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A client has a tracheostomy placed due to chronic respiratory failure. Upon return to the unit, the nurse notes that the outer cannula has been coughed from the trachea. What is the nurse’s priority action?

On auscultation of patient’s lungs, the nurse hears high pitched musical noise on inspiration. How will the nurse document this finding?

A client at the clinic is diagnosed with tuberculosis. When developing this client’s plan of care, which medications will the nurse anticipate as being prescribed as a first-line agent? Select all that apply.

A patient with acute shortness of breath is admitted to the hospital. Which action will the nurse take during the initial assessment of the patient?

A 74-year old female is admitted to the Emergency room with increasing dyspnea, productive cough, and fatigue.   Nurses’ Notes       1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of  chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally. Vital Signs       Time  1000   Oral Temp  99.0 F (37.2C)   Pulse 104   Respiratory Rate 27   Blood Pressure 157/86   Pulse oximeter  91% Room air   Pain  0   The nurse anticipates that multiple medication orders will be provided from the physician. In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply.

A 74-year-old female is admitted to the Emergency Room with increasing dyspnea, productive cough, and fatigue.   Nurses’ Notes       1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of  chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally. Vital Signs       Time  1000   Oral Temp  99.0 F (37.2C)   Pulse 104   Respiratory Rate 27   Blood Pressure 157/86   Pulse oximeter  91% Room air   Pain  0   What intervention for airway management will the nurse delegate to the UAP?

Which of the following health promotion activities will the nurse include in the discharge plan for a client with asthma.

The client diagnosed with a cold is taking diphenhydramine (Benedryl). Which statement indicates to the nurse the client needs additional teaching concerning this medication?

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? 

A client goes into shock as a result of a leaking aortic aneurysm. What assessment findings are recorded in the electronic health record?