Oxygenation - Nursing Test Questions

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 15 Oxygenation
The Concept of Oxygenation
1) In a client with a tracheostomy, the nurse should monitor for complications related to the loss
of which protective mechanism?
A) Filtration and humidification of inspired air
B) The ability to cough
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages
Answer: A
Explanation: A) When the nasal passages are bypassed, as they would be in the case of a client
with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also
bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
B) When the nasal passages are bypassed, as they would be in the case of a client with a
tracheostomy, the filtration, humidification, and warming of the nasal passages are also
C) When the nasal passages are bypassed, as they would be in the case of a client with a
D) When the nasal passages are bypassed, as they would be in the case of a client with a
Page Ref: 984
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the structure and physiologic processes of the respiratory
system related to oxygenation.
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Copyright © 2015 Pearson Education, Inc.
2) What factors should the nurse assess in a client who has been diagnosed with lung disease but
has no history of smoking?
Select all that apply.
A) Participation in recreational activities
B) Cardiac status
C) Exposure to airborne pollutants
D) Exposure to second-hand smoke
E) Nutritional status
Answer: C, D
Explanation: A) The nurse should assess the client for exposure to airborne pollutants and
secondhand smoke. A number of factors affect a healthy respiratory system. The air an
individual breathes, either indoors or outdoors, may be polluted. Exposure to airborne irritants
may produce an inflammatory response within the airways. Assessing the client's participation in
recreational activities and nutritional status is important; however, it might not provide the
needed information regarding the client's exposure to pollutants. The client's cardiac status may
or may not be affected by the lung disease.
B) The nurse should assess the client for exposure to airborne pollutants and secondhand smoke.
A number of factors affect a healthy respiratory system. The air an individual breathes, either
indoors or outdoors, may be polluted. Exposure to airborne irritants may produce an
inflammatory response within the airways. Assessing the client's participation in recreational
activities and nutritional status is important; however, it might not provide the needed
information regarding the client's exposure to pollutants. The client's cardiac status may or may
not be affected by the lung disease.
C) The nurse should assess the client for exposure to airborne pollutants and secondhand smoke.
D) The nurse should assess the client for exposure to airborne pollutants and secondhand smoke.
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E) The nurse should assess the client for exposure to airborne pollutants and secondhand smoke.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Learning Outcome: 2. Examine the relationship between oxygenation and other
concepts/systems.
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3) A firefighter has been admitted to the ED. He has no visible burn injuries. He is somewhat
inattentive and uncoordinated and is frequently attempting to get off the gurney and leave the
ED. What might the nurse hypothesize about his condition?
A) The firefighter is exhibiting normal anxiety after a traumatic event and is ready for discharge.
B) The firefighter is showing signs of mild cerebral hypoxia related to smoke inhalation.
C) The firefighter has severe cerebral hypoxia.
D) The firefighter is suffering from ARDS.
E) Further tests are indicated to determine the extent of the problem.
Answer: B, E
Explanation: A) Symptoms of mild cerebral hypoxia include change in attention, poor judgment,
and uncoordinated movement. Symptoms of severe cerebral hypoxia include complete
unawareness and unresponsiveness, no breathing, and no response of the pupils of the eye to
light. ARDS is a severe form of acute respiratory failure. Inattention and lack of coordination are
not anxiety-related symptoms. X-rays and blood tests may be used to further assess the problem.
B) Symptoms of mild cerebral hypoxia include change in attention, poor judgment, and
uncoordinated movement. Symptoms of severe cerebral hypoxia include complete unawareness
and unresponsiveness, no breathing, and no response of the pupils of the eye to light. ARDS is a
severe form of acute respiratory failure. Inattention and lack of coordination are not anxiety-
related symptoms. X-rays and blood tests may be used to further assess the problem.
C) Symptoms of mild cerebral hypoxia include change in attention, poor judgment, and
D) Symptoms of mild cerebral hypoxia include change in attention, poor judgment, and
E) Symptoms of mild cerebral hypoxia include change in attention, poor judgment, and
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Learning Outcome: 2. Examine the relationship between oxygenation and other
concepts/systems.
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4) What therapies may the nurse expect to provide to a client with asthma?
A) Ventilatory support
B) Oral and nasal suctioning
C) Instruction on aggravating factors
D) How to measure daily peak expiratory flow rates
E) Oxygen therapy
Answer: C, D
Explanation: A) Treatment for the client with asthma includes instruction on the identification
and avoidance of aggravating factors and measuring daily peak expiratory flow rates. Oral and
nasal suctioning is not indicated with the treatment of asthma. Clients with asthma are not
prescribed oxygen therapy. Clients with asthma do not usually need ventilatory support.
B) Treatment for the client with asthma includes instruction on the identification and avoidance
of aggravating factors and measuring daily peak expiratory flow rates. Oral and nasal suctioning
is not indicated with the treatment of asthma. Clients with asthma are not prescribed oxygen
therapy. Clients with asthma do not usually need ventilatory support.
C) Treatment for the client with asthma includes instruction on the identification and avoidance
D) Treatment for the client with asthma includes instruction on the identification and avoidance
E) Treatment for the client with asthma includes instruction on the identification and avoidance
Page Ref: 1001
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring alterations in oxygenation and their related
therapies.
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5) When auscultating the lungs of a client with shortness of breath, the nurse hears a low-pitched
sound that is continuous throughout inspiration. What does this lung sound indicate?
A) Narrow bronchi
B) Narrow trachea passages
C) Blocked large airway passages
D) Inflamed pleural surfaces
Answer: C
Explanation: A) The nurse auscultated rhonchi, which are low-pitched sounds that are
continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which
may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-
pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow
bronchi.
B) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout
inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with
coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound
is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
C) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout
D) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout
Page Ref: 963
Learning Outcome: 4. Differentiate common physical assessment procedures used to evaluate
respiratory health across the life span.
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6) The nurse is reviewing the results of laboratory tests conducted on a client admitted with a
respiratory disorder. Which laboratory finding would be most significant for this client?
A) Hemoglobin level 12 mg/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32
Answer: D
Explanation: A) The blood pH of 7.32 indicates acidosis, which indicates inadequate
oxygenation. The serum sodium does not impact the oxygen capacity of the body. The
hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the
value is within normal limits. Oxygen saturation of 96% is within normal limits.
B) The blood pH of 7.32 indicates acidosis, which indicates inadequate oxygenation. The serum
sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the
amount of oxygen that can be carried in the blood; however, the value is within normal limits.
Oxygen saturation of 96% is within normal limits.
C) The blood pH of 7.32 indicates acidosis, which indicates inadequate oxygenation. The serum
D) The blood pH of 7.32 indicates acidosis, which indicates inadequate oxygenation. The serum
Page Ref: 966
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
oxygenation status.
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7) A client with chronic obstructive lung disease is prescribed oxygen 24% 2 L/min. What does
the nurse determine to be the best method of providing oxygen to this client?
A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask
Answer: B
Explanation: A) The oxygen delivery device that would safely administer 24% oxygen at the
flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better
suited for higher percentages of oxygen and higher flow rates.
B) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2
liters per minute is through nasal cannula. The other delivery devices are better suited for higher
percentages of oxygen and higher flow rates.
C) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2
D) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2
Page Ref: 972
Nursing Process: Planning
Learning Outcome: 6. Explain management of respiratory health and prevention of respiratory
illness.
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8) The nurse is planning care for a client with shortness of breath. What should the nurse do to
address the client's activity intolerance?
A) Encourage activity.
B) Consult a dietitian for low-calorie meals.
C) Consult physical therapy for endurance and musculoskeletal function.
D) Encourage independence with activities of daily living.
Answer: C
Explanation: A) The client with shortness of breath will experience activity intolerance due to a
lack of oxygen and fatigue. The nurse should consult with Physical Therapy for endurance and
musculoskeletal function. Clients with respiratory disorders often need an increase, not a
decrease, in calories to maintain body functions. The client will be weak, so the nurse should not
encourage activity or independence with the activities of daily living.
B) The client with shortness of breath will experience activity intolerance due to a lack of
oxygen and fatigue. The nurse should consult with Physical Therapy for endurance and
C) The client with shortness of breath will experience activity intolerance due to a lack of
D) The client with shortness of breath will experience activity intolerance due to a lack of
Page Ref: 969
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in oxygenation.
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9) A client is admitted for acute symptoms of asthma and lung inflammation. What would the
nurse expect the physician to prescribe to this client?
A) Xenopenex
B) Atrovent
C) Slo-Bid
D) Advair
Answer: A
Explanation: A) The client is experiencing acute symptoms of asthma due to lung inflammation.
A bronchodilator of short duration, such as Xenopenex, would be indicated. Advair would be
more applicable for the client with chronic obstructive pulmonary disease. Atrovent is an
anticholinergic medication. Slo-Bid is a xanthine.
B) The client is experiencing acute symptoms of asthma due to lung inflammation. A
bronchodilator of short duration, such as Xenopenex, would be indicated. Advair would be more
applicable for the client with chronic obstructive pulmonary disease. Atrovent is an
C) The client is experiencing acute symptoms of asthma due to lung inflammation. A
D) The client is experiencing acute symptoms of asthma due to lung inflammation. A
Page Ref: 971
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in oxygenation.
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10) The nurse is working in the nursery and finds a newborn's respiratory rate is 52 breaths per
minute. What action taken by the nurse is most appropriate at this time?
A) Notify the physician of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
D) Continue to monitor the newborn per facility policy.
Answer: D
Explanation: A) A respiratory rate of 52 breaths per minute is a normal finding in a newborn.
Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or
newborn is 30-60 breaths per minute.
B) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates
are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60
breaths per minute.
C) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates
breaths per minute.
D) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates
breaths per minute.
Page Ref: 956
Learning Outcome: 4. Differentiate common assessment procedures used to examine respiratory
health across the life span.
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11) The nursing instructor preparing a lecture on alterations in oxygenation is aware that which
of the following are manifestations of tachypnea?
A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis
Answer: A, C, D
Explanation: A) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all
manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late
manifestation of hypoxemia.
B) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations
of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation
of hypoxemia.
C) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations
of hypoxemia.
D) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all
manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late
manifestation of hypoxemia.
E) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations
of hypoxemia.
Page Ref: 960
Cognitive Level: Understanding
Nursing Process: Teaching and Learning
therapies.
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12) The charge nurse is observing a newly licensed nurse conduct an admission assessment on a
client admitted with asthma. Which action observed would indicate to the charge nurse the need
to intervene immediately?
A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after
the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history
while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.
Answer: B
Explanation: A) The charge nurse should intervene immediately if the nurse observes the client
is demonstrating impairment at or near respiratory failure; the client will not be able to respond
to questions. Assessment questions should be tailored and asked of any family member or friend
accompanying the client. The client's physician should be notified immediately on the client's
arrival to the unit. The immediate concern is to return respiratory status as near to normal as
possible. Although the pulse oximetry reading may not be a true indicator of the level of
respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes
of this assessment, it is still an appropriate action for the newly licensed nurse to take and does
not require the charge nurse to intervene immediately. The charge nurse may speak to the newly
licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and
nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use
of a stethoscope is appropriate.
B) The charge nurse should intervene immediately if the nurse observes the client is
demonstrating impairment at or near respiratory failure; the client will not be able to respond to
questions. Assessment questions should be tailored and asked of any family member or friend
C) The charge nurse should intervene immediately if the nurse observes the client is
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D) The charge nurse should intervene immediately if the nurse observes the client is
Page Ref: 963, 965
Client Need Sub: Reduction of Risk Potential
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in oxygenation.
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13) The newly licensed nurse is having a discussion with the charge nurse about alterations in
oxygenation. The newly licensed nurse is aware that which of the following are examples
independent nursing interventions when providing care to clients with alterations in
oxygenation?
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Administering bronchodilators
E) Monitoring activity intolerance
Answer: A, B, C, E
Explanation: A) Examples of independent interventions that nurses can provide to clients with
alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking
cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and
assisting with activities of daily living (ADLs). Administration of bronchodilators requires a
physician's order and is considered a collaborative intervention and not an independent nursing
intervention.
B) Examples of independent interventions that nurses can provide to clients with alterations in
oxygenation include deep breathing exercises, positioning, encouraging smoking cessation,
monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with
activities of daily living (ADLs). Administration of bronchodilators requires a physician's order
and is considered a collaborative intervention and not an independent nursing intervention.
C) Examples of independent interventions that nurses can provide to clients with alterations in
D) Examples of independent interventions that nurses can provide to clients with alterations in
E) Examples of independent interventions that nurses can provide to clients with alterations in
Page Ref: 986
therapies.
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14) The nurse caring for a client on the medical unit is aware that the client with a PaO2 of 82,
PaCO2 level of 49, HCO3 of 26, and pH of 7.55 is experiencing which acid-base imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic alkalosis
D) Metabolic acidosis
Answer: A
Explanation: A) Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the
carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH greater
than 7.45 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg,
respiratory acidosis is present. The PaO2 of 82 is on the low end of normal and the bicarbonate
level is normal.
B) Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide
levels are regulated by the lungs. Therefore, a blood gas that has a pH greater than 7.45 indicates
acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis
is present. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal.
C) Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide
D) Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide
Page Ref: 958
Client Need Sub: Reduction of Risk Potential
Nursing Process: Diagnosis
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
oxygenation status.
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Exemplar 15.1 Acute Respiratory Distress Syndrome
1) When planning care for the client who was a victim of a near-drowning, the nurse will include
interventions to address:
A) Chronic obstructive pulmonary disease.
B) Heart failure.
C) Chronic renal failure.
D) Acute respiratory distress syndrome.
Answer: D
Explanation: A) One of the conditions associated with the development of acute respiratory
distress syndrome is an inhalation injury sustained from a near-drowning. Not enough
information is provided to determine whether the client will develop heart failure or chronic
renal failure. The development of chronic obstructive pulmonary disease is not associated with
near-drowning.
B) One of the conditions associated with the development of acute respiratory distress syndrome
is an inhalation injury sustained from a near-drowning. Not enough information is provided to
determine whether the client will develop heart failure or chronic renal failure. The development
of chronic obstructive pulmonary disease is not associated with near-drowning.
C) One of the conditions associated with the development of acute respiratory distress syndrome
D) One of the conditions associated with the development of acute respiratory distress syndrome
Page Ref: 975
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of acute respiratory distress syndrome (ARDS).
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2) What is the normal progression of ARDS?
1. Initiation of ARDS
2. Onset of pulmonary edema
3. End-stage ARDS
4. Alveolar collapse
Answer: 1, 2, 4, 3
Explanation: ARDS begins with inflammatory cellular responses and biochemical mediators
that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the
alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages
surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension,
and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal
tract, central nervous system, and cardiovascular system are the leading causes of death in
ARDS.
Page Ref: 975
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3) A client with a systemic infection from an infected leg wound tells the nurse, "It's getting hard
to breathe." What does the nurse suspect this client is at risk for developing?
A) Allergic response from antibiotic therapy
B) Deep vein thrombosis
C) Acute respiratory distress syndrome
D) Anemia
Answer: C
Explanation: A) Sepsis is the most common cause of acute respiratory distress syndrome. The
client has a systemic infection, which is sepsis, and is complaining that it is getting hard to
breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein
thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated
with a systemic infection from an infected leg wound and are not associated with the
development of acute respiratory distress syndrome.
B) Sepsis is the most common cause of acute respiratory distress syndrome. The client has a
systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The
nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis,
anemia, or allergic response from antibiotic therapy may or may not be associated with a
systemic infection from an infected leg wound and are not associated with the development of
acute respiratory distress syndrome.
C) Sepsis is the most common cause of acute respiratory distress syndrome. The client has a
D) Sepsis is the most common cause of acute respiratory distress syndrome. The client has a
Page Ref: 975
Learning Outcome: 2. Identify risk factors and prevention methods associated with ARDS.
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4) While performing nasotracheal suctioning, the nurse notes the older client is moving the head
around and pulling at the nurse's hand to remove the suction catheter. What should the nurse do?
A) Remove the suction catheter.
B) Lower the head of the bed.
C) Hyperinflate the client's lungs.
D) Apply restraints to the client's arms and legs.
E) Hyperoxygenate the client.
Answer: A, C, E
Explanation: A) The older client is demonstrating signs of hypoxemia. The nurse should remove
the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client
does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or
high-Fowler position.
B) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction
catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need
to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler
position.
C) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction
position.
D) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction
position.
E) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction
position.
Page Ref: 986
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with ARDS.
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5) A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.
Which nursing diagnosis is a priority for this client?
A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output
Answer: B
Explanation: A) The client has a respiratory pattern of 8 breaths per minute with an oxygen
saturation of 82%. The nursing diagnosis of priority for this client is Impaired Spontaneous
Ventilation. If this breathing pattern continues without intervention, the client could be at risk for
decreased cardiac output and risk for acute confusion. There is not enough information to
determine whether the client is at risk for infection.
B) The client has a respiratory pattern of 8 breaths per minute with an oxygen saturation of 82%.
The nursing diagnosis of priority for this client is Impaired Spontaneous Ventilation. If this
breathing pattern continues without intervention, the client could be at risk for decreased cardiac
output and risk for acute confusion. There is not enough information to determine whether the
client is at risk for infection.
C) The client has a respiratory pattern of 8 breaths per minute with an oxygen saturation of 82%.
D) The client has a respiratory pattern of 8 breaths per minute with an oxygen saturation of 82%.
Page Ref: 985
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
ARDS.
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6) A client with acute respiratory distress syndrome is being weaned from ventilatory support.
What should the nurse do to improve the weaning process for this client?
A) Reduce percentage of oxygen being provided through the ventilator.
B) Place in the Fowler position.
C) Provide morning care during the weaning procedures.
D) Begin weaning procedures in the morning.
E) Medicate with morphine for pain as needed.
Answer: B, D
Explanation: A) Weaning a client from ventilatory support should begin in the morning when
the client is well-rested. The client should be in the Fowler or high-Fowler position, as this
facilitates lung expansion and reduces the work of breathing. Activities and care should be
limited during the weaning process to reduce the demand for oxygen. The client should not be
given any medication known to suppress respirations, as this would interfere with the weaning
process. Medicating for pain would be appropriate when the client is back on the ventilator after
concluding the weaning procedures. The nurse should not reduce the percentage of oxygen being
provided through the ventilator, as this is not part of the weaning process.
B) Weaning a client from ventilatory support should begin in the morning when the client is
well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung
expansion and reduces the work of breathing. Activities and care should be limited during the
weaning process to reduce the demand for oxygen. The client should not be given any
medication known to suppress respirations, as this would interfere with the weaning process.
Medicating for pain would be appropriate when the client is back on the ventilator after
C) Weaning a client from ventilatory support should begin in the morning when the client is
D) Weaning a client from ventilatory support should begin in the morning when the client is
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E) Weaning a client from ventilatory support should begin in the morning when the client is
Page Ref: 986
Learning Outcome: 7. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with ARDS.
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7) A client receiving treatment for acute respiratory distress syndrome is demonstrating anxiety
and fear of having to stay on the ventilator indefinitely. What can the nurse do to help reduce this
client's anxiety?
A) Explain about care areas specifically designed for long-term ventilatory support.
B) Dim the lights and reduce distracting noise, such as the television.
C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.
Answer: C, D, E
Explanation: A) A critical illness creates anxiety for any client. For the client with acute
respiratory distress syndrome, anxiety is compounded by intubation and mechanical ventilation.
To reduce this client's anxiety, the nurse should encourage the family to visit and participate in
care. The nurse should also remain with the client as much as possible and instruct that
intubation and ventilation are temporary measures to allow the lungs to rest and heal. Explaining
that there are care areas designed for long-term ventilatory support could increase the client's
anxiety. The nurse should provide distractions such as television or radio and not dim the lights
or turn off the television, which could also increase the client's anxiety.
B) A critical illness creates anxiety for any client. For the client with acute respiratory distress
syndrome, anxiety is compounded by intubation and mechanical ventilation. To reduce this
client's anxiety, the nurse should encourage the family to visit and participate in care. The nurse
should also remain with the client as much as possible and instruct that intubation and ventilation
are temporary measures to allow the lungs to rest and heal. Explaining that there are care areas
designed for long-term ventilatory support could increase the client's anxiety. The nurse should
provide distractions such as television or radio and not dim the lights or turn off the television,
which could also increase the client's anxiety.
C) A critical illness creates anxiety for any client. For the client with acute respiratory distress
D) A critical illness creates anxiety for any client. For the client with acute respiratory distress
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E) A critical illness creates anxiety for any client. For the client with acute respiratory distress
Page Ref: 987
Learning Outcome: 8. Plan evidence-based care for an individual with ARDS and his or her
family in collaboration with other members of the healthcare team.
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8) The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome informs
the parents that the newborn is improving. Which data supports the nurse's assessment?
A) Increased PCO2
B) Increased urination
C) Pulmonary vascular resistance increases
D) Decreased urine output
Answer: B
Explanation: A) As fluid moves out of the lungs and into the bloodstream, alveoli open and
kidney perfusion increases, thereby increasing urine output. Increased urination could be an
indication that the newborn's condition is improving. Decreased urine output could indicate
deterioration in the newborn's condition or, at best, no improvement from the current status.
Pulmonary vascular resistance increases with hypoxia. Increased PCO2 results from alveolar
hypoventilation.
B) As fluid moves out of the lungs and into the bloodstream, alveoli open and kidney perfusion
increases, thereby increasing urine output. Increased urination could be an indication that the
newborn's condition is improving. Decreased urine output could indicate deterioration in the
newborn's condition or, at best, no improvement from the current status. Pulmonary vascular
resistance increases with hypoxia. Increased PCO2 results from alveolar hypoventilation.
C) As fluid moves out of the lungs and into the bloodstream, alveoli open and kidney perfusion
D) As fluid moves out of the lungs and into the bloodstream, alveoli open and kidney perfusion
Page Ref: 987
Nursing Process: Evaluation
Learning Outcome: 6. Evaluate expected outcomes for an individual with ARDS.
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9) The nursing instructor is preparing to speak to a group of nursing students about direct and
indirect insults to the lungs that may lead to the development of acute respiratory distress
syndrome (ARDS). The nurse educator is aware that which conditions may lead to the
development of ARDS?
A) Septic shock
B) Viral pneumonia
C) Aspirin overdose
D) Head injury
E) Percutaneous intervention
Answer: A, B, C, D
Explanation: A) Acute respiratory distress syndrome (ARDS) is a severe form of acute
respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include
but are not limited to hemorrhagic or septic shock, smoke inhalation, aspiration, viral
pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple
transfusions. Percutaneous interventions such as an atherectomy or an angioplasty are not
conditions that would lead to the development of ARDS. However, undergoing an open heart
surgery with cardiopulmonary bypass is.
B) Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure that
occurs in response to pulmonary or systemic insults. Such insults include but are not limited to
hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or
aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. Percutaneous
interventions such as an atherectomy or an angioplasty are not conditions that would lead to the
development of ARDS. However, undergoing an open heart surgery with cardiopulmonary
bypass is.
C) Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure that
bypass is.
D) Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure that
bypass is.
27
E) Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure that
bypass is.
Page Ref: 975
Client Need Sub: Physiological Adaptation
10) The nurse caring for a client admitted with septic shock is aware of the need to assess for the
development of acute respiratory distress syndrome (ARDS). Which of the following is
considered an early clinical manifestation?
A) Intercostal retractions
B) Cyanosis
C) Tachypnea
D) Tachycardia
Answer: C
Explanation: A) Dyspnea and tachypnea are early manifestations. As the distress progresses, the
client would demonstrate an increasing respiratory rate, intercostal retractions, and use of
accessory muscles, as well as tachycardia. Cyanosis is a late manifestation.
B) Dyspnea and tachypnea are early manifestations. As the distress progresses, the client would
demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles,
as well as tachycardia. Cyanosis is a late manifestation.
C) Dyspnea and tachypnea are early manifestations. As the distress progresses, the client would
D) Dyspnea and tachypnea are early manifestations. As the distress progresses, the client would
Page Ref: 978
28
11) A client admitted with smoke inhalation injuries develops signs and symptoms of respiratory
distress. The nurse anticipates the physician will order which course of action with regard to
oxygen therapy?
A) Oxygen via a nasal cannula
B) Mechanical ventilation
C) Oxygen via a facial mask
D) Oxygen via a venturi mask
Answer: B
Explanation: A) With ARDS, it is rarely possible to maintain adequate tissue oxygenation with
oxygen therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the
percentage of oxygen administered) is set at the lowest possible level to maintain a PaO2 higher
than 60 mmHg and oxygen saturation of approximately 90%. It is important to remember that
mechanical ventilation does not cure ARDS; it simply supports respiratory function while the
underlying problem is identified and treated.
B) With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the
C) With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
D) With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
Page Ref: 978
care of an individual with ARDS.
29
12) The nurse in the Intensive Care Unit (ICU) is caring for a client diagnosed with acute
respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation are blood
pressure 88/58, heart rate 108, respiratory rate 32, and oxygen saturation 82%. The client has an
endotracheal tube placed and is placed on mechanical ventilation with positive pressure
ventilation. The nurse is aware that with positive pressure ventilation, the client is at risk for
decreased cardiac output due to increased intrathoracic pressure. Which assessment finding
would indicate to the nurse that there is a decrease in cardiac output?
A) Blood pressure 90/60
B) Urine output 25mL/hr
C) Heart rate 110 bpm
D) Oxygen saturation 90%
Answer: B
Explanation: A) Because a significant portion of the cardiac output goes directly to the kidneys,
a fall in urine output to less than 30 mL/hour is often the first sign of decreased cardiac output.
Although hypotension and tachycardia are indicative of a decreased cardiac output and the client
is experiencing hypotension and tachycardia, this is not a change from the previous assessment
and would not indicate a further decrease in cardiac output due to mechanical ventilation. The
oxygen saturation level is within normal limits for this client and improving from the previous
assessment.
B) Because a significant portion of the cardiac output goes directly to the kidneys, a fall in urine
output to less than 30 mL/hour is often the first sign of decreased cardiac output. Although
hypotension and tachycardia are indicative of a decreased cardiac output and the client is
experiencing hypotension and tachycardia, this is not a change from the previous assessment and
would not indicate a further decrease in cardiac output due to mechanical ventilation. The
assessment.
C) Because a significant portion of the cardiac output goes directly to the kidneys, a fall in urine
assessment.
D) Because a significant portion of the cardiac output goes directly to the kidneys, a fall in urine
assessment.
Page Ref: 987
Learning Outcome: 2. Identify risk factors and prevention methods associated with ARDS.
30
Exemplar 15.2 Asthma
1) Which assessment findings indicate that a client with asthma needs immediate attention?
A) Retractions and fatigue
B) Tachycardia and tachypnea
C) Inaudible breath sounds
D) Diffuse wheezing and the use of accessory muscles when inhaling
E) Reduced wheezing and an ineffective cough
Answer: C, E
Explanation: A) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that
little or no air movement into and out of the lungs is taking place. Therefore, this set of
symptoms represents the most urgent need, which is immediate intervention by the nurse to open
up the lungs with drug management to prevent total respiratory failure. During an asthma attack,
tachycardia, tachypnea, and prolonged expirations are common. They are early symptoms of the
disease process and can be addressed without urgency. Diffuse wheezing and the use of
accessory muscles when inhaling indicate a progression of the severity of the symptoms, but
airflow is still occurring; therefore, they do not require the most urgent action. Retractions and
fatigue are also a progression of symptoms that occur with an asthma attack and represent a more
severe episode. But they are not the worst or most serious set of symptoms listed, because air is
still moving and exchanging.
B) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air
movement into and out of the lungs is taking place. Therefore, this set of symptoms represents
the most urgent need, which is immediate intervention by the nurse to open up the lungs with
drug management to prevent total respiratory failure. During an asthma attack, tachycardia,
tachypnea, and prolonged expirations are common. They are early symptoms of the disease
process and can be addressed without urgency. Diffuse wheezing and the use of accessory
muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still
occurring; therefore, they do not require the most urgent action. Retractions and fatigue are also
a progression of symptoms that occur with an asthma attack and represent a more severe episode.
But they are not the worst or most serious set of symptoms listed, because air is still moving and
exchanging.
C) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air
exchanging.
31
D) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air
exchanging.
E) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air
exchanging.
Page Ref: 993
direct and indirect causes of asthma.
32
2) Friends of a client hospitalized with asthma would like to bring the client a gift. Which of the
following could the nurse suggest as a gift for the client?
A) A basket of flowers
B) A stuffed animal
C) Fruit and candy
D) A book
Answer: D
Explanation: A) Limiting problems associated with respiratory health by controlling exposure to
allergens, pollutants, and irritants in the client's environment is important. Flowers, food, and
items that may contain dust and mold, such as stuffed animals, should be avoided. Objects void
of any irritant, such as a book, would be the best selection for a gift. Other ideas include movies,
music, coloring books (depending on the age of client), or craft items that are age-appropriate.
B) Limiting problems associated with respiratory health by controlling exposure to allergens,
pollutants, and irritants in the client's environment is important. Flowers, food, and items that
may contain dust and mold, such as stuffed animals, should be avoided. Objects void of any
irritant, such as a book, would be the best selection for a gift. Other ideas include movies, music,
coloring books (depending on the age of client), or craft items that are age-appropriate.
C) Limiting problems associated with respiratory health by controlling exposure to allergens,
D) Limiting problems associated with respiratory health by controlling exposure to allergens,
Page Ref: 992
Learning Outcome: 2. Identify risk factors and prevention methods associated with asthma.
33
3) A nurse is teaching environmental control to the parents of a child with asthma. Which
statement by the parents indicates effective teaching?
A) "We'll be sure to use the fireplace often to keep the house warm in the winter."
B) "We will replace the carpet in our child's bedroom with tile."
C) "We'll keep the plants in our child's room dusted."
D) "We're glad the dog can continue to sleep in our child's room."
Answer: B
Explanation: A) Control of dust in the child's bedroom is an important aspect of environmental
control for asthma management, and replacing the carpeting in the child's bedroom with tile
flooring will reduce dust. When possible, pets and plants should not be kept in the home. Smoke
from fireplaces should be eliminated.
B) Control of dust in the child's bedroom is an important aspect of environmental control for
asthma management, and replacing the carpeting in the child's bedroom with tile flooring will
reduce dust. When possible, pets and plants should not be kept in the home. Smoke from
fireplaces should be eliminated.
C) Control of dust in the child's bedroom is an important aspect of environmental control for
D) Control of dust in the child's bedroom is an important aspect of environmental control for
Page Ref: 992
across the life span for individuals with asthma.
34
4) An older client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes
upon inspiration. What would be an appropriate nursing diagnosis for this client?
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance
Answer: C
Explanation: A) The client is experiencing an increased respiratory rate and is wheezing, which
is an ineffective breathing pattern. Not enough information is provided to determine whether the
client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
B) The client is experiencing an increased respiratory rate and is wheezing, which is an
ineffective breathing pattern. Not enough information is provided to determine whether the client
has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
C) The client is experiencing an increased respiratory rate and is wheezing, which is an
D) The client is experiencing an increased respiratory rate and is wheezing, which is an
Page Ref: 1001
asthma.
35
5) A client asks why asthma medication is needed even though the client's last attack was several
months ago. What would be the best response for the nurse to make to the client?
A) "The medication needs to be taken or your lungs will be severely damaged and we will not be
able to prevent an acute attack."
B) "The medication needs to be taken indefinitely according to your doctor, so you should
discuss this with him."
C) "The medication is still needed to decrease inflammation in your airways and help prevent an
attack."
D) "The medication needs to be taken for at least a year; then, if you have not had an acute
attack, you can stop it."
Answer: C
Explanation: A) Effective treatment of asthma includes long-term treatment to prevent attacks
and decrease inflammation, as well as short-term treatment when an attack occurs. Long-term
treatment of asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be
severely damaged is nontherapeutic; the inability to prevent an acute attack in this client is not
true. The nurse is able to answer the client's question; it does not need to be referred to the
physician.
B) Effective treatment of asthma includes long-term treatment to prevent attacks and decrease
inflammation, as well as short-term treatment when an attack occurs. Long-term treatment of
asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be severely
damaged is nontherapeutic; the inability to prevent an acute attack in this client is not true. The
nurse is able to answer the client's question; it does not need to be referred to the physician.
C) Effective treatment of asthma includes long-term treatment to prevent attacks and decrease
D) Effective treatment of asthma includes long-term treatment to prevent attacks and decrease
Page Ref: 997
care of an individual with asthma.
36
6) The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma.
What should be included in this client's teaching?
A) Take no more than the prescribed number of doses each day.
B) Rinse the mouth after taking this medication.
C) Take on an empty stomach.
D) Take with meals or a full glass of water.
E) Use hard candy or drink extra fluids to help with a dry mouth.
Answer: A, E
Explanation: A) Ipratropium (Atrovent) can cause a dry mouth. The nurse should instruct the
client to use hard candy or drink extra fluids to help with this side effect. The nurse should also
instruct the client to take no more than the prescribed number of doses each day to prevent
overdosage. The mouth does not need to be rinsed after taking this medication. This medication
does not need to be taken with meals or a full glass of water, or on an empty stomach.
B) Ipratropium (Atrovent) can cause a dry mouth. The nurse should instruct the client to use hard
candy or drink extra fluids to help with this side effect. The nurse should also instruct the client
to take no more than the prescribed number of doses each day to prevent overdosage. The mouth
does not need to be rinsed after taking this medication. This medication does not need to be taken
with meals or a full glass of water, or on an empty stomach.
C) Ipratropium (Atrovent) can cause a dry mouth. The nurse should instruct the client to use hard
D) Ipratropium (Atrovent) can cause a dry mouth. The nurse should instruct the client to use hard
E) Ipratropium (Atrovent) can cause a dry mouth. The nurse should instruct the client to use hard
Page Ref: 999
Learning Outcome: 6. Plan evidence-based care for an individual with asthma and his or her
37
7) What are some evidence-based interventions that could be most useful for an adolescent with
asthma?
A) Provide the school with materials for group activities targeted towards students with asthma.
B) Provide educational materials to the adolescent.
C) Create a peer self-management program for adolescents with asthma.
D) Counsel the adolescent's parents to restrict their child's interaction with other children to
reduce stress.
Answer: A, C
Explanation: A) Although educational information and parental involvement are important,
adolescents are more likely to adhere to medical treatment for chronic conditions when they
experience peer support.
B) Although educational information and parental involvement are important, adolescents are
more likely to adhere to medical treatment for chronic conditions when they experience peer
support.
C) Although educational information and parental involvement are important, adolescents are
support.
D) Although educational information and parental involvement are important, adolescents are
support.
Page Ref: 995
Cognitive Level: Creating
Learning Outcome: 6. Plan evidence-based care for an individual with asthma and his or her
38
8) The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates
client understanding?
A) "The medication widens the airways because it acts on the parasympathetic nervous system."
B) "The medication widens the airways because it stimulates the fight-or-flight response of the
nervous system."
C) "The medication widens the airways because it decreases the production of histamine that
narrows the airways."
D) "The medication widens the airways because it decreases the production of mucous that
narrows the airways."
Answer: B
Explanation: A) During the fight-or-flight response, beta2-adrenergic receptors of the
sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and
bronchodilation occurs. Bronchodilators act on the sympathetic nervous system, not the
parasympathetic nervous system. Bronchodilators do not decrease the production of mucus.
Bronchodilators do not decrease the production of histamine.
B) During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous
system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs.
Bronchodilators act on the sympathetic nervous system, not the parasympathetic nervous system.
Bronchodilators do not decrease the production of mucus. Bronchodilators do not decrease the
production of histamine.
C) During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous
D) During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous
Page Ref: 996-997
Learning Outcome: 7. Evaluate expected outcomes for an individual with asthma.
39
9) The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma.
Which respiratory assessments findings may indicate this client is exhausted and will require
immediate intervention?
A) Shallow respirations
B) Slightly diminished breath sounds
C) Decreased wheezing
D) Increased crackles
E) Increased respiratory rate
Answer: A, C
Explanation: A) Respiratory status can change rapidly during an acute asthma attack. Slowed,
shallow respirations with significantly diminished breath sounds and decreased wheezing may
indicate exhaustion and impending respiratory failure. Immediate intervention is necessary.
Increased crackles are usually associated with heart failure and are not an indication of
exhaustion.
B) Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
respirations with significantly diminished breath sounds and decreased wheezing may indicate
exhaustion and impending respiratory failure. Immediate intervention is necessary. Increased
crackles are usually associated with heart failure and are not an indication of exhaustion.
C) Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
D) Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
E) Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
Page Ref: 1002
direct and indirect causes of asthma.
40
10) A nurse working on a pediatric unit is caring for an infant. The mother of the infant
frantically calls the nurse into the room and states, "I believe my child is choking on a piece of
candy." The nurse finds the infant and determines there is a total airway obstruction. Which is an
appropriate action for the nurse to take?
A) Attempt to clear the obstruction by delivering back blows and chest thrusts.
B) Attempt to clear the obstruction by delivering back blows and chest compressions.
C) Attempt to clear the obstruction by delivering back blows and abdominal thrusts.
D) Attempt to clear the obstruction by delivering abdominal thrusts.
Answer: A
Explanation: A) When a life-threatening total airway obstruction occurs, efforts to clear the
obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in
older children.
B) When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse
to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older
children.
C) When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
children.
D) When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
children.
Page Ref: 1003
across the life span for individuals with asthma.
41
11) The nurse caring for a client newly diagnosed with asthma is developing the client's plan of
care. Which intervention would be most appropriate for the nurse to include in the plan of care if
the nurse wants to promote airway clearance?
A) Provide adequate rest periods.
B) Reduce excessive stimuli.
C) Assist with ADLs.
D) Place in Fowler position.
Answer: D
Explanation: A) Placing in Fowler position facilitates breathing and lung expansion, promoting
airway clearance. Providing adequate rest periods prevents fatigue and reduces oxygen demands.
Reducing excessive stimuli promotes rest. Assisting with ADLs conserves energy and reduces
oxygen demands.
B) Placing in Fowler position facilitates breathing and lung expansion, promoting airway
clearance. Providing adequate rest periods prevents fatigue and reduces oxygen demands.
oxygen demands.
C) Placing in Fowler position facilitates breathing and lung expansion, promoting airway
oxygen demands.
D) Placing in Fowler position facilitates breathing and lung expansion, promoting airway
oxygen demands.
Page Ref: 1002
asthma.
42
12) The nurse is reviewing discharge instructions with a client who is newly diagnosed with
asthma. Which statement made by the client indicates a need for further teaching?
A) "I need to rinse my mouth after every use of my inhaler."
B) "I need to take my Singulair at least 1 hour before I eat."
C) "I can resume my ephedra when I return home."
D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."
Answer: C
Explanation: A) Herbal preparations that include atropa belladonna (the natural form of
atropine) or ephedra (also called ma huang), an herb that contains ephedrine, should not be used,
as they can interact with prescribed medications, indicating a need for further teaching. The other
statements are accurate and require no further education.
B) Herbal preparations that include atropa belladonna (the natural form of atropine) or ephedra
(also called ma huang), an herb that contains ephedrine, should not be used, as they can interact
with prescribed medications, indicating a need for further teaching. The other statements are
accurate and require no further education.
C) Herbal preparations that include atropa belladonna (the natural form of atropine) or ephedra
D) Herbal preparations that include atropa belladonna (the natural form of atropine) or ephedra
Page Ref: 1001
Learning Outcome: 7. Evaluate expected outcomes for an individual with asthma.
43
Exemplar 15.3 Chronic Obstructive Pulmonary Disease
1) Which assessment finding leads a nurse to suspects a client may have symptoms of chronic
obstructive pulmonary disease (COPD)?
A) Dysrhythmias
B) Cyanotic nail beds
C) Clubbing of the fingers
D) Cough in the morning producing clear sputum
Answer: D
Explanation: A) The earliest-presenting symptom of COPD is coughing in the morning with
clear sputum unless the client develops an infection, in which case the sputum would become
yellow or green in color. With the progression of COPD, the body compensates by producing
extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading
to the development of cyanotic nail beds and clubbing of the fingertips. Enlargement and
thickening of the right ventricle of the heart often results in dysrhythmias.
B) The earliest-presenting symptom of COPD is coughing in the morning with clear sputum
unless the client develops an infection, in which case the sputum would become yellow or green
in color. With the progression of COPD, the body compensates by producing extra red blood
cells. These extra blood cells clog the small blood vessels of the fingers, leading to the
development of cyanotic nail beds and clubbing of the fingertips. Enlargement and thickening of
the right ventricle of the heart often results in dysrhythmias.
C) The earliest-presenting symptom of COPD is coughing in the morning with clear sputum
D) The earliest-presenting symptom of COPD is coughing in the morning with clear sputum
Page Ref: 1008
direct and indirect causes of chronic obstructive pulmonary disease (COPD).
44
2) A typical physical manifestation of COPD with an etiology of emphysema is:
A) Tachycardia
B) Cough
C) Barrel chest
D) Wheezing
Answer: C
Explanation: A) Barrel chest occurs because the lungs are chronically overinflated with air, so
the rib cage stays partially expanded. Coughing, wheezing, and tachycardia are not usually
associated with emphysema.
B) Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage
stays partially expanded. Coughing, wheezing, and tachycardia are not usually associated with
emphysema.
C) Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage
emphysema.
D) Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage
emphysema.
Page Ref: 1009
45
3) Which precipitating factors lead the nurse to determine that a client is at risk for developing
chronic obstructive pulmonary disease (COPD)?
A) Working in an industrial environment
B) Working in an office setting with air conditioning
C) History of asthma
D) Cigarette smoking
E) Playing golf several times a week
Answer: A, C, D
Explanation: A) The number one risk factor for the development of COPD is cigarette smoking.
Individuals with asthma can develop COPD. COPD can develop from working in an industrial
environment. Working in an office setting with air conditioning and playing golf several times a
week are not risk factors for the development of asthma.
B) The number one risk factor for the development of COPD is cigarette smoking. Individuals
with asthma can develop COPD. COPD can develop from working in an industrial environment.
Working in an office setting with air conditioning and playing golf several times a week are not
risk factors for the development of asthma.
C) The number one risk factor for the development of COPD is cigarette smoking. Individuals
D) The number one risk factor for the development of COPD is cigarette smoking. Individuals
E) The number one risk factor for the development of COPD is cigarette smoking. Individuals
Page Ref: 1007
Learning Outcome: 2. Identify risk factors and prevention methods associated with COPD.
46
4) The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic
obstructive pulmonary disease (COPD). Which intervention would be the most beneficial for this
client?
A) Obtain a Spanish-speaking interpreter to assist with the completion of the assessment.
B) Encourage activity.
C) Encourage family members to stay with the client to assist with communication needs.
D) Obtain educational materials regarding the disease process and smoking cessation written in
Spanish.
Answer: D
Explanation: A) There is a high rate of cigarette smoking and other tobacco use among the
Hispanic population in the U.S. The intervention that would be most beneficial for the client
would be for the nurse to obtain educational materials regarding the disease process and smoking
cessation written in Spanish, so that the client may use it to refer to in the future. The client may
or may not be able to tolerate activity. Obtaining a Spanish-speaking interpreter would be more
beneficial for the nurse than the client. Encouraging family members to stay to assist with
communication might be beneficial in the short term; however, it will not address the client's
need to learn about the disease process and ways to stop the progression.
B) There is a high rate of cigarette smoking and other tobacco use among the Hispanic
population in the U.S. The intervention that would be most beneficial for the client would be for
the nurse to obtain educational materials regarding the disease process and smoking cessation
written in Spanish, so that the client may use it to refer to in the future. The client may or may
not be able to tolerate activity. Obtaining a Spanish-speaking interpreter would be more
C) There is a high rate of cigarette smoking and other tobacco use among the Hispanic
D) There is a high rate of cigarette smoking and other tobacco use among the Hispanic
Page Ref: 1007
across the life span for individuals with COPD.
47
5) The nurse is planning care for the client with COPD who has a breathing rate of 32 per
minutes, elevated blood pressure, and fatigue. Which diagnosis would the priority for this client
at this time?
A) Ineffective Coping
B) Ineffective Airway Clearance
C) Anxiety
D) Ineffective Breathing Pattern
Answer: D
Explanation: A) The client's respiratory rate of 32 per minute is an indication of an ineffective
breathing pattern. The elevated blood pressure and fatigue are indications of a compromised
respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the
client at this time. There is no information to support Ineffective Airway Clearance, as there is no
mention that the client is coughing. There is no information to support Anxiety or Ineffective
Coping.
B) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing
pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory
status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this
time. There is no information to support Ineffective Airway Clearance, as there is no mention
that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
C) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing
D) The client's respiratory rate of 32 per minute is an indication of an ineffective breathing
Page Ref: 1013
COPD.
48
6) Which interventions would assist a client with chronic obstructive pulmonary disease (COPD)
to control a breathing pattern?
A) Instruct in pursed-lip breathing.
B) Teach visualization and meditation.
C) Deep breathing and coughing every hour.
D) Instruct in abdominal breathing.
E) Provide oxygen 2 liters nasal cannula.
Answer: A, B, D
Explanation: A) Techniques used to instruct a client to control the breathing pattern include
pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation.
Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep
breathing and coughing should be done every 2 hours to help keep the airway clear and prevent
the pooling of secretions, not to control the breathing pattern.
B) Techniques used to instruct a client to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing
oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing
and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling
of secretions, not to control the breathing pattern.
C) Techniques used to instruct a client to control the breathing pattern include pursed-lip
D) Techniques used to instruct a client to control the breathing pattern include pursed-lip
E) Techniques used to instruct a client to control the breathing pattern include pursed-lip
Page Ref: 1013
Learning Outcome: 5. Plan evidence-based care for an individual with COPD and his or her
49
7) A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of
93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100,
respirations 35, and a chest x-ray that showed a flattened diaphragm with infiltrates. Which
healthcare provider order should the nurse question for this client?
A) Antibiotic therapy
B) Nonsteroidal anti-inflammatory agents
C) Oxygen by nasal cannula at 3-4 liters/minute
D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents
Answer: C
Explanation: A) The nurse should be concerned about the order for oxygen to be provided at 3-4
liters/minute. This amount of oxygen is too much for a client with COPD because the client's
breaths are stimulated by a hypoxic drive and this disease process causes the body to retain
carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels,
leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2
liters/minute, with close assessments of the client's breathing status. The order for antibiotic
therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators
will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively
and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly
ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and
carbon dioxide exchange and to improve symptoms, and would be expected for this client.
B) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute.
This amount of oxygen is too much for a client with COPD because the client's breaths are
stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide.
Providing this much oxygen can result in an increase in carbon dioxide levels, leading to
respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute,
with close assessments of the client's breathing status. The order for antibiotic therapy is
expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep
the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and
would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered
to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon
dioxide exchange and to improve symptoms, and would be expected for this client.
C) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute.
50
D) The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute.
Page Ref: 1011
care of an individual with COPD.
51
8) The nurse is planning the care to address Imbalanced Nutrition: Less than Body Requirements
for a client with chronic obstructive pulmonary disease (COPD). Which interventions would be
appropriate for this client?
A) Encourage a diet high in protein and fats.
B) Keep snacks to a minimum.
C) Provide frequent small meals with between meal supplements.
D) Encourage carbohydrate-rich foods to provide needed calories for energy.
E) Suggest the client eat 3 meals per day to maintain energy needs.
Answer: A, C
Explanation: A) A diet high in protein and fats without excess carbohydrates is recommended to
minimize carbon dioxide production during metabolism. Frequent small meals help maintain
intake and reduce fatigue associated with eating. Carbohydrate-rich foods would increase the
client's carbon dioxide production and worsen the symptoms of the disease. The client should be
encouraged to eat frequent small meals, not 3 meals a day. The client should be encouraged to
eat frequent snacks, not limit snacks.
B) A diet high in protein and fats without excess carbohydrates is recommended to minimize
carbon dioxide production during metabolism. Frequent small meals help maintain intake and
reduce fatigue associated with eating. Carbohydrate-rich foods would increase the client's carbon
dioxide production and worsen the symptoms of the disease. The client should be encouraged to
eat frequent small meals, not 3 meals a day. The client should be encouraged to eat frequent
snacks, not limit snacks.
C) A diet high in protein and fats without excess carbohydrates is recommended to minimize
D) A diet high in protein and fats without excess carbohydrates is recommended to minimize
E) A diet high in protein and fats without excess carbohydrates is recommended to minimize
Page Ref: 1015
Learning Outcome: 6. Plan evidence-based care for an individual with COPD and his or her
52
9) Which observation would indicate that care provided to a client with chronic obstructive
pulmonary disease (COPD) has been effective?
A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation
of 92% on room air per oximetry reading.
B) Client needs assistance with morning care and meals due to shortness of breath.
C) Client states family members would prefer he was admitted to a nursing home for continuing
care.
D) Client leaves hospital unit to smoke outside 4 times a day.
Answer: A
Explanation: A) Evidence that care provided to a client with COPD was successful would be the
client conducting morning care and ambulating in the room while maintaining an oxygen
saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation
and perform activities of daily living. The client's leaving the unit to smoke suggests that care
has not been effective. The client who needs assistance with morning care and meals because of
shortness of breath needs additional interventions. The client who states that his family would
prefer he go to a nursing home may or may not have been positively affected by the
interventions; not enough information is provided to know.
B) Evidence that care provided to a client with COPD was successful would be the client
conducting morning care and ambulating in the room while maintaining an oxygen saturation of
92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform
activities of daily living. The client's leaving the unit to smoke suggests that care has not been
effective. The client who needs assistance with morning care and meals because of shortness of
breath needs additional interventions. The client who states that his family would prefer he go to
a nursing home may or may not have been positively affected by the interventions; not enough
information is provided to know.
C) Evidence that care provided to a client with COPD was successful would be the client
D) Evidence that care provided to a client with COPD was successful would be the client
Page Ref: 1013
Learning Outcome: 7. Evaluate expected outcomes for an individual with COPD.
53
10) The nurse is caring for a client diagnosed chronic obstructive pulmonary disease (COPD).
The nurse is in the process of developing the plan of care. Which interventions would be
appropriate for the nurse to include in the plan of care if the nurse wants to enhance breathing
patterns?
A) Provide adequate rest periods.
B) Assist with ADLs.
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer expectorants as ordered.
Answer: A, B, C, D
Explanation: A) Providing adequate rest periods prevents fatigue and reduces oxygen demands.
Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques
reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways
open by maintaining positive pressure. While expectorants would be appropriate for this client
and it is appropriate for the nurse to administer and monitor the effectiveness of this medication,
this medication is associated with increasing the effectiveness in clearing airways and therefore
would be appropriate for promoting airway clearance, and does not directly enhance breathing
patterns.
B) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with
ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and
its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining
positive pressure. While expectorants would be appropriate for this client and it is appropriate for
the nurse to administer and monitor the effectiveness of this medication, this medication is
associated with increasing the effectiveness in clearing airways and therefore would be
appropriate for promoting airway clearance, and does not directly enhance breathing patterns.
C) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with
D) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with
54
E) Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with
Page Ref: 1014
across the life span for individuals with COPD.
11) The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD)
is educating the client on effective coughing techniques. Which statement made by the client
indicates a need for further teaching?
A) "I should inhale by sniffing."
B) "I should avoid aerosol sprays."
C) "I should limit my fluid intake to 1-1.5 quarts daily."
D) "I should get a flu vaccine every year."
Answer: C
Explanation: A) Adequate fluid intake is at least 2.0-2.5 quarts of fluid daily, so the statement
about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are
accurate so do not indicate a need for further teaching.
B) Adequate fluid intake is at least 2.0-2.5 quarts of fluid daily, so the statement about drinking
1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do
not indicate a need for further teaching.
C) Adequate fluid intake is at least 2.0-2.5 quarts of fluid daily, so the statement about drinking
D) Adequate fluid intake is at least 2.0-2.5 quarts of fluid daily, so the statement about drinking
Page Ref: 1014
Learning Outcome: 7. Evaluate expected outcomes for an individual with COPD.
55
12) The nurse on the medical unit is admitting a client with chronic obstructive pulmonary
disease (COPD). The nurse anticipates the physician will order which course of action to reduce
the risk of developing a respiratory infection?
A) A broad-spectrum antibiotic
B) A bronchodilator
C) A corticosteroid
D) An influenza vaccine
Answer: D
Explanation: A) An influenza vaccine may be ordered to reduce the risk of respiratory
infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not
be ordered to reduce the risk of developing an infection. Bronchodilators may be ordered to
improve airflow and reduce air trapping, resulting in improved dyspnea and exercise tolerance,
but would not be ordered to reduce the risk of developing an infection. Corticosteroid therapy
may be used when asthma is a major component of COPD. It improves symptoms and exercise
tolerance and may reduce the severity of exacerbations but would not be ordered to reduce the
risk of developing an infection.
B) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-
spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to
reduce the risk of developing an infection. Bronchodilators may be ordered to improve airflow
and reduce air trapping, resulting in improved dyspnea and exercise tolerance, but would not be
ordered to reduce the risk of developing an infection. Corticosteroid therapy may be used when
asthma is a major component of COPD. It improves symptoms and exercise tolerance and may
reduce the severity of exacerbations but would not be ordered to reduce the risk of developing an
infection.
C) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-
infection.
D) An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-
infection.
Page Ref: 1011
Client Need Sub: Pharmacological and Parenteral Therapies
care of an individual with COPD.
56
13) The student nurse is attending a seminar on chronic obstructive pulmonary disease (COPD).
At the conclusion of the seminar, the student nurse is aware that chronic obstructive pulmonary
disease (COPD) typically includes which two disorders?
A) Asthma and bronchitis
B) Asthma and emphysema
C) Bronchitis and emphysema
D) Emphysema and atelectasis
Answer: C
Explanation: A) Although one or the other may dominate, COPD typically includes components
of both chronic bronchitis and emphysema, two distinctly different processes. Although the
COPD complex can also include asthma, small airways disease, and narrowing of small
bronchioles, it is more commonly known to include bronchitis and emphysema.
B) Although one or the other may dominate, COPD typically includes components of both
chronic bronchitis and emphysema, two distinctly different processes. Although the COPD
complex can also include asthma, small airways disease, and narrowing of small bronchioles, it
is more commonly known to include bronchitis and emphysema.
C) Although one or the other may dominate, COPD typically includes components of both
D) Although one or the other may dominate, COPD typically includes components of both
Page Ref: 1010
57
Exemplar 15.4 Respiratory Syncytial Virus/Bronchiolitis
1) The mother of a 5-month-old baby is concerned because the child has developed a runny nose,
cough, and low-grade fever over the last few days. What do these signs suggest to the nurse?
A) Meningitis
B) Respiratory syncytial virus (RSV) bronchiolitis
C) Bronchitis
D) The common cold
Answer: B
Explanation: A) The typical clinical presentation of respiratory syncytial virus (RSV)
bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early
signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade
fever for 1-3 days. A fever might not be associated with the common cold. A runny nose and
cough might not be associated with meningitis. Bronchitis has a distinctive cough and may or
may not be associated with a fever.
B) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in
otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild
infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3
days. A fever might not be associated with the common cold. A runny nose and cough might not
be associated with meningitis. Bronchitis has a distinctive cough and may or may not be
associated with a fever.
C) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in
D) The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in
Page Ref: 1019
direct and indirect causes of respiratory syncytial virus (RSV)/bronchiolitis.
58
2) The mother of an 8-month-old baby who has developed respiratory syncytial virus
(RSV)/bronchiolitis wants to know what factors contribute to the risk of contracting RSV. What
can the nurse tell this mother?
A) "There is a higher risk in children who are being breastfed."
B) "There is no way to avoid the illness."
C) "There is a higher risk in children who are exposed to secondary cigarette smoke."
D) "It is seen more frequently in children who do not attend daycare."
Answer: C
Explanation: A) Risk of infection is higher when the parent or caregiver smokes. Tobacco
smoke increases mucus production and reduces the action of cilia within the airway passages.
Exposure to secondhand smoke is thought to alter maturation of the respiratory epithelium. The
risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes
with secondary cigarette exposure, attend daycare, live in crowded conditions, or are
socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.
B) Risk of infection is higher when the parent or caregiver smokes. Tobacco smoke increases
mucus production and reduces the action of cilia within the airway passages. Exposure to
secondhand smoke is thought to alter maturation of the respiratory epithelium. The risk of
infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with
secondary cigarette exposure, attend daycare, live in crowded conditions, or are
C) Risk of infection is higher when the parent or caregiver smokes. Tobacco smoke increases
D) Risk of infection is higher when the parent or caregiver smokes. Tobacco smoke increases
Page Ref: 1019
Learning Outcome: 2. Identify risk factors and prevention methods associated with
RSV/bronchiolitis.
59
3) The nurse observes a young child, admitted with possible respiratory syncytial virus (RSV)
bronchiolitis, grunting with expiration. What should the nurse do to assist this child?
A) Assist the child to clear the nasal passages.
B) Limit fluids.
C) Suction the airway to relieve the obstruction.
D) Lay the child on his back.
Answer: C
Explanation: A) Grunting is seen with partial airway obstruction caused by increased secretions
and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on
his back will not improve the child's ability to breathe. Fluids should be increased to thin
secretions. Assisting the child to clear the nasal passages would be applicable if the child were
experiencing rhinorrhea.
B) Grunting is seen with partial airway obstruction caused by increased secretions and edema.
The nurse should suction the airway to relieve the obstruction. Laying the child on his back will
not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting
the child to clear the nasal passages would be applicable if the child were experiencing
rhinorrhea.
C) Grunting is seen with partial airway obstruction caused by increased secretions and edema.
rhinorrhea.
D) Grunting is seen with partial airway obstruction caused by increased secretions and edema.
rhinorrhea.
Page Ref: 1020
across the life span for individuals with RSV/bronchiolitis.
60
4) The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial
virus (RSV). Which diagnosis would be most appropriate for the infant?
A) Acute Pain
B) Ineffective Tissue Perfusion
C) Activity Intolerance
D) Decreased Cardiac Output
Answer: C
Explanation: A) Activity intolerance is a problem because of the imbalance between oxygen
supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac
output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated
with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.
B) Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is
not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute
bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.
C) Activity intolerance is a problem because of the imbalance between oxygen supply and
D) Activity intolerance is a problem because of the imbalance between oxygen supply and
Page Ref: 1021
RSV/bronchiolitis.
61
5) The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis with
Impaired Gas Exchange. What should be included in this client's plan of care?
A) Weigh daily.
B) Monitor vital signs and pulse oximetry.
C) Administer oxygen as prescribed.
D) Weigh diapers.
E) Provide frequent rest periods.
Answer: B, C
Explanation: A) Interventions appropriate for the client with Impaired Gas Exchange due to
RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and
administering oxygen. Daily weight would be appropriate for the diagnosis of Impaired
Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the
diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the
diagnosis of Activity Intolerance.
B) Interventions appropriate for the client with Impaired Gas Exchange due to RSV bronchiolitis
include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen.
Daily weight would be appropriate for the diagnosis of Impaired Nutrition: Less than Body
Requirements. Weighing diapers would be appropriate for the diagnosis of Fluid Volume Deficit.
Providing frequent rest periods would be appropriate for the diagnosis of Activity Intolerance.
C) Interventions appropriate for the client with Impaired Gas Exchange due to RSV bronchiolitis
D) Interventions appropriate for the client with Impaired Gas Exchange due to RSV bronchiolitis
E) Interventions appropriate for the client with Impaired Gas Exchange due to RSV bronchiolitis
Page Ref: 1022
Learning Outcome: 6. Plan evidence-based care for an individual with RSV/bronchiolitis and his
or her family in collaboration with other members of the healthcare team.
62
6) A child with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to
maintain an adequate airway. The nurse will collaborate on the care of this client with:
A) An advanced practice nurse.
B) A dietitian.
C) The primary care physician.
D) A respiratory therapist.
E) Anesthesiology.
Answer: B, D, E
Explanation: A) Infants who need endotracheal intubation will be closely cared for by the
respiratory therapist. In addition, the nurse will collaborate with anesthesiology to place the
endotracheal tube and the dietitian will be consulted for nutritional support once the endotracheal
tube is in place. The primary care physician and advanced practice nurse are not responsible for
maintaining the client's endotracheal tube and adequate airway.
B) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist.
In addition, the nurse will collaborate with anesthesiology to place the endotracheal tube and the
dietitian will be consulted for nutritional support once the endotracheal tube is in place. The
primary care physician and advanced practice nurse are not responsible for maintaining the
client's endotracheal tube and adequate airway.
C) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist.
D) Infants who need endotracheal intubation will be closely cared for by the respiratory
therapist. In addition, the nurse will collaborate with anesthesiology to place the endotracheal
tube and the dietitian will be consulted for nutritional support once the endotracheal tube is in
place. The primary care physician and advanced practice nurse are not responsible for
maintaining the client's endotracheal tube and adequate airway.
E) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist.
Page Ref: 1020
care of an individual with RSV/bronchiolitis.
63
7) Which pharmacologic therapies may be expected in the treatment of RSV when the condition
is less severe and the client is not immunocompromised?
A) Nebulized epinephrine
B) Ribavirin
C) Systemic corticosteroids
D) Antibiotics
E) Antipyretics
Answer: A, C, E
Explanation: A) Use of nebulized epinephrine in combination with systemic corticosteroids has
been found to result in some reduction in RSV hospitalizations. Unless the client also has a
bacterial infection, antibiotics will not be used. The use of Ribavirin remains controversial
because it has only marginal benefit. Antipyretics may be used.
B) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to
result in some reduction in RSV hospitalizations. Unless the client also has a bacterial infection,
antibiotics will not be used. The use of Ribavirin remains controversial because it has only
marginal benefit. Antipyretics may be used.
C) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to
D) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to
E) Use of nebulized epinephrine in combination with systemic corticosteroids has been found to
Page Ref: 1021
Learning Outcome: 5. Summarize the therapies used by interdisciplinary teams in the
collaborative care of individuals with RSV/bronchiolitis.
64
8) Which interventions would be the most beneficial for the nurse to discuss with the parents of a
child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis?
A) Do not smoke, and avoid all secondhand smoke around the child.
B) Practice frequent hand washing.
C) Encourage physical activity and play.
D) Consider alternatives to sending the child to daycare.
E) Ensure an adequate nutritional intake.
Answer: A, D
Explanation: A) The child has had repeated admissions for RSV bronchiolitis, and exposure to
cigarette smoke is a known risk factor for the development of the illness. The nurse should
discuss with the parents the need for smoking cessation and not permitting the child to be
exposed to other sources of secondhand smoke. Attending daycare is another risk factor for the
development of the disorder. The nurse should ask the parents to consider alternatives to sending
the child to daycare. Practicing frequent hand washing is beneficial but not the priority for this
client and parents at this time. Nutritional intake and physical activity are also important but not
of the highest priority to the child and parents at this time.
B) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke
is a known risk factor for the development of the illness. The nurse should discuss with the
parents the need for smoking cessation and not permitting the child to be exposed to other
sources of secondhand smoke. Attending daycare is another risk factor for the development of
the disorder. The nurse should ask the parents to consider alternatives to sending the child to
daycare. Practicing frequent hand washing is beneficial but not the priority for this client and
parents at this time. Nutritional intake and physical activity are also important but not of the
highest priority to the child and parents at this time.
C) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke
D) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette
smoke is a known risk factor for the development of the illness. The nurse should discuss with
the parents the need for smoking cessation and not permitting the child to be exposed to other
65
E) The child has had repeated admissions for RSV bronchiolitis, and exposure to cigarette smoke
Page Ref: 1019
Learning Outcome: 6. Plan evidence-based care for an individual with RSV/bronchiolitis and his
or her family in collaboration with other members of the healthcare team.
66
9) The nurse determines that care provided to a client with respiratory syncytial virus (RSV)
bronchiolitis has been effective when what is assessed?
A) Client ingesting small amounts of clear fluids when encouraged
B) Client resting in bed with limited interest in play or activities
C) Client respiratory rate within normal limits for age
D) Client coughing copious amounts of green sputum and requires occasional suctioning.
Answer: C
Explanation: A) Evidence that care is effective would include normal rate, rhythm, and quality
of the breathing patterns for the client's age. The client who is resting in bed with limited interest
in play or activities is not demonstrating an improvement in respiratory status. The client who is
ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is
coughing copious amounts of green sputum and requiring occasional suctioning, the
interventions have not been effective, as the child still needs assistance with clearing the airway.
B) Evidence that care is effective would include normal rate, rhythm, and quality of the
breathing patterns for the client's age. The client who is resting in bed with limited interest in
play or activities is not demonstrating an improvement in respiratory status. The client who is
C) Evidence that care is effective would include normal rate, rhythm, and quality of the
D) Evidence that care is effective would include normal rate, rhythm, and quality of the
Page Ref: 1022
Learning Outcome: 7. Evaluate expected outcomes for an individual with RSV/bronchiolitis.
67
10) The clinic nurse is educating a group of new moms on the risk factors and prevention of
respiratory syncytial virus (RSV). The nurse is aware that which action is the best way to prevent
RSV?
A) Hand washing
B) Monitoring temperature
C) Administering antibiotics
D) Limiting fluid intake
Answer: A
Explanation: A) According to the CDC, the best way to prevent RSV is through good hand
hygiene and infection-control measures. This can be accomplished through frequent washing of
hands with soap and water and avoiding sharing items such as food, cups, or utensils with
infected individuals. Using hand disinfectants will also kill the virus. Monitoring temperature
would not prevent infection but would be appropriate for monitoring infection. Administering
antibiotics is usually ordered by the physician when infection is suspected. There is no indication
of the need to limit fluids, which could potentially produce other complications.
B) According to the CDC, the best way to prevent RSV is through good hand hygiene and
infection-control measures. This can be accomplished through frequent washing of hands with
soap and water and avoiding sharing items such as food, cups, or utensils with infected
individuals. Using hand disinfectants will also kill the virus. Monitoring temperature would not
prevent infection but would be appropriate for monitoring infection. Administering antibiotics is
usually ordered by the physician when infection is suspected. There is no indication of the need
to limit fluids, which could potentially produce other complications.
C) According to the CDC, the best way to prevent RSV is through good hand hygiene and
D) According to the CDC, the best way to prevent RSV is through good hand hygiene and
Page Ref: 1019
Learning Outcome: 2. Identify risk factors and prevention methods associated with
RSV/bronchiolitis.
68
11) The student nurse attends a workshop on culture and diversity with regards to respiratory
syncytial virus (RSV) and is now aware that RSV is a major cause of hospitalization among
which group of infants?
A) Alaskan Native infants
B) African-American infants
C) Native American infants
D) Asian-American infants
Answer: A
Explanation: A) According to the National Center for Preparedness, Detection, and Control of
Infectious Diseases, RSV is a major cause of hospitalization among Alaskan Native infants and
is responsible for one-third of hospitalizations of children younger than 3 years in Alaska.
Alaskan children hospitalized with RSV at any age are at a high risk for rehospitalization as a
result of respiratory infection. Alaskan Native children living in rural areas have a higher rate of
chronic lung disease; however, the relationship between RSV and chronic lung disease remains
unclear.
B) According to the National Center for Preparedness, Detection, and Control of Infectious
Diseases, RSV is a major cause of hospitalization among Alaskan Native infants and is
responsible for one-third of hospitalizations of children younger than 3 years in Alaska. Alaskan
children hospitalized with RSV at any age are at a high risk for rehospitalization as a result of
respiratory infection. Alaskan Native children living in rural areas have a higher rate of chronic
lung disease; however, the relationship between RSV and chronic lung disease remains unclear.
C) According to the National Center for Preparedness, Detection, and Control of Infectious
D) According to the National Center for Preparedness, Detection, and Control of Infectious
Page Ref: 1019
Client Need: Psychosocial Integrity
69
12) The Emergency Department nurse assessing an infant client would recognize which clinical
manifestations as indications of possible respiratory syncytial virus (RSV)?
A) Rhinorrhea
B) Irritability
C) Grunting
D) Bradypnea
E) Tachypnea
Answer: A, B, C, E
Explanation: A) The typical clinical presentation in otherwise healthy children begins 3-5 days
after exposure to the virus. The early signs of a mild infection include rhinorrhea (drainage of
mucus from the nose), cough, irritability, and a low-grade fever for 1-3 days. Copious mucous
secretions occur in the lung fields and nasal passages and are usually green in color. The fever
can lead to dehydration. Other clinical manifestations include, but are not limited to, tachypnea,
wheezing, and grunting.
B) The typical clinical presentation in otherwise healthy children begins 3-5 days after exposure
to the virus. The early signs of a mild infection include rhinorrhea (drainage of mucus from the
nose), cough, irritability, and a low-grade fever for 1-3 days. Copious mucous secretions occur in
the lung fields and nasal passages and are usually green in color. The fever can lead to
dehydration. Other clinical manifestations include, but are not limited to, tachypnea, wheezing,
and grunting.
C) The typical clinical presentation in otherwise healthy children begins 3-5 days after exposure
and grunting.
D) The typical clinical presentation in otherwise healthy children begins 3-5 days after exposure
and grunting.
E) The typical clinical presentation in otherwise healthy children begins 3-5 days after exposure
and grunting.
Page Ref: 1019
70
13) The nurse is developing a plan of care for a toddler with respiratory syncytial virus (RSV).
Which intervention would not be appropriate for this client?
A) Offer small, frequent meals.
B) Encourage to ambulate frequently.
C) Encourage oral intake.
D) Monitor intake and output.
Answer: B
Explanation: A) It would not be appropriate to encourage frequent ambulation. Nursing
interventions should be introduced in an effort to reduce fatigue, such as allowing rest periods.
All other interventions are appropriate for this client.
B) It would not be appropriate to encourage frequent ambulation. Nursing interventions should
be introduced in an effort to reduce fatigue, such as allowing rest periods. All other interventions
are appropriate for this client.
C) It would not be appropriate to encourage frequent ambulation. Nursing interventions should
D) It would not be appropriate to encourage frequent ambulation. Nursing interventions should
Page Ref: 1022
across the life span for individuals with RSV/bronchiolitis.
71
Exemplar 15.5 Sudden Infant Death Syndrome
1) A new mother asks what needs to be done to prevent the baby from sudden infant death
syndrome. What should the nurse do to assist the mother?
A) Instruct the mother to keep the baby with her at all times to assess for apnea periods.
B) There is no one cause for the syndrome; the best thing is to keep the baby healthy.
C) Encourage the mother to place the child in a face-down position for sleep.
D) Suggest the mother avoid immunizing the child.
Answer: B
Explanation: A) The best intervention would be for the nurse to explain that there is no single
cause for the syndrome and to instruct the mother to keep the baby healthy. According to one
theory for the syndrome, a face-down position could encourage a reduction in respirations. The
nurse should instruct the mother to position the baby face-up for sleep. Immunizations and
newborn apnea have not been found to be associated with the syndrome.
B) The best intervention would be for the nurse to explain that there is no single cause for the
syndrome and to instruct the mother to keep the baby healthy. According to one theory for the
syndrome, a face-down position could encourage a reduction in respirations. The nurse should
instruct the mother to position the baby face-up for sleep. Immunizations and newborn apnea
have not been found to be associated with the syndrome.
C) The best intervention would be for the nurse to explain that there is no single cause for the
D) The best intervention would be for the nurse to explain that there is no single cause for the
Page Ref: 1024
Learning Outcome: 1. Describe the pathophysiology, etiology, and direct and indirect
contributing factors related to sudden infant death syndrome (SIDS).
72
2) The nurse is instructing new parents on ways to avoid sudden infant death syndrome with their
newborn son. What should be included in these instructions?
A) There is nothing that can be done, so requirements for toys and bedding are of no
consequence.
B) Instruct that it is more common in babies from ages 6 months to 18 months.
C) Avoid placing the baby in the prone or side-lying position for sleep.
D) Remind the parents that the syndrome is more common in females than males, and that they
have a male child.
E) Do not smoke near the child and reduce all exposure to secondhand smoke.
Answer: C, E
Explanation: A) The nurse should instruct the parents to not smoke and to reduce all exposure to
secondhand smoke to reduce the child's risk of the syndrome. Sleeping in the prone or side-lying
position is a risk factor for the syndrome. Other risk factors for sudden infant death syndrome
include being male, being 2-4 months of age, having loose bedding and toys that could occlude
the airway, and being exposed to smoke or having a mother who smoked during pregnancy.
B) The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand
smoke to reduce the child's risk of the syndrome. Sleeping in the prone or side-lying position is a
risk factor for the syndrome. Other risk factors for sudden infant death syndrome include being
male, being 2-4 months of age, having loose bedding and toys that could occlude the airway, and
being exposed to smoke or having a mother who smoked during pregnancy.
C) The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand
D) The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand
E) The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand
Page Ref: 1024
Learning Outcome: 2. Identify risk factors and prevention methods associated with SIDS.
73
3) When assessing the risk of a newborn for SIDS, what are some of the factors the nurse should
consider?
A) Race
B) Gender
C) Father's age
D) Age
E) Eye color
Answer: A, B, D
Explanation: A) SIDS is most common in American Indians and Alaska Natives, followed by
non-Hispanic Blacks, non-Hispanic Whites, Asian or Pacific Islanders, and Hispanics. It is more
common in males than in females. SIDS is most common in infants between 2 and 4 months of
age. Father's age and infant eye color are not related to the risk of SIDS.
B) SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic
Blacks, non-Hispanic Whites, Asian or Pacific Islanders, and Hispanics. It is more common in
males than in females. SIDS is most common in infants between 2 and 4 months of age. Father's
age and infant eye color are not related to the risk of SIDS.
C) SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic
D) SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic
E) SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic
Page Ref: 1024
74
4) The nurse caring for the new mother of African-American descent should implement which
intervention regarding sudden infant death syndrome (SIDS)?
A) Instruct on side-lying and face-down positions when in the crib.
B) Instruct on face-up position when in the crib.
C) Ensure adequate nutritional intake for the mother and newborn.
D) Encourage good hand washing.
Answer: B
Explanation: A) Rates for SIDS are highest for African-American children. The nurse should
instruct the mother to place the baby in the face-up position when in the crib. Side-lying and
face-down positions are associated with a higher risk of the syndrome and should not be
instructed. Although important, good hand washing and adequate nutrition are not interventions
that would assist in preventing SIDS.
B) Rates for SIDS are highest for African-American children. The nurse should instruct the
mother to place the baby in the face-up position when in the crib. Side-lying and face-down
positions are associated with a higher risk of the syndrome and should not be instructed.
Although important, good hand washing and adequate nutrition are not interventions that would
assist in preventing SIDS.
C) Rates for SIDS are highest for African-American children. The nurse should instruct the
D) Rates for SIDS are highest for African-American children. The nurse should instruct the
Page Ref: 1024
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
infants, parents, and caregivers to reduce the risk of SIDS.
75
5) The nurse is planning care for a baby of African-American descent born to a mother who
smoked during the pregnancy. Which diagnosis would be appropriate for this baby?
A) Risk for Sudden Infant Death Syndrome
B) Readiness for Enhanced Parenting
C) Anxiety
D) Deficient Knowledge
Answer: A
Explanation: A) The most important nursing diagnosis for the baby at this time is risk for
sudden infant death syndrome. Babies of African-American descent have twice the risk of
sudden infant death syndrome than babies of Caucasian descent. Another risk factor is that the
mother smoked during the pregnancy. Deficient Knowledge, Readiness for Enhanced Parenting,
and Anxiety might be diagnoses appropriate for the mother.
B) The most important nursing diagnosis for the baby at this time is risk for sudden infant death
syndrome. Babies of African-American descent have twice the risk of sudden infant death
syndrome than babies of Caucasian descent. Another risk factor is that the mother smoked during
the pregnancy. Deficient Knowledge, Readiness for Enhanced Parenting, and Anxiety might be
diagnoses appropriate for the mother.
C) The most important nursing diagnosis for the baby at this time is risk for sudden infant death
D) The most important nursing diagnosis for the baby at this time is risk for sudden infant death
Page Ref: 1026
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an infant at risk for
SIDS.
76
6) The nurse is planning care for a new mother of African-American descent who smoked during
the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). What
should be included in this client's plan of care?
A) Information on bottle-feeding the infant
B) Reasons why the child should sleep with others
C) Ages at which the child should receive immunizations
D) Using bedding that is firm
E) Smoking cessation information
Answer: D, E
Explanation: A) The plan of care to decrease the child's risk of SIDS should include habits to
lower the risk of SIDS, one of which is smoking cessation. The nurse should also instruct the
mother to use bedding that is firm. The method of feeding is not associated with the syndrome.
Immunizations are not associated with the syndrome. Sleeping with others will increase the
child's risk of the syndrome and should not be in the plan of care.
B) The plan of care to decrease the child's risk of SIDS should include habits to lower the risk of
SIDS, one of which is smoking cessation. The nurse should also instruct the mother to use
bedding that is firm. The method of feeding is not associated with the syndrome. Immunizations
are not associated with the syndrome. Sleeping with others will increase the child's risk of the
syndrome and should not be in the plan of care.
C) The plan of care to decrease the child's risk of SIDS should include habits to lower the risk of
D) The plan of care to decrease the child's risk of SIDS should include habits to lower the risk of
E) The plan of care to decrease the child's risk of SIDS should include habits to lower the risk of
Page Ref: 1026
77
7) The nurse is placing a newborn baby in the nursery crib with the baby's back down. The
mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family
members sleep on their stomachs. What should the nurse do?
A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant
death syndrome (SIDS).
B) Place the baby on the stomach.
C) Suggest the mother place the baby on the stomach when at home.
D) Instruct the mother that babies do not really care in which position they are in but placing on
the back is easier to provide care.
Answer: A
Explanation: A) The nurse needs to model protective behavior for the mother to use when the
baby is taken home. The nurse should instruct the mother that placing the baby on the back will
reduce the risk of sudden infant death syndrome. The nurse should not place the baby on the
stomach or suggest that the mother place the baby on the stomach when at home. Placing the
baby on the back does not necessarily make it easier to provide care.
B) The nurse needs to model protective behavior for the mother to use when the baby is taken
home. The nurse should instruct the mother that placing the baby on the back will reduce the risk
of sudden infant death syndrome. The nurse should not place the baby on the stomach or suggest
that the mother place the baby on the stomach when at home. Placing the baby on the back does
not necessarily make it easier to provide care.
C) The nurse needs to model protective behavior for the mother to use when the baby is taken
D) The nurse needs to model protective behavior for the mother to use when the baby is taken
Page Ref: 1024
care of an infant at risk for SIDS.
78
8) Supportive care for the parents of an infant who died from sudden infant death syndrome
(SIDS) would include:
A) Advising the parents that an autopsy is not necessary.
B) Sheltering the parents from their grief by not giving them any personal items of the infant,
such as footprints.
C) Interviewing the parents to determine the cause of the SIDS incident.
D) Allowing the parents to hold, touch, and rock the infant.
Answer: D
Explanation: A) The parents should be allowed to hold, touch, and rock the infant, giving them a
chance to say good-bye to their baby. The other options are nontherapeutic. The death of an
infant without a known medical condition is an indication for an autopsy, even though a specific
cause of death may not be identified for SIDS.
B) The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say
good-bye to their baby. The other options are nontherapeutic. The death of an infant without a
known medical condition is an indication for an autopsy, even though a specific cause of death
may not be identified for SIDS.
C) The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say
D) The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say
Page Ref: 1026
Learning Outcome: 6. Plan evidence-based care for the family who loses an infant to SIDS.
79
9) The nurse is evaluating care provided to a new mother whose infant is at risk for sudden death
syndrome (SIDS). Evidence that care has been effective would be the mother expressing:
A) The need to purchase loose-fitting sheets and blankets for the bed.
B) A plan to quit smoking.
C) The proper way to place the infant in the crib as being prone or side-lying.
D) The reasons why bottle-feeding is preferred over breastfeeding.
Answer: B
Explanation: A) If the mother of an infant at risk for SIDS expresses her plan to quit smoking,
the nursing care would have been effective. Loose-fitting sheets and blankets are associated with
an increased risk for the syndrome. The prone and side-lying positions increase the risk for the
syndrome. The feeding method is not implicated with the syndrome and would not be used to
evaluate the plan of care for an infant at risk for SIDS.
B) If the mother of an infant at risk for SIDS expresses her plan to quit smoking, the nursing care
would have been effective. Loose-fitting sheets and blankets are associated with an increased
risk for the syndrome. The prone and side-lying positions increase the risk for the syndrome. The
feeding method is not implicated with the syndrome and would not be used to evaluate the plan
of care for an infant at risk for SIDS.
C) If the mother of an infant at risk for SIDS expresses her plan to quit smoking, the nursing care
D) If the mother of an infant at risk for SIDS expresses her plan to quit smoking, the nursing care
Page Ref: 1025
Learning Outcome: 7. Evaluate expected outcomes for an individual with an infant at risk for
SIDS.
80
10) A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS).
Which should the nurse include when presenting significant stressors that contribute to SIDS?
A) Prone sleeping
B) Side sleeping
C) Face-down sleeping
D) Bed sharing
E) Supine sleeping
Answer: A, B, C, D
Explanation: A) Significant stressors contributing to SIDS are prone or side sleeping, face-down
sleeping, and bed sharing. Infants in the prone or side-lying positions are vulnerable because the
brainstem abnormality compromises their protective reflexes, such as arousal and head turning,
when experiencing asphyxia.
B) Significant stressors contributing to SIDS are prone or side sleeping, face-down sleeping, and
bed sharing. Infants in the prone or side-lying positions are vulnerable because the brainstem
abnormality compromises their protective reflexes, such as arousal and head turning, when
experiencing asphyxia.
C) Significant stressors contributing to SIDS are prone or side sleeping, face-down sleeping, and
D) Significant stressors contributing to SIDS are prone or side sleeping, face-down sleeping, and
E) Supine sleeping is appropriate and is not a contributing factor to the occurrence of SIDS.
Page Ref: 1024
81
11) The student nurse attends a workshop on culture and diversity with regard to sudden infant
death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which
group of infants?
A) American Indians
B) African-Americans
C) Asians
D) Hispanics
Answer: A
Explanation: A) According to the Health Resources Services Administration, rates of SIDS are
highest for African-Americans and American Indians and lowest for Asians and Hispanics. In
2008, the rate of SIDS among African-Americans was more than twice that of Caucasians, and
the rate among American Indians was more than three times greater than that among Caucasians.
B) According to the Health Resources Services Administration, rates of SIDS are highest for
African-Americans and American Indians and lowest for Asians and Hispanics. In 2008, the rate
of SIDS among African-Americans was more than twice that of Caucasians, and the rate among
American Indians was more than three times greater than that among Caucasians.
C) According to the Health Resources Services Administration, rates of SIDS are highest for
D) According to the Health Resources Services Administration, rates of SIDS are highest for
Page Ref: 1024
Learning Outcome: 1. Describe the pathophysiology, etiology, and direct and indirect
contributing factors related to sudden infant death syndrome (SIDS).
82
12) The Emergency Department nurse provided care to an infant that arrived in cardiac and
respiratory arrest. The death of the infant was determined to be caused from sudden infant death
syndrome (SIDS). The parents are grieving and will need collaborative interventions. The nurse
is aware that which collaborative intervention would be appropriate for the parents?
A) A psychosocial assessment
B) A grief counselor referral
C) A psychotherapist referral
D) A visit from the chaplain
Answer: A, B, C, D
Explanation: A) Collaborative care for the parents may include grief counselors, chaplains and
religious leaders, nurses (including school nurses working with older children who lose a
sibling), and psychotherapists. In particular, the parents' grief will be acute, and they should
receive a psychosocial assessment at each healthcare interaction.
B) Collaborative care for the parents may include grief counselors, chaplains and religious
leaders, nurses (including school nurses working with older children who lose a sibling), and
psychotherapists. In particular, the parents' grief will be acute, and they should receive a
psychosocial assessment at each healthcare interaction.
C) Collaborative care for the parents may include grief counselors, chaplains and religious
D) Collaborative care for the parents may include grief counselors, chaplains and religious
Page Ref: 1025-1026
Nursing Process: Caring
care of an infant at risk for SIDS.
83
13) A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS).
Which of the following should the nurse include when presenting information on environmental
factors that contribute to the occurrence of SIDS?
A) Use of bedding that is firm
B) Avoiding overheating the sleeping room
C) Avoiding smoking around infants
D) Blanket secured lower than chest
E) Prone-position sleeping
Answer: A, B, C, D
Explanation: A) This is an appropriate environmental factor that will reduce the risk of sudden
infant death syndrome (SIDS).
B) This is an appropriate environmental factor that will reduce the risk of sudden infant death
syndrome (SIDS).
C) This is an appropriate environmental factor that will reduce the risk of sudden infant death
syndrome (SIDS).
D) This is an appropriate environmental factor that will reduce the risk of sudden infant death
syndrome (SIDS).
E) Prone position sleeping is not appropriate and is found to contribute to the occurrence of
sudden infant death syndrome (SIDS). Furthermore, it is not an environmental factor.
Page Ref: 1025
84

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