
After the nurse has received change-of-shift report, which patient should the nurse
assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with possible lung cancer who has just returned after bronchoscopy
c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function
testing (PFT) that indicates low forced vital capacity
ANS: B
Because the cough and gag are decreased after bronchoscopy, this patient should be
assessed for airway patency. The other patients do not have clinical manifestations or
procedures that require immediate assessment by the nurse.
The laboratory has just called with the arterial blood gas (ABG) results on four patients.
Which result is most important for the nurse to report immediately to the health care
provider?
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
ANS: D
These ABGs indicate uncompensated respiratory acidosis and should be reported to
the health care provider. The other values are normal or close to normal.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who
has been admitted with increasing dyspnea over the last 3 days. Which finding is most
important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/minute.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
ANS: A
The increase in respiratory rate indicates respiratory distress and a need for rapid
interventions such as administration of oxygen or medications. The other findings are
common chronic changes occurring in patients with COPD.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel
(UAP)?
a. Listen to a patient's lung sounds for wheezes or rhonchi.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient's intradermal skin test.
ANS: B
Labeling of specimens is within the scope of practice of UAP. The other actions require
nursing judgment and should be done by licensed nursing personnel.
A patient is scheduled for a computed tomography (CT) of the chest with contrast
media. Which assessment findings should the nurse immediately report to the health
care provider (select all that apply)?
a. Patient is claustrophobic.
b. Patient is allergic to shellfish.
c. Patient recently used a bronchodilator inhaler.
d. Patient is not able to remove a wedding band.
e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
ANS: B, E
Because the contrast media is iodine-based and may cause dehydration and decreased
renal blood flow, asking about iodine allergies (such as allergy to shellfish) and
monitoring renal function before the CT scan are necessary. The other actions are not
contraindications for CT of the chest, although they may be for other diagnostic tests,
such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing

diagnosis of ineffective airway clearance. Which assessment data best supports this
diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway
effectively. The other data would be used to support diagnoses such as impaired gas
exchange and ineffective breathing pattern.
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which
finding would the nurse expect?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation
ANS: A
Increased tactile fremitus over the area of pulmonary consolidation is expected with
bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal
pneumonia typically presents with a loose, productive cough. Adventitious breath
sounds such as crackles and wheezes are typical. A grating sound is more
representative of a pleural friction rub rather than pneumonia.
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's
most appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Teach the patient about the need for fluid restrictions.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
ANS: A
Coughing is less painful and more likely to be effective when the patient splints the
chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal
oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip
breathing is used to improve gas exchange in patients with COPD, but will not improve
airway clearance.
4. The nurse provides discharge instructions to a patient who was hospitalized for
pneumonia. Which statement, if made by the patient, indicates a good understanding of
the instructions?
a. "I will call the doctor if I still feel tired after a week."
b. "I will continue to do the deep breathing and coughing exercises at home."
c. "I will schedule two appointments for the pneumonia and influenza vaccines."
d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is
expected for several weeks. The Pneumovax and influenza vaccines can be given at
the same time in different arms. Explain that a follow-up chest x-ray needs to be done in
6 to 8 weeks to evaluate resolution of pneumonia.
5. The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which
nursing action will be most effective?
a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
d. Insert nasogastric tube for feedings for patients with swallowing problems.
ANS: B
The risk for aspiration is decreased when patients with a decreased level of
consciousness are placed in a side-lying or upright position. Frequent turning prevents
pooling of secretions in immobilized patients but will not decrease the risk for aspiration
in patients at risk. Monitoring of parameters such as breath sounds and oxygen
saturation will help detect pneumonia in immunocompromised patients, but it will not
decrease the risk for aspiration. Conditions that increase the risk of aspiration include
decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol
intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration
is more likely to occur. Other high-risk groups are those who are seriously ill, have poor
dentition, or are receiving acid-reducing medications.
6. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3
days. Which assessment data obtained by the nurse indicates that the treatment has
been effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient's white blood cell (WBC) count is 9000/µL.
d. Increased tactile fremitus is palpable over the right chest.
ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other
data suggest that a change in treatment is needed.
7. The health care provider writes an order for bacteriologic testing for a patient who has
a positive tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d. Instruct the patient to expectorate three specimens as soon as possible.
ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for
M. tuberculosis. The patient should not provide all the specimens at once. Blood
cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing.
Although the findings on chest x-ray examination are important, it is not possible to
make a diagnosis of TB solely based on chest x-ray findings because other diseases
can mimic the appearance of TB.
8. A patient is admitted with active tuberculosis (TB). The nurse should question a
health care provider's order to discontinue airborne precautions unless which
assessment finding is documented?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
ANS: D
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the
sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays
are not used to determine whether treatment has been successful. Taking medications
for 6 months is necessary, but the multidrug-resistant forms of the disease might not be
eradicated after 6 months of therapy. Repeat Mantoux testing would not be done
because the result will not change even with effective treatment.
9. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB).
Which statement, if made by the patient, indicates that teaching was effective?
a. "I will avoid being outdoors whenever possible."
b. "My husband will be sleeping in the guest bedroom."
c. "I will take the bus instead of driving to visit my friends."
d. "I will keep the windows closed at home to contain the germs."
ANS: B
Teach the patient how to minimize exposure to close contacts and household members.
Homes should be well ventilated, especially the areas where the infected person
spends a lot of time. While still infectious, the patient should sleep alone, spend as
much time as possible outdoors, and minimize time in congregate settings or on public
transportation.
10. A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports
having orange discolored urine and tears. Which is the best response by the nurse?
a. Ask if the patient is experiencing shortness of breath, hives, or itching.
b. Ask the patient about any visual abnormalities such as red-green color discrimination.
c. Explain that orange discolored urine and tears are normal while taking this
medication.
d. Advise the patient to stop the drug and report the symptoms to the health care
provider.
ANS: C
Orange-colored body secretions are a side effect of rifampin. The patient does not have
to stop taking the medication. The findings are not indicative of an allergic reaction.
Alterations in red-green color discrimination commonly occurs when taking ethambutol
(Myambutol), which is a different TB medication.
11. An older patient is receiving standard multidrug therapy for tuberculosis (TB). The
nurse should notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged skin
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices
ANS: A
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide,
and patients who develop hepatotoxicity will need to use other medications. Changes in
hearing and nail thickening are not expected with the four medications used for initial TB
drug therapy. Presbycusis is an expected finding in the older adult patient. Orange
discoloration of body fluids is an expected side effect of rifampin and not an indication to
call the health care provider.
12. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which
intervention by the nurse will be most effective in ensuring adherence with the treatment
regimen?
a. Arrange for a friend to administer the medication on schedule.
b. Give the patient written instructions about how to take the medications.
c. Teach the patient about the high risk for infecting others unless treatment is followed.
d. Arrange for a daily noon meal at a community center where the drug will be
administered.
ANS: D
Directly observed therapy is the most effective means for ensuring compliance with the
treatment regimen, and arranging a daily meal will help ensure that the patient is
available to receive the medication. The other nursing interventions may be appropriate
for some patients but are not likely to be as helpful for this patient.
13. After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin),
pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum
smears for acid-fast bacilli (AFB). Which action should the nurse take next?
a. Teach about treatment for drug-resistant TB treatment.
b. Ask the patient whether medications have been taken as directed.
c. Schedule the patient for directly observed therapy three times weekly.
d. Discuss with the health care provider the need for the patient to use an injectable
antibiotic.
ANS: B
The first action should be to determine whether the patient has been compliant with
drug therapy because negative sputum smears would be expected if the TB bacillus is
susceptible to the medications and if the medications have been taken correctly.
Assessment is the first step in the nursing process. Depending on whether the patient
has been compliant or not, different medications or directly observed therapy may be
indicated. The other options are interventions based on assumptions until an
assessment has been completed.
14. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm
induration and a negative chest x-ray for a staff nurse working on the pulmonary unit.
The nurse has no symptoms of TB. Which information should the occupational health
nurse plan to teach the staff nurse?
a. Standard four-drug therapy for TB
b. Need for annual repeat TB skin testing
c. Use and side effects of isoniazid (INH)
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: C
The nurse is considered to have a latent TB infection and should be treated with INH
daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had
active TB. TB skin testing is not done for individuals who have already had a positive
skin test. BCG vaccine is not used in the United States for TB and would not be helpful
for this individual, who already has a TB infection.
15. When caring for a patient who is hospitalized with active tuberculosis (TB), the
nurse observes a student nurse who is assigned to take care of a patient. Which action,
if performed by the student nurse, would require an intervention by the nurse?
a. The patient is offered a tissue from the box at the bedside.
b. A surgical face mask is applied before visiting the patient.
c. A snack is brought to the patient from the unit refrigerator.
d. Hand washing is performed before entering the patient's room.
ANS: B
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical
mask, should be used when entering the patient's room because the HEPA mask can
filter out 100% of small airborne particles. Hand washing before entering the patient's
room is appropriate. Because anorexia and weight loss are frequent problems in
patients with TB, bringing food to the patient is appropriate. The student nurse should
perform hand washing after handling a tissue that the patient has used, but no
precautions are necessary when giving the patient an unused tissue.
16. An occupational health nurse works at a manufacturing plant where there is
potential exposure to inhaled dust. Which action, if recommended by the nurse, will be
most helpful in reducing the incidence of lung disease?
a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing.
ANS: C
Prevention of lung disease requires the use of appropriate protective equipment such as
masks. The other actions will help in recognition or early treatment of lung disease but
will not be effective in prevention of lung damage. Repeated exposure eventually results
in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
17. The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking
about lung disease. Which information will be most important for the nurse to include?
a. Options for smoking cessation
b. Reasons for annual sputum cytology testing
c. Erlotinib (Tarceva) therapy to prevent tumor risk
d. Computed tomography (CT) screening for lung cancer
ANS: A
Because smoking is the major cause of lung cancer, the most important role for the
nurse is teaching patients about the benefits of and means of smoking cessation. CT
scanning is currently being investigated as a screening test for high-risk patients.
However, if there is a positive finding, the person already has lung cancer. Erlotinib may
be used in patients who have lung cancer, but it is not used to reduce the risk of
developing cancer.
18. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The
patient tells the nurse, "I would rather have chemotherapy than surgery." Which
response by the nurse is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Did you have bad experiences with previous surgeries?"
c. "Surgery is the treatment of choice for stage I lung cancer."
d. "Tell me what you know about the various treatments available."
ANS: D
More assessment of the patient's concerns about surgery is indicated. An open-ended
response will elicit the most information from the patient. The answer beginning,
"Surgery is the treatment of choice" is accurate, but it discourages the patient from
sharing concerns about surgery. The remaining two answers indicate that the nurse has
jumped to conclusions about the patient's reasons for not wanting surgery.
Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung
cancer, chemotherapy may be used in the treatment of nonresectable tumors or as
adjuvant therapy to surgery.
19. An hour after a thoracotomy, a patient complains of incisional pain at a level 7
(based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural
drainage system has 100 mL of bloody drainage and a large air leak. Which action is
best for the nurse to take next?
a. Milk the chest tube gently to remove any clots.
b. Clamp the chest tube momentarily to check for the origin of the air leak.
c. Assist the patient to deep breathe, cough, and use the incentive spirometer.
d. Set up the patient controlled analgesia (PCA) and administer the loading dose of
morphine.
ANS: D
The patient is unlikely to take deep breaths or cough until the pain level is lower. A
chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would
not require milking of the chest tube. An air leak is expected in the initial postoperative
period after thoracotomy.
20. A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to
live to see my next birthday." Which response by the nurse is best?
a. "Would you like to talk to the hospital chaplain about your feelings?"
b. "Can you tell me what it is that makes you think you will die so soon?"
c. "Are you afraid that the treatment for your cancer will not be effective?"
d. "Do you think that taking an antidepressant medication would be helpful?"
ANS: B
The nurse's initial response should be to collect more assessment data about the
patient's statement. The answer beginning "Can you tell me what it is" is the most open-
ended question and will offer the best opportunity for obtaining more data. The answer
beginning, "Are you afraid" implies that the patient thinks that the cancer will be
immediately fatal, although the patient's statement may not be related to the cancer
diagnosis. The remaining two answers offer interventions that may be helpful to the
patient, but more assessment is needed to determine whether these interventions are
appropriate.
21. The nurse monitors a patient after chest tube placement for a hemopneumothorax.
The nurse is most concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
ANS: B
The large amount of blood may indicate that the patient is in danger of developing
hypovolemic shock. An air leak would be expected immediately after chest tube
placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber
when a pneumothorax is evacuated. The pain should be treated but is not as urgent a
concern as the possibility of continued hemorrhage. Subcutaneous emphysema should
be monitored but is not unusual in a patient with pneumothorax. A small amount of
subcutaneous air is harmless and will be reabsorbed.
22. A patient experiences a chest wall contusion as a result of being struck in the chest
with a baseball bat. The emergency department nurse would be most concerned if
which finding is observed during the initial assessment?
a. Paradoxic chest movement
b. Complaint of chest wall pain
c. Heart rate of 110 beats/minute
d. Large bruised area on the chest
ANS: A
Paradoxic chest movement indicates that the patient may have flail chest, which can
severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall
pain, a slightly elevated pulse rate, and chest bruising all require further assessment or
intervention, but the priority concern is poor gas exchange.
23. When assessing a patient who has just arrived after an automobile accident, the
emergency department nurse notes tachycardia and absent breath sounds over the
right lung. For which intervention will the nurse prepare the patient?
a. Emergency pericardiocentesis
b. Stabilization of the chest wall with tape
c. Administration of an inhaled bronchodilator
d. Insertion of a chest tube with a chest drainage system
ANS: D
The patient's history and absent breath sounds suggest a right-sided pneumothorax or
hemothorax, which will require treatment with a chest tube and drainage. The other
therapies would be appropriate for an acute asthma attack, flail chest, or cardiac
tamponade, but the patient's clinical manifestations are not consistent with these
problems.
24. A patient who has a right-sided chest tube following a thoracotomy has continuous
bubbling in the suction-control chamber of the collection device. Which action by the
nurse is most appropriate?
a. Document the presence of a large air leak.
b. Notify the surgeon of a possible pneumothorax.
c. Take no further action with the collection device.
d. Adjust the dial on the wall regulator to decrease suction.
ANS: C
Continuous bubbling is expected in the suction-control chamber and indicates that the
suction-control chamber is connected to suction. An air leak would be detected in the
water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing
the vacuum source will not adjust the suction pressure. The amount of suction applied is
regulated by the amount of water in this chamber and not by the amount of suction
applied to the system.
25. The nurse provides preoperative instruction for a patient scheduled for a left
pneumonectomy for cancer of the lung. Which information should the nurse include
about the patient's postoperative care?
a. Positioning on the right side
b. Bed rest for the first 24 hours
c. Frequent use of an incentive spirometer
d. Chest tube placement with continuous drainage
ANS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent
atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on
the surgical side. Early mobilization decreases the risk for postoperative complications
such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may
or may not be placed in the space from which the lung was removed. If a chest tube is
used, it is clamped and only released by the surgeon to adjust the volume of
serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it
could compress the remaining lung and compromise the cardiovascular and pulmonary
function. Daily chest x-rays can be used to assess the volume and space.
26. The nurse administers prescribed therapies for a patient with cor pulmonale and
right-sided heart failure. Which assessment would best evaluate the effectiveness of the
therapies?
a. Observe for distended neck veins.
b. Auscultate for crackles in the lungs.
c. Palpate for heaves or thrills over the heart.
d. Review hemoglobin and hematocrit values.
ANS: A
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical
manifestations of right ventricular failure such as peripheral edema, jugular venous
distention, and right upper-quadrant abdominal tenderness would be expected.
Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor
pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG
and an increase in intensity of the second heart sound. Heaves or thrills are not
common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased
total blood volume and viscosity of the blood. The hemoglobin and hematocrit values
are more likely to be elevated with cor pulmonale than decreased.
27. A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving
nifedipine (Procardia). Which assessment would best indicate to the nurse that the
patient's condition is improving?
a. Blood pressure (BP) is less than 140/90 mm Hg.
b. Patient reports decreased exertional dyspnea.
c. Heart rate is between 60 and 100 beats/minute.
d. Patient's chest x-ray indicates clear lung fields.
ANS: B
Because a major symptom of IPAH is exertional dyspnea, an improvement in this
symptom would indicate that the medication was effective. Nifedipine will affect BP and
heart rate, but these parameters would not be used to monitor the effectiveness of
therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the
therapy is not effective.
28. A patient with a pleural effusion is scheduled for a thoracentesis. Which action
should the nurse take to prepare the patient for the procedure?
a. Start a peripheral IV line to administer the necessary sedative drugs.
b. Position the patient sitting upright on the edge of the bed and leaning forward.
c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time.
d. Remove the water pitcher and remind the patient not to eat or drink anything for 6
hours.
ANS: B
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases
and can more easily be located and removed. The patient does not usually require
sedation for the procedure, and there are no restrictions on oral intake because the
patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is
removed at one time. Rapid removal of a large volume can result in hypotension,
hypoxemia, or pulmonary edema.
29. The nurse completes discharge teaching for a patient who has had a lung
transplant. The nurse evaluates that the teaching has been effective if the patient
makes which statement?
a. "I will make an appointment to see the doctor every year."
b. "I will stop taking the prednisone if I experience a dry cough."
c. "I will not worry if I feel a little short of breath with exercise."
d. "I will call the health care provider right away if I develop a fever."
ANS: D
Low-grade fever may indicate infection or acute rejection so the patient should notify the
health care provider immediately if the temperature is elevated. Patients require
frequent follow-up visits with the transplant team. Annual health care provider visits
would not be sufficient. Home oxygen use is not an expectation after lung transplant.
Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough,
and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including
prednisone, needs to be continued to prevent rejection.
30. A patient has just been admitted with probable bacterial pneumonia and sepsis.
Which order should the nurse implement first?
a. Chest x-ray via stretcher
b. Blood cultures from two sites
c. Ciprofloxacin (Cipro) 400 mg IV
d. Acetaminophen (Tylenol) rectal suppository
ANS: B
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be
obtained before antibiotic administration. The chest x-ray and acetaminophen
administration can be done last.
31. The nurse cares for a patient who has just had a thoracentesis. Which assessment
information obtained by the nurse is a priority to communicate to the health care
provider?
a. Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: A
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of
88% indicates that a complication such as pneumothorax may be occurring. The other
assessment data also indicate a need for ongoing assessment or intervention, but the
low oxygen saturation is the priority.
32. A patient who has just been admitted with community-acquired pneumococcal
pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of
severe pleuritic chest pain. Which prescribed medication should the nurse give first?
a. Codeine
b. Guaifenesin (Robitussin)
c. Acetaminophen (Tylenol)
d. Piperacillin/tazobactam (Zosyn)
ANS: D
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The
other medications are also appropriate and should be given as soon as possible, but the
priority is to start antibiotic therapy.
33. A patient is diagnosed with both human immunodeficiency virus (HIV) and active
tuberculosis (TB) disease. Which information obtained by the nurse is most important to
communicate to the health care provider?
a. The Mantoux test had an induration of 7 mm.
b. The chest-x-ray showed infiltrates in the lower lobes.
c. The patient is being treated with antiretrovirals for HIV infection.
d. The patient has a cough that is productive of blood-tinged mucus.
ANS: C
Drug interactions can occur between the antiretrovirals used to treat HIV infection and
the medications used to treat TB. The other data are expected in a patient with HIV and
TB.
34. A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough,
and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and
needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as
the highest priority?
a. Hyperthermia related to infectious illness
b. Impaired transfer ability related to weakness
c. Ineffective airway clearance related to thick secretions
d. Impaired gas exchange related to respiratory congestion
ANS: D
All these nursing diagnoses are appropriate for the patient, but the patient's oxygen
saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange
is improved.
35. The nurse supervises unlicensed assistive personnel (UAP) who are providing care
for a patient with right lower lobe pneumonia. The nurse should intervene if which action
by UAP is observed?
a. UAP splint the patient's chest during coughing.
b. UAP assist the patient to ambulate to the bathroom.
c. UAP help the patient to a bedside chair for meals.
d. UAP lower the head of the patient's bed to 15 degrees.
ANS: D
Positioning the patient with the head of the bed lowered will decrease ventilation. The
other actions are appropriate for a patient with pneumonia.
36. A patient with a possible pulmonary embolism complains of chest pain and difficulty
breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60
mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient's health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position.
ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the
head of the bed will improve ventilation and gas exchange. The other actions can be
accomplished after the head is elevated (and oxygen is started). A spiral CT may be
ordered by the health care provider to identify PE. Anticoagulants may be ordered after
confirmation of the diagnosis of PE.
37. The nurse receives change-of-shift report on the following four patients. Which
patient should the nurse assess first?
a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing
scheduled
b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of
breath
c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications
due in 15 minutes
d. A 35-year-old patient who was admitted the previous day with pneumonia and has a
temperature of 100.2° F (37.8° C)
ANS: B
Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT).
Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary
embolism and requires immediate assessment and action such as oxygen
administration. The other patients should also be assessed as soon as possible, but
there is no indication that they may need immediate action to prevent clinical
deterioration.
38. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many
patients who have immigrated to the United States. Which question is most important
for the nurse to ask before the skin test?
a. "Is there any family history of TB?"
b. "How long have you lived in the United States?"
c. "Do you take any over-the-counter (OTC) medications?"
d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
ANS: D
Patients who have received the BCG vaccine will have a positive Mantoux test. Another
method for screening (such as a chest x-ray) will need to be used in determining
whether the patient has a TB infection. The other information also may be valuable but
is not as pertinent to the decision about doing TB skin testing.
39. A patient is admitted to the emergency department with an open stab wound to the
left chest. What is the first action that the nurse should take?
a. Position the patient so that the left chest is dependent.
b. Tape a nonporous dressing on three sides over the chest wound.
c. Cover the sucking chest wound firmly with an occlusive dressing.
d. Keep the head of the patient's bed at no more than 30 degrees elevation.
ANS: B
The dressing taped on three sides will allow air to escape when intrapleural pressure
increases during expiration, but it will prevent air from moving into the pleural space
during inspiration. Placing the patient on the left side or covering the chest wound with
an occlusive dressing will allow trapped air in the pleural space and cause tension
pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate
breathing.
40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered
rhonchi after a thoracotomy. Which action should the nurse take first?
a. Assist the patient to sit upright in a chair.
b. Splint the patient's chest during coughing.
c. Medicate the patient with prescribed morphine.
d. Observe the patient use the incentive spirometer.
ANS: C
A major reason for atelectasis and poor airway clearance in patients after chest surgery
is incisional pain (which increases with deep breathing and coughing). The first action
by the nurse should be to medicate the patient to minimize incisional pain. The other
actions are all appropriate ways to improve airway clearance but should be done after
the morphine is given.
41. The nurse is caring for a patient with idiopathic pulmonary arterial hypertension
(IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires
the most immediate action by the nurse?
a. The oxygen saturation is 94%.
b. The blood pressure is 98/56 mm Hg.
c. The patient's central IV line is disconnected.
d. The international normalized ratio (INR) is prolonged.
ANS: C
The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as
soon as possible to prevent rapid clinical deterioration. The other data also indicate a
need for ongoing monitoring or intervention, but the priority action is to reconnect the
infusion.
42. A patient who was admitted the previous day with pneumonia complains of a sharp
pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the
nurse take next?
a. Auscultate breath sounds.
b. Administer the PRN morphine.
c. Have the patient cough forcefully.
d. Notify the patient's health care provider.
ANS: A
The patient's statement indicates that pleurisy or a pleural effusion may have developed
and the nurse will need to listen for a pleural friction rub and/or decreased breath
sounds. Assessment should occur before administration of pain medications. The
patient is unlikely to be able to cough forcefully until pain medication has been
administered. The nurse will want to obtain more assessment data before calling the
health care provider.
43. A patient has acute bronchitis with a nonproductive cough and wheezes. Which
topic should the nurse plan to include in the teaching plan?
a. Purpose of antibiotic therapy
b. Ways to limit oral fluid intake
c. Appropriate use of cough suppressants
d. Safety concerns with home oxygen therapy
ANS: C
Cough suppressants are frequently prescribed for acute bronchitis. Because most acute
bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic
symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute
bronchitis, although it may be used for chronic bronchitis.
44. Which action by the nurse will be most effective in decreasing the spread of
pertussis in a community setting?
a. Providing supportive care to patients diagnosed with pertussis
b. Teaching family members about the need for careful hand washing
c. Teaching patients about the need for adult pertussis immunizations
d. Encouraging patients to complete the prescribed course of antibiotics
ANS: C
The increased rate of pertussis in adults is thought to be due to decreasing immunity
after childhood immunization. Immunization is the most effective method of protecting
communities from infectious diseases. Hand washing should be taught, but pertussis is
spread by droplets and contact with secretions. Supportive care does not shorten the
course of the disease or the risk for transmission. Taking antibiotics as prescribed does
assist with decreased transmission, but patients are likely to have already transmitted
the disease by the time the diagnosis is made.
45. An experienced nurse instructs a new nurse about how to care for a patient with
dyspnea caused by a pulmonary fungal infection. Which action by the new nurse
indicates a need for further teaching?
a. Listening to the patient's lung sounds several times during the shift
b. Placing the patient on droplet precautions and in a private hospital room
c. Increasing the oxygen flow rate to keep the oxygen saturation above 90%
d. Monitoring patient serology results to identify the specific infecting organism
ANS: B
Fungal infections are not transmitted from person to person. Therefore no isolation
procedures are necessary. The other actions by the new nurse are appropriate.
46. Which intervention will the nurse include in the plan of care for a patient who is
diagnosed with a lung abscess?
a. Teach the patient to avoid the use of over-the-counter expectorants.
b. Assist the patient with chest physiotherapy and postural drainage.
c. Notify the health care provider immediately about any bloody or foul-smelling sputum.
d. Teach about the need for prolonged antibiotic therapy after discharge from the
hospital.
ANS: D
Long-term antibiotic therapy is needed for effective eradication of the infecting
organisms in lung abscess. Chest physiotherapy and postural drainage are not
recommended for lung abscess because they may lead to spread of the infection. Foul
smelling and bloody sputum are common clinical manifestations in lung abscess.
Expectorants may be used because the patient is encouraged to cough.
47. The nurse provides discharge teaching for a patient who has two fractured ribs from
an automobile accident. Which statement, if made by the patient, would indicate that
teaching has been effective?
a. "I am going to buy a rib binder to wear during the day."
b. "I can take shallow breaths to prevent my chest from hurting."
c. "I should plan on taking the pain pills only at bedtime so I can sleep."
d. "I will use the incentive spirometer every hour or two during the day."
ANS: D
Prevention of the complications of atelectasis and pneumonia is a priority after rib
fracture. This can be ensured by deep breathing and coughing. Use of a rib binder,
shallow breathing, and taking pain medications only at night are likely to result in
atelectasis.
48. The nurse is caring for a patient who has a right-sided chest tube after a right lower
lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. Document the amount of drainage every eight hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.
ANS: A
UAP education includes documentation of intake and output. The other actions are
within the scope of practice and education of licensed nursing personnel.
49. After change-of-shift report, which patient should the nurse assess first?
a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
ANS: D
The patient's history and symptoms suggest possible tension pneumothorax, a medical
emergency. The other patients also require assessment as soon as possible, but
tension pneumothorax will require immediate treatment to avoid death from inadequate
cardiac output or hypoxemia.
50. Which factors will the nurse consider when calculating the CURB-65 score for a
patient with pneumonia (select all that apply)?
a. Age
b. Blood pressure
c. Respiratory rate
d. Oxygen saturation
e. Presence of confusion
f. Blood urea nitrogen (BUN) level
ANS: A, B, C, E, F
Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood
pressure (decreased), respiratory rate (increased), and age (65 and older). The other
information is also essential to assess, but are not used for CURB-65 scoring.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD)
and pneumonia who has an order for arterial blood gases to be drawn. What is the
minimum length of time the nurse should plan to hold pressure on the puncture site?

A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
B. 5 minutes

After obtaining blood for an arterial blood gas measurement, the nurse should hold
pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has
stopped. An artery is an elastic vessel under much higher pressure than veins, and
significant blood loss or hematoma formation could occur if the time is insufficient.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the
presence of nodules. In an effort to determine whether the nodules are malignant or
benign, what is the primary care provider likely to order?
A. Thoracentesis
B. Pulmonary angiogram
C. CT scan of the patient's chest
D. Positron emission tomography (PET)
D. Positron emission tomography (PET)

PET is used to distinguish benign and malignant pulmonary nodules. Because

malignant lung cells have an increased uptake of glucose, the PET scan (which uses an
IV radioactive glucose preparation) can demonstrate increased uptake of glucose in
malignant lung cells. This differentiation cannot be made using CT, a pulmonary
angiogram, or thoracentesis.

After assisting at the bedside with a thoracentesis, the nurse should continue to assess
the patient for signs and symptoms of what?

A. Bronchospasm
B. Pneumothorax
C. Pulmonary edema
D. Respiratory acidosis
B. Pneumothorax

Because thoracentesis involves the introduction of a catheter into the pleural space,
there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for
causing bronchospasm, pulmonary edema, or respiratory acidosis.
The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes
have decreased. The nurse knows this could be due to what occurring?

A. Pain
B. Atelectasis
C. Pneumonia
D. Pleural effusion
B. Atelectasis

Postoperatively there is an increased risk for atelectasis from anesthesia as well as

restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant
secretion to hold the alveoli open is not promoted. Pneumonia will occur later after
surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an
imbalance between intravascular and oncotic fluid pressures, which is not expected in
this case
The patient is hospitalized with pneumonia. Which diagnostic test should be used to
measure the efficiency of gas transfer in the lung and tissue oxygenation?

A. Thoracentesis
B. Bronchoscopy
C. Arterial blood gases
D. Pulmonary function tests
C. Arterial blood gases

Arterial blood gases are used to assess the efficiency of gas transfer in the lung and
tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for
diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to
assess changes resulting from treatment. Pulmonary function tests measure lung
volumes and airflow to diagnose pulmonary disease, monitor disease progression,
evaluate disability, and evaluate response to bronchodilators
The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient
with end-stage kidney disease secondary to diabetes mellitus. Which finding would
indicate a positive reaction?

A. Acid-fast bacilli cultured at the injection site

B. 15-mm area of redness at the TST injection site
C. 11-mm area of induration at the TST injection site
D. Wheal formed immediately after intradermal injection
C. 11-mm area of induration at the TST injection site

An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage

kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal
appears when the TST is administered that indicates correct administration of the
intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active
tuberculosis.
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for
analysis. The nurse would prepare the patient for which test?

A. Thoracentesis
B. Bronchoscopy
C. Pulmonary angiography
D. Sputum culture and sensitivity
A. Thoracentesis

Thoracentesis is the insertion of a large-bore needle through the chest wall into the
pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or
instill medication into the pleural space.
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information
should the nurse include in the teaching plan?
a. Hand washing is the primary way to prevent spreading the condition to others.
b. Use of oral antihistamines for 2 weeks before the allergy season may prevent
reactions.
c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their
use.
d. Identification and avoidance of environmental triggers are the best way to avoid
symptoms.
ANS: D
The most important intervention is to assist the patient in identifying and avoiding
potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started
several weeks before the allergy season. Corticosteroid nasal sprays have minimal
systemic absorption. Acute viral rhinitis (the common cold) can be prevented by
washing hands.
3. The nurse discusses management of upper respiratory infections (URI) with a patient
who has acute sinusitis. Which statement by the patient indicates that additional
teaching is needed?
a. "I can take acetaminophen (Tylenol) to treat my discomfort."
b. "I will drink lots of juices and other fluids to stay well hydrated."
c. "I can use my nasal decongestant spray until the congestion is all gone."
d. "I will watch for changes in nasal secretions or the sputum that I cough up."
ANS: C
The nurse should clarify that nasal decongestant sprays should be used for no more
than 3 days to prevent rebound vasodilation and congestion. The other responses
indicate that the teaching has been effective.
12. Which action should the nurse take first when a patient develops a nosebleed?
a. Pinch the lower portion of the nose for 10 minutes.
b. Pack the affected nare tightly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauterization.
d. Apply ice compresses over the patient's nose and cheeks.
ANS: A
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.
Application of cold packs may decrease blood flow to the area, but will not be sufficient
to stop bleeding. Cauterization and nasal packing are medical interventions that may be
needed if pressure to the nares does not stop the bleeding, but these are not the first
actions to take for a nosebleed.
15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test
c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
ANS: A
The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar
abscess that could lead to an airway obstruction requiring rapid assessment and
potential treatment. The other patients do not have diagnoses or symptoms that indicate
any life-threatening problems.
16. The nurse obtains the following assessment data on an older patient who has
influenza. Which information will be most important for the nurse to communicate to the
health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
ANS: B
The crackles indicate that the patient may be developing pneumonia, a common
complication of influenza, which would require aggressive treatment. Myalgia,
headache, mild temperature elevation, and sore throat with cough are typical
manifestations of influenza and are treated with supportive care measures such as
over-the-counter (OTC) pain relievers and increased fluid intake.

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18. The nurse is caring for a hospitalized older patient who has nasal packing in place
to treat a nosebleed. Which assessment finding will require the most immediate action
by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient's temperature is 100.1° F (37.8° C).
d. The patient complains of level 8 (0 to 10 scale) pain.
ANS: A
Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2
saturation of 89% should alert the nurse to further assess for these complications. The
other assessment data also indicate a need for nursing action but not as immediately as
the low O2 saturation.
20. A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue
being "stuck up my nose" and with foul-smelling nasal drainage from the right nare.
Which action should the nurse take first?
a. Notify the clinic health care provider.
b. Obtain aerobic culture specimens of the drainage.
c. Ask the patient about how the cotton got into the nose.
d. Have the patient occlude the left nare and blow the nose.
ANS: D
Because the highest priority action is to remove the foreign object from the nare, the
nurse's first action should be to assist the patient to remove the object. The other
actions are also appropriate but should be done after attempting to clear the nose.
21. The nurse is caring for a patient who has acute pharyngitis caused by Candida
albicans. Which action is appropriate for the nurse to include in the plan of care?
a. Avoid giving patient warm liquids to drink.
b. Assess patient for allergies to penicillin antibiotics.
c. Teach the patient about the need to sleep in a warm, dry environment.
d. Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).
ANS: D
Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the
"swish and swallow" technique is to expose all of the oral mucosa to the antifungal
agent. Warm liquids may be soothing to a sore throat. The patient should be taught to
use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin
allergies because Candida albicans infection is treated with antifungals.
22. When assessing a patient with a sore throat, the nurse notes anterior cervical lymph
node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils.
Which action will the nurse anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
ANS: B
The patient's clinical manifestations are consistent with streptococcal pharyngitis and
the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because
patients with streptococcal pharyngitis usually do not have a cough, use of expectorants
will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral
infections, but the patient's assessment data are not consistent with a fungal infection.
NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.
1. The clinic nurse is teaching a patient with acute sinusitis. Which interventions should
the nurse plan to include in the teaching session (select all that apply)?
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secretions.
e. You will be more comfortable if you keep your head in an upright position.
ANS: A, C, D, E
The steam and heat from a shower will help thin secretions and improve drainage.
Decongestants can be used to relieve swelling. Patients can use either over-the-counter
(OTC) sterile saline solutions or home-prepared saline solutions to thin and remove
secretions. Maintaining an upright posture decreases sinus pressure and the resulting
pain. Blowing the nose after a hot shower or using the saline spray is recommended to
expel secretions.
2. The nurse is reviewing the medical records for five patients who are scheduled for
their yearly physical examinations in September. Which patients should receive the
inactivated influenza vaccination (select all that apply)?
a. A 76-year-old nursing home resident
b. A 36-year-old female patient who is pregnant
c. A 42-year-old patient who has a 15 pack-year smoking history
d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-year-old patient who has allergies to penicillin and cephalosporins
ANS: A, B, D
Current guidelines suggest that healthy individuals between 6 months and age 49
receive intranasal immunization with live, attenuated influenza vaccine. Individuals who
are pregnant, residents of nursing homes, or are immunocompromised or who have
chronic medical conditions should receive inactivated vaccine by injection. The
corticosteroid use by the 30-year-old increases the risk for infection.
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing
diagnosis of ineffective airway clearance. Which assessment data best supports this
diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway
effectively. The other data would be used to support diagnoses such as impaired gas
exchange and ineffective breathing pattern.
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which
finding would the nurse expect?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation
ANS: A
Increased tactile fremitus over the area of pulmonary consolidation is expected with
bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal
pneumonia typically presents with a loose, productive cough. Adventitious breath
sounds such as crackles and wheezes are typical. A grating sound is more
representative of a pleural friction rub rather than pneumonia.
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's
most appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Teach the patient about the need for fluid restrictions.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
ANS: A
Coughing is less painful and more likely to be effective when the patient splints the
chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal
oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip
breathing is used to improve gas exchange in patients with COPD, but will not improve
airway clearance.
4. The nurse provides discharge instructions to a patient who was hospitalized for
pneumonia. Which statement, if made by the patient, indicates a good understanding of
the instructions?
a. "I will call the doctor if I still feel tired after a week."
b. "I will continue to do the deep breathing and coughing exercises at home."
c. "I will schedule two appointments for the pneumonia and influenza vaccines."
d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is
expected for several weeks. The Pneumovax and influenza vaccines can be given at
the same time in different arms. Explain that a follow-up chest x-ray needs to be done in
6 to 8 weeks to evaluate resolution of pneumonia.
5. The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which
nursing action will be most effective?
a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
d. Insert nasogastric tube for feedings for patients with swallowing problems.
ANS: B
The risk for aspiration is decreased when patients with a decreased level of
consciousness are placed in a side-lying or upright position. Frequent turning prevents
pooling of secretions in immobilized patients but will not decrease the risk for aspiration
in patients at risk. Monitoring of parameters such as breath sounds and oxygen
saturation will help detect pneumonia in immunocompromised patients, but it will not
decrease the risk for aspiration. Conditions that increase the risk of aspiration include
decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol
intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration
is more likely to occur. Other high-risk groups are those who are seriously ill, have poor
dentition, or are receiving acid-reducing medications.
6. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3
days. Which assessment data obtained by the nurse indicates that the treatment has
been effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient's white blood cell (WBC) count is 9000/µL.
d. Increased tactile fremitus is palpable over the right chest.
ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other
data suggest that a change in treatment is needed.
7. The health care provider writes an order for bacteriologic testing for a patient who has
a positive tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d. Instruct the patient to expectorate three specimens as soon as possible.
ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for
M. tuberculosis. The patient should not provide all the specimens at once. Blood
cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing.
Although the findings on chest x-ray examination are important, it is not possible to
make a diagnosis of TB solely based on chest x-ray findings because other diseases
can mimic the appearance of TB.
8. A patient is admitted with active tuberculosis (TB). The nurse should question a
health care provider's order to discontinue airborne precautions unless which
assessment finding is documented?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
ANS: D
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the
sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays
are not used to determine whether treatment has been successful. Taking medications
for 6 months is necessary, but the multidrug-resistant forms of the disease might not be
eradicated after 6 months of therapy. Repeat Mantoux testing would not be done
because the result will not change even with effective treatment.

Patient presents with fever and burning pain in chest with breathing, auscultation
reveals crackles, and patient's cough produced yellow sputum. What is the patient likely
suffering from?
Pneumonia
A patient arrives at the hospital and complains of difficulty breathing with a productive
cough that you suspect is pneumonia, what should you do first?
A: Administer 02
B: Administer broad spectrum IV antibiotics
C: Collect sputum sample
D: Take full health history
A: administer 02

Remember your ABCs! Airways, blood, circulation.

After giving 02, you'd want to take a sputum sample and then admin broad spectrum
antibiotics so that the antibiotics would not affect the sputum sample.
Which patient is most at risk for pneumonia?
A: A very active and thin elderly woman who gets all of her vaccines on time.
B: A young man who is in the hospital recovering from a small bowel re-sectioning
C: A 50 year old stroke victim who has been bedridden during recovery and is receiving
tube feedings
D: A young, diabetic man who works in a factory with a risk of chemical inhalation
C: A 50 year old stroke victim who has been bedridden during recovery and is receiving
tube feedings

The patient's history of stroke puts them at risk for aspiration pneumonia as do the tube
feedings. The bed rest is another risk factor.
This patient has 3 risk factors which is more than any of the other patients: patient A
has one risk factor, patient B has one RF, patient D has two risk factors
What labs would you look at to determine if a patient has pneumonia?
Sputum C&S, chest X-ray, 02 saturation, ABGs
What complications can occur from pneumonia?
Pleurisy, pleural effusion, atelectasis, bacteremia, lung abscess, empyema, pericarditis,
meningitis, sepsis, respiratory failure, pneumothorax
Patient complains of increasing burning pain with breathing and worsening cough,
which complications do you suspect?
Pleurisy, pleural effusion, empyema
Medical Care Associated pneumonia
Symptoms begin within 48 hours of hospital admission, within 48 hours of hospital
discharge, or 48 hours following ventiliation
Community Acquired pneumonia
Patient has not been hospitalized in the last 14 days and begins developing symptoms
Opportunistic Pneumonia
An organism (P. jiroveci or cytolomegalovirus) that does not normally cause pneumonia
in healthy individuals causes an infection in an immunocompromised individual.
Aspiration Pneumonia
Mouth or GI contents enter the lung and leads to an infection. RFs are stroke victim,
tube feedings, dysphagia
What changes should be made to a pneumonia patient's diet?
Patient should be given small, frequent meals that are nutrient dense and high in
calories. Patient should increase fluids.
Select all the patient teaching you would want to include:
1: Deep breathing/effective coughing techniques
2: Proper handwashing
3: Cough etiquette
4: Ambulate until exhausted
5: smoking cessation
1, 2, 3, 5

Patient should not exercise to the point of exhaustion.

How is mycobacterium tuberculosis normally spread?
Airborne
Select all the individuals who are at risk for developing TB
1: A young immigrant woman who is the primary caretaker for a relative with active TB
infection
2: A middle aged man who smokes and drinks at least six beers a day
3: A mission worker who lives with five other missionaries in a small apartment and
provides medical care to the impoverished, underdeveloped community she serves
4: An elderly, financial retiree who lives alone and has never traveled outside of the
United States.
1: People who have lived in other countries where TB is common are at risk, caretakers
of those with TB are at Risk
2: Individuals who have substance abuse problems are at increased risk of TB
3: People living in other countries where TB is common are at risk, people living in
cramped quarters are at risk, people who work in healthcare (especially respiratory
areas) are at risk, people living in poverty are at risk of TB
4: This man's advanced age could put him at risk, but he will probably never be exposed
to TB and so would not be at risk.
What is a major concern of those undergoing TB drug therapy?
Compliance. If a patient does not adhere to their multi-drug regiment a resistant strain of
TB could develop. Directly observed therapy can be required to ensure drug
compliance.
Select which drugs a TB patient could be given?
1: Isonazid
2: Rifampin
3: Erythromycin
4: Ethambutol
5: Gentamycin
6: Streptomycin
7: Pyrazinamide
8: Albuterol
1, 2, 4, 6, 7
A patient who is being given Rifampin, Isonazid, and pyrazinamide begins having light
colored stools and yellowed skin, this is a sign of
A: Nephrotoxicity
B: Improved condition
C: Hepatotoxicity
D: An expected adverse Effect
C: Hepatotoxicity
Patient presents with weight loss due to anorexia, she states that she has been very
fatigued and has had absent menses. She reports non-productive cough which began
around same time of weight loss. Auscultation reveals rhonchi and crackles. She has
been out of the country recently. What do you suspect?
These are all signs and symptoms of TB
Select which tests can be used to confirm a diagnosis of TB?
1: 3 consecutive positive acid fast sputum tests
2: positive interferon assay
3: positive mantoux test
4: chest X-ray
1, 2

Chest X-rays can not be used to confirm TB infection, the TB skin test (mantoux test)
only indicates exposure and not active infection
What are some complications of active TB infection?
Miliary TB, pneumonia, pleural effusion, empyema
When is a patient declared in remission?
After two clear sputum samples, following 6-12 months of drug therapy. Follow-up
continues for one year.
Are men or women more at risk for asthmas?
Before puberty males are more affected. Following puberty women are more affected
and are more likely to be hospitalized or die from complications.
What are some risk factors for asthma?
Genetics, immune response, allergens, air pollutant exposure/occupational exposure
What are some triggers of asthma attacks?
Exercise, respiratory infections, nose and sinus problems, food/drug additives, GERD,
psychologic factors
Which medications could be given to manage asthma exacerbation?
anti-inflammatory agents/corticosteroids (prednisone)

anticholinergics (ipratropium/atrovent, tiotrpium/spiriva)

leukotriene modifiers (montelukast/singulair)

beta-adrenergics agonists (albuterol)

methylxanthines (theophylline)
What teaching should be included for a patient using an inhaler?
Oral hygiene, count number of uses, clean inhaler following uses, shake before use,
inhale while activating the inhaler, hold breath for 10 seconds following inspiration
What are the two types of obstructive airways diseases included in COPD?
Chronic Bronchitis and Emphysema
Select which patients are at risk for developing COPD
1: Patient has a long history of smoking
2: Patient worked in a dusty factory for 25 years before retiring
3: Patient lived in a city which extremely high levels of pollution for many years
4: An adult with a history of many childhood respiratory diseases
All of these patients are at risk for developing COPD
What is the genetic factor which can determine COPD risk?
alpha antitrypsin (AAT) deficiency
Chronic Bronchitis is characterized by:
A) loss of lung elasticity
B) Alveolar problems
C) Inflammation of bronchi and bronchioles
D)hyperinflation of lungs
C

In chronic bronchitis, inflammation and thickened mucous leads to a productive cough

lasting for more than 3 months. The alveoli are unaffected.
Select all symptoms which are characteristics of emphysema:
1: loss of lung elasticity
2: productive cough lasting more than 3 months
3: bulla formation
4: small airway collapse
5: alveolar problems
1, 3, 4, 5
Which ABG finding would not be a sign of COPD?
A) Low PaO2
B) Normal HCO3
C) Elevated PaCO2
D) Low pH
E) Increased HCO3
B

HCO3 would be elevated

A patient with COPD has been started on O2 therapy and ceases to breath, this is
called:
A) Carbon Dioxide Narcosis
B) Hypoxemia
C) End-stage COPD
D) Hypercarbia
A) CO2 narcosis

This is when a patient has a high CO2 tolerence, in order to avoid CO2 narcosis O2
therapy should be started at the lowest effective dose.
What dietary changes should a patient with COPD make?
High protien, high calorie meals
Which is not a physical change associated with COPD?
A) Barrel chest
B) Clubbed fingers and toe nails
C) Decreased hair growth in lower extremities
D) Weight loss
C) Decreased hair growth in lower extremities

This is a physical change associated with peripheral vascular disease

A patient with COPD presents with jugular distension, weight gain, venous edema, and
increased lung pressure what is a serious concern?
A) Hypoxemia
B) Anxiety
C) Respiratory infection
D) Cor pulmonale
D) Cor pulmonale
Patient reports difficulty sleeping due to nightly asthma exacerbations, this patient would
be described as having ______ persistent symptoms.
Severe, symptoms occur continually with frequent exacerbations that limit physical
activity and quality of life
Select which nursing interventions would be most appropriate for a patient with asthma:
1) Position the patient in high-Fowler's
2) Initiate and maintain IV access
3) Avoid administering O2 therapy until you're certain the patient is not faking
4) Monitor cardiac rate and rhythm
5) Allow patient work through any anxiety alone
1, 2, 4

3) You should administer O2 according to facility policy/as prescribed to all patients who
are in distress, withholding O2 therapy can be dangerous
5) Reassure patient and maintain a calm demeanor to reduce patient's anxiety
When a patient is given albuterol, the nurse should observe for:
A) black, tarry stools
B) tremors and tachycardia
C) blurred vision
D) oral thrush
B) tremors and tachycardia

Other AEs are nervousness, insomnia, nausea, vomiting

Which medication is not an anti-inflammatory used to treat symptoms of asthma?
A) fluticasone (flovent)
B) prednisone (deltasone)
C) montelukast (singulair)
D) ipratropium (atrovent)
D) ipratropium (atrovent)

This is a bronchodilator.
A patient is taking a corticosteroid for asthma, what should you monitor for?
Decreased immune function, hyperglycemia, black stools, fluid retention/weight gain,
dry mouth, and mouth sores
A patient with COPD should be discouraged from exercising:
A) True
B) False
B) False

Exercise can improve a client's pulmonary status: the patient should walk until they
experience dyspnea and then rest before resuming activity. Rest and exercise should
be carefully balanced.
A patient with COPD should be encouraged to drink ___ L of fluids per day.
2-3
A patient is taught to breath deeply from the diaphragm while lying on back with bent
knees with hands on abdomen. The patient should aim to have their hand rise and fall
with each breath, this technique is called _____
Diaphragmatic/abdominal breathing
Patient should position lips as if they were about to whistle, breath slowly in through
nose and out through mouth without puffing the cheeks, this technique is called
_______
Pursed lip breathing

Select all patients who are at risk for hypertension:

1) An elderly male patient with a history of tobacco and alcohol use
2) An active middle aged woman who ensures each that the foods she eats has less
than 300mg of Na per serving
3) An obese patient with DM who has lipidemia
4) A hispanic woman living in poverty who leads a sedentary lifestyle
1, 3, 4

Advanced age, alcohol and tobacco use, DM, hyperlipidemia, high Na intake, male,
family history, obesity, ethnicity, sedentary lifestyle, socioeconomic status, and stress
are all RFs of hypertension
A patient states willingness to make lifestyle changes to lower their BP, select the best
teaching you could give them:
1) Read labels of food to ensure that food has less than 300mg of Na per serving
2) Walk for 30 minutes per day, and it can be broken up
3) Go on a diet and lose weight until you are within the range of ideal body weight for
your height, age, and sex
4) Have fruits, veggies, and whole grains with every meal
1, 2, 4

3 does not provide specific lifestyle changes so it would not be one of the best choices
to teach to a patient
Which medications would you NOT expect to administer to a patient with hypertension?
A) Beta Blockers
B) Ca channel blockers
C) NSAIDs
D) ACE inhibitors
C) NSAIDs

These can actually increase BP

Other drugs that can be given to treat high BP are diuretics, adrengeric inhibitors and
angiotension II blockers
Why is hypertension known as the silent killer?
It often has no clinical manifestations
Patient presents with chest pain, a severe headache, confusion, and anxiety. Patient
states they forgot to take their beta blocker today and their BP is 220/140. What is this
patient experiencing?
Hypertensive Crisis
What is the major complication of hypertensive crisis?
Organ damage
00:0201:21

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A patient comes to the ER with complaints of chest pain. The patient had been
prescribed sub-lingual nitroglycerin for chronic stable angina, but the current pain has
been non-responsive to the nitrates. What is the likely cause of the pain?
Myocardial infarction,
Select all diagnostic tests used to determine severity of CAD:
1) Stress test
2) ECG
3) Chest x-ray
4) Thallium Scan
5) Coronary bypass
6) Cardiac Catheter
1, 2, 3, 4, 6

Other tests include: cardiac markers (troponin, creatine kinase, and myoglobin),
coronary angiography, PET, electron beam CT scan
Hyperlipidemia would be treated with:
1) Statins
2) Beta Blockers
3) Bile acid sequestrants
4) Ca Channel Blockers
1, 3

2 and 4 are antihypertensives

Myocardial ischemia results in damage that is:
A) reversible
B) irreversible
A
What are some precipitating factors of angina?
physical exertion/sexual activity, emotional situations, use of tobacco or ilicit drugs
A patient comes to the hospital with fever, nausea, vomiting and chest pain which
radiates down into their arms that has been going on for over 20 minutes, what findings
do you expect to see on the ECG?
A)changes to the ST segment, QRS complex, or T wave.

ST segment elevation is a sign of more significant occlusion than non-STEMI which

indicates only partial occlusion and can be treated with medication
What drugs would you expect to administer to a patient with CAD?
Nitro, morphine, beta blockers, ACE inhibitors, anti-dysrhythmias, stool softeners,
cholesterol lowering drugs
What teaching would you give to a patient with CAD?
When to seek help, CMs of MI, etiology of CAD, decrease RFs (obesity, hyperlipidemia,
hypertension, DM, increase activity, smoking cessation), importance of gradual
resumption of activity
Peripheral artery disease (PAD)
thickening of the arterial walls which results in the narrowing of arteries in the upper and
lower extremities
Which patient is not at risk for developing PAD?
A) Obese middle aged woman who works at a job that requires her to stand for long
periods
B) A woman taking birth control pills who smokes and does not exercise
C) A person who avoids foods high in sodium and cholesterol
D) An elderly, diabetic man.
C) A person who avoids foods high in sodium and cholesterol
What physical changes does a person with PAD exhibit?
Loss of extremity hair, thickened nails, muscle atrophy, capillary refill >3 seconds,
ulcerations, dependant rubor of skin, thinning skin, cool skin
What symptoms would a person with PAD experience?
intermittant claudication, paresthesia, and eventually pain while at rest
What tool is most useful for determining blood flow to an extremity?
Doppler ultrasound
Which is not a diagnostic test used to determine presence of PAD?
A) Angiography
B) API
C) Segmental systolic BP
D) Bypass surgery
D) Bypass surgery is a treatment to restore bloodflow to the extremity.
Buerger's Disease/Thromboangiitis obliterans
non-atherosclerotic vaso-occlusive disorder that affects the arteries and veins of the
upper extremities. It is most common in young, male smokers.
Reynaud's phenonenon
Vasospasms of the extremities in response to cold or stress
Phlebitis
inflammation of a superficial vein without presence of a thrombus
Superficial vein thrombosis
formation of a thrombus in a superficial vein, resulting in inflammation along the
superficial vein, normally benign
Deep vein thrombosis/venous thromboembolism
formation of a thrombus in a deep veing normally the femoral and iliac veins
A patient has tenderness to pressure in leg, muscle is hard to the touch, the limb is
swollen and red, the major concern for this patient is:
A) Superficial vein thrombosis
B) Ulceration
C) Pulmonary embolism
D) Myocardial infarction
C) Pulmonary embolism

The patient likely has deep vein thrombosis and if embolization occurs then the patient
could possibly die from complications of a pulmonary embolism
Which is not part of Virchow's Triad?
A) Hypercoagulability of blood
B) Hyperlipidemia resulting in atherosclerosis
C) Endothelial damage
D) Venous stasis
B) Hyperlipidemia resulting in atherosclerosis
You should monitor aPTT with which drug?
A) Heparin
B) Coumadin
A) Heparin

INR is used to monitor coumadin

Vitamin K is the antidote for:
A) Heparin
B) Coumadin
B) Coumadin
Protamine sulfate is the antidote for:
A) Heparin
B) Coumadin
A) Heparin
The normal INR values are:
A) 0.75-1.25
B) 70-120 seconds
C) 25-35 seconds
D) 2-3
A) 0.75-1.25
The normal aPTT values are:
A) 0.75-1.25
B) 70-120 seconds
C) 25-35 seconds
D) 2-3
C) 25-35 seconds
What is the therapeutic range for INR?
A) 0.75-1.25
B) 70-120 seconds
C) 25-35 seconds
D) 2-3
D) 2-3
What is the therapeutic range for aPTT?
A) 0.75-1.25
B) 70-120 seconds
C) 25-35 seconds
D) 2-3
B) 70-120 seconds
Patients with DVT and venous insufficiently should be encouraged to ____ while
resting.
Elevate affected limb
Patients with DVT and venous insufficiently should be encouraged to wear ______
Compression stockings
Which enzyme peaks 2 hours post MI?
Mygloblin
Which cardiac enzyme peaks 20 hours post MI?
Troponin
Which cardiac enzyme peaks 24 hours post MI?
Creatine Kinase MB
Which cardiac marker appears first?
Myoglobin

Heart Failure
When the heart is unable to pump effectively resulting in inadequate cardiac output. The
heart is unable to maintain adequate perfusion.
Select which cardiopulmonary disorders below often lead to heart failure?
1) MI
2) Systemic/pulmonary hypertension
3) DM
4) valvular heart disease
5) Stable angina
6) CAD
1, 2, 4, 6

1) 33% of MI patients develop heart failure

2) Systemic HTN results in 75% of HF cases
4) Any changes to the structure of the heart/valves cause pressure or volume overload
on the heart.

Pulmonary problems, such as cor pulmonale, can result in right sided failure without
accompanying left sided failure.
Compensatory mechanisms
Methods the heart uses to try and maintain adequate cardiac output.
Which is not a compensatory mechanism the heart uses?
1) SNS activation
2) Neurohormonal responses
3) ventricular hypertrophy
4) Pulmonary edema
5) Ventricular dilation
4) Pulmonary edema is a CM of heart failure
Cardiac Output
Cardiac output depends on preload, afterload, myocardial contractility, and heart rate.
What are the four types of heart failure?
Right sided, left sided, systolic, diastolic
SNS activation
Least effective compensatory mechanism. Epinephrine and NE increase HR and cause
vasoconstriction. Eventually this becomes damaging.
Neuro-hormonal response
Kidneys release renin which becomes angiotensin II which results in Na and H2O
retention and vasoconstriction which increases BP. Pituitary gland also releases
vasopressin which increases H2O retention. This increases cardiac workload and
further decreases output.
Ventricular Dilation
Enlargement of the chambers of the heart. This eventually leads to the heart becoming
too stretched to contract effectively which decreases cardiac output.
Ventricular hypertrophy
Enlarging of the cardiac muscles that normally follows ventricular dilation. The muscle
size increases in an attempt to increase cardiac output.
A patient comes to the hospital with a visible jugular vein, generalized edema which
started in the lower extremities, and tachycardia. Patient states anxiety and feeling
nauseous. What type of heart failure do you suspect?
Right sided.

Blood backs up into the R atrium and the rest of the body.
Patient reports being unable to breathe while lying down and reports a cough. The
patient states feelings of fatigue and appears confused or distracted. What type of heart
failure do you suspect?
Left sided.

This is the most common type of heart failure, blood backs up into the atrium and the
pulmonary veins which results in pulmonary congestion.
What is the most common cause of right sided heart failure?
Left sided heart failure.
Systolic heart failure
The heart is unable to contract forcefully enough during systole to eject adequate
amounts of blood. The leads to an increase in afterload and decreases in ejection
fraction.
Diastolic heart failure
Ventricles are unable to relax enough to fill during diastole. The lack of filling decreases
cardiac output. Patients can have normal ejection fraction.
Cardiac decompensation
When cardiac compensatory mechanisms are no longer maintaining adequate cardiac
output and perfusion.
Counter-regulatory mechanisms
Natriuretic peptides (atrial and B-type) and nitric oxide.

These promote vasodilation and reduce preload and afterload.

Acute decompensated HF
A worsening of the symptoms of heart failure which can lead to respiratory distress, due
to inadequate perfusion to the organs.
left ventricular thrombus
Enlargement of the left ventricle and decreased cardiac output combine to increase the
chance of thrombus formation in the left ventricle, a complication of HF
hepatomegaly
Most associated with R ventricular failure, the liver becomes congested with venous
blood which leads to fibrosis and cirrhosis, a complication of HF
renal failure
Decreased kidney perfusion, a complication of HF
pleural effusion
Increased pressure in the plural capillaries, a complication of HF
dysrhythmias
Enlargement causes changes in the normal electrical pathways, a complication of HF
Compensation vs decompensation
Compensation=body is able to maintain cardiac output through counter-regulatory
mechanisms

decompensation=mechanisms failed to maintain cardiac output

Your patient is at risk for heart failure, what clinical manifestations would you teach your
patient to look out for?
F-fatigue
A-activity intolerance
C-chest congestion
E-edema
S-shortness of breath
A patient with existing heart disease begins to have decreased O2sat and increased
RR. The patient looks pale and is using accessory muscles to breath, what do you
suspect is happening?
These are the early signs of Acute Decompensated Heart failure, and are caused by
increased pulmonary venous pressure
Which serum electrolytes should you monitor in a patient with heart failure?
1) Na
2) K
3) O2
4)Ca
5) Cl
6)Mg
1, 2, 4, 5, 6
A patient with a history of heart disease has a K level of 3.0, what diuretic would you
expect to administer?
A) Lasix
B) Microzide
C) Bumetanide
D) Spironolactone
D) Spironolactone, a potassium sparing diruretic
What dietary restrictions would you expect a patient recovering from heart failure have?
Fluid restrictions and a low Na diet (2g per day)
What assessment data should you gather from a patient with suspected heart failure?
Past medical history, medications, fatigue, depression/anxiety, Na intake, nausea,
vomiting, anorexia, weight gain, ankle swelling, nocturia, decreased daytime urine,
constipation, dypnea/orthopnea, cough, palpitations, dizziness
Which NDx is most appropriate for a patient with R sided heart failure?
A) Impaired gas exchange
B) Decreased cardiac output
C) Excess fluid volume
D) Activity intolerence
C) Excess fluid volume

Fluid builds up in the body in R sided heart failure which causes generalized edema.
Which NDx is most appropriate for a patient with L sided heart failure?
A) Impaired gas exchange
B) Decreased cardiac output
C) Excess fluid volume
D) Activity intolerance
A) Impaired gas exchange

L sided heart failure causes blood to pool in the lungs, leading to increased capillary
pressure and edema. This makes it difficult for the patient to breathe.
When caring for your patient with heart failure, you carefully monitor their activity level--
balancing rest and ambulation. You consult with PT and OT about your patient's
activities. Which NDx did you choose which led to you deciding on these specific
interventions?
Activity intolerance
Which intervention would not be a priority with the NDx of Excess fluid volume?
A) Administer diuretics per orders
B) Monitor serum electrolytes
C) Consult with respiratory therapy
D) Assess extremities for changes in edema
C) Consult with respiratory therapy
Your patient goal is for the patient's heart to pump adequate blood to meet the demands
of the body, which interventions are your priority?
1) CV assessment
2) Monitor fluid balance
3) Encourage flu and pneumonia vaccines
4) Promote adherence to treatment plan
1, 2, 4

Vaccines would not be a priority if your patient has poor perfusion.

Other priority interventions would be monitor respiratory status and restrict activity until
patient is more stable.
A patient reports gaining three pounds over two days, what should you advise the
patient to do?
Contact their healthcare provider. 3lbs over 2 days or 3-5lbs over a week is a cause for
concern in at risk patients.
When monitoring a patient with heart failure which labs will the nurse focus on?
Serum electrolytes, urinalysis, BUN, creatinine, Hgb, Hct, microalbuminuria
Which is not an invasive diagnostic proceedure?
A) Cardiac catheterization
B) ECG/stress test
C) Echocardiography
D) Endomyocardial biopsy
B) ECG/stress test
B natriuretic peptide
...
What should be done to prevent a patient of heart failure from returning to the hospital?
Determine and treat the underlying cause, identify and treat risk factors, evaluate the
patient's support system, teach the importance of adherence to medical regimen, teach
patient to identify s/s of exacerbations, when to contact provider, avoiding stress, refer
patient to cardiac rehab if necessary, support groups
A patient discharged with diuretics should be able to recognize the signs/symptoms of:
A) Hypocalcemia
B) Hypokalemia
C) Hypercalcemia
D) Hyperkalemia
B) Hypokalemia

Most patients taking diuretics are at risk for hypokalemia.

A heart failure patient should be taught how to monitor which of the following at home:
1) BP
2) HR
3) K levels
4) daily weights
1, 2, 4

Patients should know how to take their pulse, BP, and monitor their daily weight at
home so that they can better recognize exacerbations.
In the discharge plan for a 65 year old heart patient you would want to include:
1) FACES, so that the patient can recognize signs/symptoms of heart failure
2) Annual flu vaccine and pneumonia vaccine every 5 years
3) Limited information on medication therapy so that the patient won't get confused
4) The importance of balancing rest and activity, and gradually beginning a prescribed
exercise plan
5) How to read labels for Na content in foods.
1, 2, 4, 5

3) You want to make sure that patient fully understands their drug therapy so that they
can monitor for toxicity and therapeutic effectiveness.
ACE inhibitors
End in -pril, 1 to II reducing aldosterone levels, inhibit ventricular hypertrophy,
decreases BP, increases perfusion, improves CO, non-productive cough
Beta blockers
End in -lol, decrease contractility of the heart to slow HR, inhibits SNS activity. Withhold
meds if HR is below 60bpm, monitor digoxin and K levels. If K levels are low
dysrhythmias are more likely to occur
Vasodilators
Nitrates, tolerance can develop
BiDil, treatment of HF in African Americans only for use in African Americans
Digoxin
Decrease HR, increases output, K levels (low or high), beware of toxicity
Angiotension II blockers
Cannot tolerate ACE inhibitors, prevent vasoconstriction,

A nurse is reinforcing preoperative teaching with a client who is to undergo a

pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery."
Which of the following statements should the nurse make?
"I will show you how to splint your incision while coughing."
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place.
Which of the following findings indicates that the nurse should suction the clients airway
secretions?
The client has coarse crackles in the lung fields.

A nurse is assisting with discharge teaching for a client who is postoperative following a
rhinoplasty. Which of the following instructions should the nurse include?
"Lie on your back with your head elevated 30* when resting"
A nurse in an urgent care clinic is collecting data from a client who reports exposure to
anthrax. Which of the following findings is an indication of the prodromal stage of
inhalation of anthrax?
Dry cough
A nurse is assisting with the plan of care for a client following placement of a chest tube
1 hr ago. Which of the following actions should the nurse include in the plan of care?
Tape all connections between the chest tube and drainage system
A nurse in a clinic is reinforcing teaching with a client who is to have a tuberculin skin
test. Which of the following information should the nurse include?
"You must return to the clinic to have the test read in 2 or 3 days."
A nurse is preparing to assist a provider to withdraw arterial blood from a clients radial
artery for measurement of ABG. Which of the following actions should the nurse plan to
take?
Check the circulation in the client's ulnar artery prior to obtaining the specimen.
A nurse is caring for an older adult client who has chronic obstructive pulmonary
disease and pneumonia. The nurse should monitor the client for which of the following
acid-base imbalances?
Respiratory acidosis
A nurse on a medical unit is assisting with the care of a client who has a possible closed
pneumothorax and significant bruising of the left chest following a motor-vehicle crash.
The client reports severe left chest pain on inspiration. The nurse should hear which of
the following findings when auscultating the client's lung sounds?
Absence of breath sounds
A nurse on a medical-surgical unit is caring for a client who is postoperative following a
hip replacement surgery. The client reports feeling apprehensive and restless. The
nurse collects additional data from the client. Which of the following findings is an
indication of pulmonary embolism?
Sudden onset of dyspnea
A nurse is collecting data from a client who has a prescription for cisplatin IV to treat
lung cancer. Which of the following client findings is an adverse effect of this
medication?
Tinnitus
A nurse is reinforcing teaching about pursed-lip breathing for a client who has chronic
obstructive pulmonary disease and emphysema. The nurse should explain that this
breathing technique does which of the following?
Keeps the airway open on exhalation

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A nurse is reinforcing teaching with a client about pulmonary function tests. Which of the
following tests measures the volume of air the lungs can hold at the end of maximum
inhalation?
Total lung capacity
A nurse is assisting with the plan of care for a client who had chronic obstructive
pulmonary disease and is malnourished. Which of the following recommendations to
promote nutritional intake should the nurse include in the plan?
Eat high-calorie foods first.
A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse
should instruct the client that which of the following positions will be used for this
procedure?
Sitting while leaning forward over the bedside table
A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for
daily chest physiotherapy. The nurse should instruct the client that which of the
following is the purpose of these treatments?
To mobilize recreations in the airway
A nurse in a provider's office is collecting data from a client who is states he was
recently exposed to tuberculosis. Which of the following findings is a clinical
manifestation of pulmonary tuberculosis?
Night sweats
A nurse is assisting with the development of a teaching plan about how to prevent an
acute asthma attack for a young adult client. Which of the following points should the
nurse plan to discuss first?
Determine the client's perception of the disease process and what might have triggered
the current attack
A nurse on a medical unit is assisting with the care of a client who aspirated gastric
contents prior to admission. The provider prescribed 100% oxygen by nonrebreather
mask after the client reported severe dyspnea. Which of the following findings is a
clinical manifestation of acute respiratory distress syndrome (ARDS)?
PaO2 50 mm Hg
A nurse is assisting with the care for a client who had a chest tube inserted 12 hr ago.
The nurse notes a crackling sensation upon palpation of the skin on the right side of the
clients chest. The nurse should notify the charge nurse that the client is demonstrating a
clinical manifestation of which of the following complications?
Crepitus

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of
the following manifestations should the nurse expect?
Lower Back Discomfort
A nurse is assisting in monitoring a client who had a myocardial infarction. For which of
the following complications should the nurse monitor in the first 24 hr?
Ventricular dysrhythmias
A nurse is collecting data from a client who has manifestations of aplastic anemia.
Which of the following findings should the nurse expect?
Petechiae and ecchymosis
A nurse is reinforcing teaching with a client who has anemia and a new prescription for
epoetin alfa. Which of the following information should the nurse include in the
teaching?
Hypertension is a common adverse effect of this medication
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
Dependent edema
A nurse is assisting in the plan of care for a client who is having a percutaneous
transluminal coronary angioplasty (PTCA) with stent placement. Which of the following
actions should the nurse anticipate in the postoperative plan of care?
Initiate an aspirin regimen
A nurse is caring for a client who has advanced heart failure. Which of the following
actions should the nurse take?
Enforce fluid restrictions
A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower
extremities. Which of the following actions should the nurse take?
Monitor the client for ototoxicity
A nurse is evaluating a clients repeat laboratory results 4 hr after administering fresh
frozen plasma (FFP). Which of the following laboratory values should the nurse review?
Prothrombin time
A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a
client who has anemia. Which of the following actions should the nurse take first?
Witness informed consent.
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has
a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The
nurse auscultates loud, bubbly sounds on inspiration. Which of the following
adventitious breath sounds should the nurse document?
Coarse crackles
A nurse is checking for cardiac tamponade on a client who has pericarditis. Which of the
following actions should the nurse take?
Auscultate blood pressure for pulses paradoxus
A nurse is reinforcing teaching about lifestyle changes with a client who had a
myocardial infarction and has a new prescription for a beta blocker. Which of the
following client statements indicates an understanding of the teaching?
"Before taking my medication, I will check my blood pressure and radial pulse rate."
A nurse in a clinic is collecting data from a client who has a history of peripheral arterial
disease. Which of the following findings on the clients lower extremities should the
nurse expect?
Cool, pale skin with minimal body hair
A nurse is reinforcing discharge teaching with a client who has a new permanent
pacemaker. Which of the following information should the nurse include in the teaching?
"Avoid lifting both arms above your head when dressing."
A nurse is collecting data from a client who reports using fish oil as a dietary
supplement. Which of the following substances in fish oil should the nurse recognize as
a health benefit to the client?
Omega-3 fatty acids
A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs)
following surgery. The client reports itching and has hives 30 min after the infusion
begins. Which of the following actions should the nurse take first?
Stop the infusion of blood
A nurse is caring for a client who has late-stage heart failure and is experiencing fluid
volume overload. Which of the following finding should the nurse expect?
Weight gain of 1 kg (2.2 lb) in 1 day
A nurse is caring for a client who has heart failure and is lethargic with muscle
weakness. The client's telemetry reading displays dysrhythmias. Which of the following
laboratory results should the nurse anticipate?
Potassium 2.8 mEq/L
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in
a joint following an injury. Which of the following actions should the nurse take?
Prepare for replacement of the missing clotting factor
A nurse is assisting in developing the plan of care for an older adult client who is to
receive a unit of packed red blood cells (RBCs). Which of the following actions should
the nurse recommend?
Verify the information on the packed RBCs with another nurse.
A nurse is checking laboratory values for an adult client who has sickle cell anemia and
is in crisis. For which of the following complications should the nurse monitor?
Elevated bilirubin
A nurse is caring for a client who is postoperative following vein ligation and stripping for
varicose veins. Which of the following actions should the nurse take?
Position the client supine with his legs elevated when in bed
A nurse is assisting in the care of a client who had an abdominal aortic aneurysm and is
scheduled for surgery. The clients vital signs are blood pressure 160/98 mm Hg, heart
rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should
the nurse take?
Administer antihypertensive medication for the blood pressure
A nurse is assisting in the care of a client who is in hypovolemic shock. While waiting for
a unit of blood, the nurse should plan to administer which of the following IV solutions?
0.9% sodium chloride
A nurse is collecting data from a client who has fluid volume overload resulting from a
cardiovascular disorder. Which of the following manifestations should the nurse expect?
(select all that apply)
Jugular vein distension
Moist crackles
Increased heart rate
A nurse is assisting in collecting data from a client who has a history of unstable angina.
Which of the following findings should the nurse expect?
The client reports chest pain when at rest
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client
over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse
should set the manual blood transfusion to deliver how many gtt/min?
10 gtt/min
A nurse is collecting data from a client who has pericarditis. Which of the following
manifestations should the nurse expect?
Dyspnea
A nurse is contributing to the plan of care for a client who has pernicious anemia. Which
of the following interventions should the nurse recommend?
Initiate weekly injections of vitamin B12

How should the nurse record smoking history on a pt who has smoked 2.5 packs a day
for 10 years?
Pt has a 25 pack-year smoking history
Which term should be used to document the musical sounds generated by airflow
through narrowed airways?
Wheezes

Which laboratory result should alert the nurse to perform further assessment on pt
admitted with respiratory distress?
SpO2 <90%
Steps for obtaining sputum culture (in order)
Check order. Obtain appropriate container. Teach pt to inhale deeply several times.
Have pt cough deeply from lungs. Send specimen immediately t olab.
Which is the best explanation to a pt by a nurse for why a health care provider does not
prescribe antibiotics for influenza?
"Influenza is caused by viruses."
After a laryngectomy, which of the following assessments takes priority?
Airway patency
Which of the following responses is correct when a pt asks why the HCP did not order a
new antiviral drug for flu symptoms that started three days ago?
"Antivirals work only if you start them within 48 hours after flu symptoms begin."
Which of the following positions is recommended for a pt experiencing a nosebleed?
Sitting up leaning slightly forward
The nurse knows that the pt understands teaching related to prevention of influenza
transmission when the pt demonstrates which behaviors?
Washing hands frequently; Covering the nose and mouth when sneezing or coughing;
Avoid sharing eating utensils with others
Which of the following communication methods is inappropriate for the pt with a total
laryngectomy?
Placing a finger over the stoma
A pt asks the nurse why he doesn't feel sick even though his TB test is positive. The
nurse knows the pt has been diagnosed with LTBI. Which explanation is best to provide
to the pt?
"You have TB infection, but not active disease. As long as your immune system stays
strong, it can keep the infection from making you feel sick."
Which of the following assessment findings does the nurse expect in the pt with
emphysema?
Diminished breath sounds
00:0201:21

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A pt with SOB is being tested for lung cancer. Which diagnostic test will be most
conclusive?
Biopsy
A pt with recurrent pneumothorax is scheduled to have pleurodesis done 1 hour. Which
nursing intervention should take priority at this time?
Administer a prn analgesic as ordered
Which of the following assessment findings in the pt with pneumonia most indicates a
need to remind the pt to cough and deep breathe?
The pt develops coarse wheezes and crackles
A pt is admitted to the hospital with SOB. The nurse notes increasing confusion and
combativeness during the past hour. Which of the following actions is appropriate first?
Assess SpO2 and apply oxygen per protocol if indicated
Which of the following interventions is most appropriate for the pt with an ineffective
breathing pattern?
Teach the pt controlled diaphragmatic breathing
A pt with end-stage COPD has a nursing diagnosis of Impaired Gas Exchange. Which
assessment finding shows that interventions have been effective?
The pt's SpO2 is 92% on 2L of oxygen
The nurse is reinforcing instructions to a hospitalized client with a diagnosis of
emphysema about positions that will enhance the effectiveness of breathing during
dyspneic episodes. Which position should the nurse instruct the client to assume?
Sitting up on the side of the bed, leaning on an overbed table.
The nurse is gathering data on a client with a diagnosis of TB. The nurse should review
the results of which diagnostic test to confirm this diagnosis?
Sputum culture
Which identifies the route of transmission of TB?
The airborne route
The nurse is preparing a list of home care instructions for the client who has been
hospitalized and treated for TB. Which instructions should the nurse reinforce? (SATA)
Activities should be resumed gradually; A sputum culture is needed every 2-4 weeks
once medication therapy is initiated; Respiratory isolation is not necessary because
family members have already been exposed; Cover the mouth and nose when coughing
or sneezing and confine used tissues to plastic bags
The nurse is instructing a client about pursed lip breathing, and the client asks the nurse
about its purpose. The nurse should tell the client that the primary purpose of pursed lip
breathing is which?
Promote carbon dioxide elimination
The low-pressure alarm sounds on the ventilator. The nurse checks the client then
attempts to determine the cause of the alarm but is unsuccessful. Which initial action
should be done?
Ventilate the client manually
The nurse is assigned to care for a client after a left pneumonectomy. Which position is
contraindicated for this patient?
Lateral position
The nurse is caring for a client after pulmonary angiography via catheter insertion into
the left groin. The nurse monitors for an allergic reaction to the contrast medium by
observing for the presence of what?
Respiratory distress
The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis.
The nurse knows that the client understands the information if the client verbalizes
which early sign of exacerbation?
SOB
The nurse is caring for several clients with respiratory disorders. Which client is at least
risk for developing TB infection?
A man who is an inspector for the US Postal Service
The nurse is reading the results of a tuberculin skin test on a client with no documented
health problems. The site has no induration and a 1-mm area of ecchymosis. Which
interpretation should the nurse make of these results?
Negative
The nurse notes that a hospitalized client has experienced a positive reaction to the
tuberculin skin test. Which action by the nurse is priority?
Report the findings
A client being discharged from the hospital to home with a diagnosis of TB is worried
about the possibility of infecting family members and others. Which information should
reassure the client that contaminating family members is not likely?
The family will receive prophylactic therapy, and the client will not be contagious after 2-
3 consecutive weeks of medication therapy.
The nurse is reinforcing discharge teaching with a client diagnosed with TB and has
been on medication for 1.5 weeks. The nurse knows that the client has understood the
information if which statement is made?
"I should not be contagious after 2-3 weeks of medication therapy."
The nurse is caring for a client with emphysema receiving oxygen. The nurse should
check the oxygen flow rate to ensure the client does not exceed how many L/min of
oxygen?
2
Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC)
disease with TB. The nurse should monitor for which side/adverse effects of the
medication? (SATA)
Signs of hepatitis; Flu-like syndrome; Low neutrophil count; Ocular pain or blurred vision
A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse
determines that the client understands the most effective use of this medication if the
client makes which statement?
"I will take the tablet with a full glass of water."
A postop client has received a dose of naloxone hydrochloride for respiratory
depression shortly after transfer to the nursing unit from the PACU. After administration
of the medication, the nurse should check the client for which sign/symptoms?
Sudden increase in pain
A client has been taking isoniazid for 2 months. The client c/o numbness, paresthesias,
and tingling in the extremeties. The nurse interprets that the client is experiencing which
problem?
Peripheral neuritis
A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to
provide which information to the client?
Report yellow eyes or skin immediately
A client has been started on long-term therapy with rifampin. Which information about
this medication should the nurse provide to the client?
Causes red-orange discoloration of sweat, tears, urine, and feces.
The nurse has given a client taking ethambutol information about the medication. The
nurse determines that the client understands the instructions if the client states to report
which occurrence immediately?
Problems with visual acuity
Cycloserine is added to the medication regimen for a client with TB. Which instruction
should the nurse reinforce in the client-teaching plan regarding this medication?
To return to the clinic weekly for serum drug-level testing
A client with TB is being started on antituberculosis therapy with isoniazid. Before giving
the client the first dose, the nurse ensures that which baseline study has been
completed?
Liver enzyme levels
A client is receiving acetylcysteine 20% solution diluted in 0.9% normal saline by
nebulizer. The nurse should have which item available for a possible adverse event
after giving this medication?
Suction equipment