471 Exam 2

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A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

27 ml/h (To administer the dobutamine at the prescribed rate of 5 mcg/kg/min from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hr.)

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. b) The client exhibits bronchial breath sounds over the affected area. c) The client exhibits restlessness and confusion. d) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.

A client who is diagnosed with chronic respiratory failure will have which of the following symptoms? a) Dyspnea b) Hypercapnia c) Hypoxemia d) Ventilatory failure

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client with a nasogastric tube b) A client who is receiving acetaminophen (Tylenol) for pain c) A client who ambulates in the hallway every 4 hours d) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

A positive Mantoux test indicates that a client: a) has produced an immune response. b) has an active case of tuberculosis. c) will develop full-blown tuberculosis. d) is actively immune to tuberculosis.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: a) Significant b) Negative c) Nonreactive d) Not significant

For a patient with pleural effusion, what does chest percussion over the involved area reveal? a) Dullness over the involved area b) Absent breath sounds c) Fluid presence d) Friction rub

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? a) Sudden onset in client who had normal lung function b) Insidious onset in client who had normal lung function c) Insidious onset in client who had compromised lung function d) Sudden onset in client who had compromised lung function

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Rapid onset of severe dyspnea b) Cyanosis c) Inspiratory crackles d) Bilateral wheezing

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? a) Classes at community centers to teach about smoking cessation strategies b) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays c) Legislation that requires homes and apartments be checked for asbestos leakage d) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes

What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections? a) Receiving vaccination b) Using prescribed opioids c) Using incentive spirometry d) Mobilizing early

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a) Progressive loss of lung function associated with chronic disease b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function

For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment? a) A patient with an overwhelming bacterial infection b) A patient who has lost blood during a child birth c) A patient who has had an overdose of opioids d) A patient who has had severe allergic reaction to a bee sting

A (A patient with an overwhelming bacterial infection.)

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Administers oxygen by nasal cannula at 2 liters per minute b) Calls the Rapid Response Team c) Re-assesses the vital signs d) Contacts the admitting physician

A (Administers oxygen by nasal cannula at 2 liters per minute.)

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

A (Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.)

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

A (Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.)

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to: A. Encourage the family to touch and talk to the client. B. Inform the family that everything is being done to assist with the client's survival. C. Open up discussion among the family members about nursing home placement. D. Contact a spiritual advisor to provide comfort to the family.

A (Encourage the family to touch and talk to the client.)

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

A (Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.)

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

A (Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.)

A client has developed shock as the result of the MVA. His treatment is focused on preventing the development of more than one type of shock and to minimize the effects of the type of shock he is demonstrating. Which of the following is NOT a category of shock? a) Hepatic b) Circulatory c) Cardiogenic d) None of the options are correct

A (Hepatic)

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? A. Lactated ringer's B. Sodium Chloride 0.9% C. 5% dextrose solution D. Hypertonic

A (Lactated ringer's)

When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Tachycardia b) Bradycardia c) Urine output of 45 cc/hour d) Respiratory acidosis

A (Tachycardia)

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

A (The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.)

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

A (The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.)

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: a) Oxygen at 2 L/min by nasal cannula b) Dopamine (Intropin) intravenous solution c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously

A (Oxygen at 2 L/min by nasal cannula)

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

A, B, C, D (Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.)

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

A, B, D, E (All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.)

A 23-year-old male client who has recently started working in a coal mine confides that he is concerned about his long-term health. The nurse instructs the client which of the following ways to prevent occupational lung disease? Select all that apply. a) Do not smoke or quit smoking if currently smoking. b) Wear appropriate protective equipment when around airborne irritants and dusts. c) Schedule an annual lung x-ray to monitor his health. d) Try to find another occupation as soon as possible.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? a) No fluid normally is present b) 5 - 15 ml c) 15 - 25 ml d) 20 - 30 ml

A Class 1 with regards to TB indicates a) disease that is not clinically active. b) exposure and no evidence of infection. c) no exposure and no infection. d) latent infection with no disease.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Pneumothorax c) Heart failure d) Myocardial infarction (MI)

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: a) "My tuberculosis isn't contagious after I take the medication for 24 hours." b) "I'll stop being contagious when I have a negative acid-fast bacilli test." c) "I'm contagious as long as I have night sweats." d) "I'm clear when my chest X-ray is negative."

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? a) Perform nasopharyngeal suctioning. b) Initiate oxygen therapy. c) Administer a heparin bolus and begin an infusion at 500 units/hour. d) Administer analgesics as ordered.

A mediastinal shift occurs in which type of chest disorder? a) Traumatic pneumothorax b) Tension pneumothorax c) Cardiac tamponade d) Simple pneumothorax

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.35, PaCO2 48 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.46, PaO2 80 mm Hg d) pH 7.36, PaCO2 32 mm Hg

A nurse is caring for a patient after a thoracentesis. Which of the following signs if noted in the patient should be reported to the physician immediately? a) "Patient has subcutaneous emphysema around needle insertion site." b) "Patient is becoming agitated and complains of pleuritic pain." c) "Patient is drowsy and complains of headache." d) "Patient has an oxygen saturation level of 93%."

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4? (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? a) The X-ray is inconclusive. b) A disease process is present. c) The ET tube must be pulled back. d) The ET tube must be advanced.

A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a) "I'll have to take these medications for 9 to 12 months." b) "The people I have contact with at work should be checked regularly." c) "I'll need to have scheduled laboratory tests while I'm on the medication." d) "It won't be necessary for the people I work with to take medication."

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years b) Daily doses of isoniazid, 300 mg for 6 months to 1 year c) Isolation until 24 hours after antitubercular therapy begins d) Nothing, until signs of active disease arise

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Developing a list of people with whom the client has had contact c) Client teaching about the importance of TB testing d) Reviewing the risk factors for TB

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 1 to 3 weeks b) 6 to 12 months c) 2 to 4 months d) 3 to 5 days

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? a) Social isolation b) Deficient knowledge (disease process and treatment regimen) c) Impaired social interaction d) Anxiety

Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? a) pH 7.35 b) pH 7.28 c) PaCO 32 mm Hg d) PaO 80 mm Hg

On auscultation, which finding suggests a right pneumothorax? a) Inspiratory wheezes in the right thorax b) Absence of breath sounds in the right thorax c) Bilateral pleural friction rub d) Bilateral inspiratory and expiratory crackles

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis

The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Impaired Gas Exchange

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress? a) Chronic lung disease b) Normal lung function c) Loss of lung function d) Slow onset of symptoms

The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? a) pH 7.47, PaCO2 28, HCO3 30 b) pH 7.25, PaCO2 48, HCO3 24 c) pH 7.87, PaCO2 38, HCO3 28 d) pH 7.49, PaCO2 34, HCO3 25

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperventilation, hypertension, and hypocapnia b) Hypercapnia, hypoventilation, and hypoxemia c) Hypotension, hyperoxemia, and hypercapnia d) Hyperoxemia, hypocapnia, and hyperventilation

Which of the following is a key characteristic of pleurisy? a) Blood-tinged secretions b) Pain c) Dyspnea d) Anxiety

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a) Bloody drainage is seemed in the collection chamber. b) Crackling is heard when skin around tube is touched. c) Skin around tube is pink. d) Absence of bloody drainage in the anterior/upper tube

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? a) Drug ingestion b) Chemical irritation c) Direct lung damage d) Aspiration

You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? a) Pain on inspiration b) Mucopurulent sputum c) Obvious trauma d) Shortness of breath

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

B (Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.)

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? A) Obtain the name and information of the allergic substance. B) Administer an epinephrine injection. C) Notify a physician. D) Call 911.

B (Administer an epinephrine injection.)

Which type of shock occurs from an antigen-antibody response? a) Neurogenic b) Anaphylactic c) Septic d) Cardiogenic

B (Anaphylactic)

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

B (Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.)

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a) Right ventricular wall b) Aorta c) Brachial artery d) Radial artery

B (Aorta)

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

B (Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.)

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

B (Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.)

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

B (Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.)

In which type of shock does the patient experience a mismatch of blood flow to the cells? a) Cardiogenic b) Circulatory c) Septic d) Hypovolemic

B (Circulatory)

Which stage of shock is characterized by a normal blood pressure? A.Initial B.Compensatory C.Progressive D.Irreversible

B (In the compensatory stage of shock, the BP remains within normal limits. In the second stage of shock, the mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, BP remains low.)

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) prevent sinus bradycardia. b) increase cardiac output. c) treat hypertension. d) treat hypotension.

B (Increase cardiac output.)

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2°F (38.4°C)

B (Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.)

Morphine sulfate has which of the following effects on the body? a) No effect on preload or afterload b) Reduces preload c) Increases preload d) Increases afterload

B (Reduces preload)

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% albumin infusion b. furosemide (Lasix) IV c. epinephrine (Adrenalin) drip d. hydrocortisone (Solu-Cortef)

B (The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.)

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? a) The client with pneumonia in the left lower lobe of the lung b) The client with testicular cancer who is receiving intravenous chemotherapy c) The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) d) The client with a BMI of 25 who has lost 3 pounds as the result of vomiting

B (The client with testicular cancer who is receiving intravenous chemotherapy.)

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

B (The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.)

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

B (The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.)

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Furosemide (Lasix) b) Famotidine (Pepcid) c) Lansoprazole (Prevacid) d) Desmopressin (DDAVP) e) Ranitidine (Zantac)

B, C, E (• Lansoprazole (Prevacid) • Famotidine (Pepcid) • Ranitidine (Zantac))

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Partial pressure of arterial carbon dioxide (PaCO2) b) pH c) Partial pressure of arterial oxygen (PaO2) d) Bicarbonate (HCO3-)

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? a) Keeping the door to the client's room open to observe the client b) Instructing the client to wear a mask at all times c) Putting on an individually fitted mask when entering the client's room d) Wearing a gown and gloves when providing direct care

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Clubbing of fingers and toes b) Respiratory acidosis c) Paradoxical chest movement d) Chest pain on inspiration

A mechanically ventilated patient is receiving a combination of atracurium (Tracrium) and an opioid analgesic morphine. The nurse monitors the patient for which potential complication? a) Pulmonary hypertension b) Cor pulmonale c) Venous thromboemboli d) Pneumothorax

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Risk for falls. b) Ineffective breathing pattern. c) Ineffective airway clearance. d) Impaired tissue integrity.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions. b) Do not allow visitors with respiratory infection. c) Encourage breathing exercises. d) Place suspected patients together.

A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following? a) Pneumothorax b) Hemothorax c) Pleural effusion d) Consolidation

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? a) Respiratory alkalosis b) Productive cough c) Blood-tinged sputum d) Bradypnea

Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is a) tertiary drug resistance. b) secondary drug resistance. c) primary drug resistance. d) multidrug resistance.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a) "Chest tube will allow air to be restored to the lung." b) "Chest tubes provide a route for medication instillation to the lung." c) "The tube will drain air from the space around the lung." d) "The tube will drain secretions from the lung."

The nurse knows the mortality rate is high in lung cancer clients due to which factor? a) Increased exposure to industrial pollutants b) Increase in women smokers c) Few early symptoms d) Increased incidence among the elderly

Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic b) Use a heat or cold application c) Turn onto the affected side d) Avoid using a pillow while splinting

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a) "There are fibrous cysts in the lungs." b) "Early treatment can stop the progression of the disease." c) "The mucus-secreting glands are abnormal." d) "Allergic reactions cause inflammation in the lungs."

You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Aspiration b) Direct lung damage c) Chemical irritation d) Drug ingestion

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? a) Provide employees with smoking cessation materials. b) Insist on adequate breaks for each employee. c) Fit all employees with protective masks. d) Give workshops on disease prevention.

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Negative Homan's sign b) Pain in the feet c) Pain in the calf d) Inability to dorsiflex

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if the chest tube is clogged. b) See if the wall suction unit has malfunctioned. c) See if there are leaks in the system. d) See if a kink has developed in the tubing.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? a) Place client on bed rest. b) Offer nutritious snacks 2 times a day. c) Encourage increased fluid intake. d) Give antibiotics as ordered.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 30 minutes b) Hourly c) 15 minutes d) 45 minutes

C (15 minutes)

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) Isotonic enteral nutrition every 6 hours c) A continuous infusion of total parenteral nutrition d) An infusion of crystalloids at an increased rate of flow

C (A continuous infusion of total parenteral nutrition.)

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs

C (Adrenergic drugs)

Which of the following colloids is expensive but rapidly expands plasma volume? a) Lactated Ringer's b) Dextran c) Albumin d) Hypertonic saline

C (Albumin)

Which of the following type of shock are older adults more likely to develop? a) Septic shock b) Neurogenic shock c) Cardiogenic shock d) Anaphylactic shock

C (Cardiogenic shock)

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? a) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Rubbing the hands together with antiseptic solution until dry when exiting the client's room

C (Hanging tape on the bedside table when changing a wet-to-dry sterile dressing.)

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client? a) Decreases blood return to the heart b) Decreases carbon dioxide exchange c) Increases myocardial contractility d) Contracts bronchioles

C (Increases myocardial contractility)

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? a) It begins when peripheral blood flow is inadequate. b) It causes respiratory distress syndrome. c) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. d) It is a component of any trauma.

C (It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.)

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: a) Positive increase in the fluid balance ratio b) Decreased pulse rate to 110 beats/minute c) Jugular venous distention d) Vesicular breath sounds

C (Jugular venous distention)

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? a. Prone b. Semi-Fowler's c. Modified Trendelenburg d. Supine

C (Modified Trendelenburg)

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? A. Increase in diastolic pressure. B. Decrease in respiratory rate. C. Narrowed pulse pressure. D. Increase in systolic pressure

C (Narrowed pulse pressure.)

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

C (Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.)

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

C (Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.)

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

C (Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.)

The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock? A. Cardiogenic shock B. Anaphylactic shock C. Septic shock D. Anaphylastic shock

C (Septic shock)

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a) Cardiogenic b) Anaphylactic c) Septic d) Neurogenic

C (Septic)

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately? A. The client feels restless and hungry. B. The client exhibits an increased urinary output. C. The client's heart rate is greater than 90 beats per minute. D. The client's heart rate is less than 60 beats per minute.

C (The client's heart rate is greater than 90 beats per minute.)

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

C (The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.)

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

C (The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.)

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment Laboratory Data Vital Signs · Petechiae noted on chest and legs · Crackles heard bilaterally in lung bases. · No redness or swelling at central line IV site. · Blood urea nitrogen (BUN) 34mg/Dl · Hematocrit 30% · Platelets 50,000/μL · Temperature 100°F (37.8°C) · Pulse 102/min · Respirations 26/min · BP 110/60 mm Hg · O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

C (The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.)

When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of: A.Hyperthermia B.Pain C.Pulmonary edema D.Tachycardia

C (The nurse should monitor for circulatory overload and pulmonary edema when large volumes of fluids are administered intravenously. Hypothermia may occur with large volumes of fluid that are not warmed. Pain would.)

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) Bilateral pedal pulses are 1+. b) Vesicular breath sounds are audible in the lung periphery. c) The right foot is cooler than the left foot. d) The balloon deflates prior to systole.

C (The right foot is cooler than the left foot.)

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure of 92/40 mm Hg

C (Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.)

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide b. nitroglycerin c. norepinephrine d. sodium nitroprusside

C (When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.)

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump? You selected: 80 mL/hr

Correct Explanation: 20/15 × 60 = 80 mL/hr

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

Correct response: 0.5

A posttraumatic seizure that is classified as early, occurs within which timeframe?

Correct response: 1 to 7 days of injury

(see full question) A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? You selected: Subacute Incorrect

Correct response: Acute

The nurse reviews the physician's emergency department progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign. The nurse knows that the physician observed which clinical manifestation?

Correct response: An area of bruising over the mastoid bone

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

Correct response: An intracerebral hematoma

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? You selected: A subdural hematoma Incorrect

Correct response: An intracerebral hematoma

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Correct response: Autonomic dysreflexia

(see full question) After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Correct response: Flat, except for logrolling as needed

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Correct response: Herniation

(see full question) The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

Correct response: Insertion of a nasogastric tube

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury?

Correct response: It results from inadequate delivery of nutrients and oxygen to the cells.

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Correct response: Loss of consciousness

The most important nursing priority of treatment for a patient with an altered LOC is to: You selected: Position the patient to prevent injury and ensure dignity. Incorrect

Correct response: Maintain a clear airway to ensure adequate ventilation.

The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP?

Correct response: Maintaining cerebral perfusion pressure from 50 to 70 mm Hg

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Correct response: Meticulous cleanliness

(see full question) A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Correct response: Paresthesia

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Correct response: Severe TBI.

The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury?

Correct response: Spinal shock

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Correct response: Suction the airway.

A 7-year-old gymnast fell off the balance beam at practice, striking her head. She was taken to surgery to repair an epidural hematoma and arrives postoperatively at the ICU where you practice nursing. In your postoperative assessments, you measure her temperature every 15 minutes. Why is this measurement important?

Correct response: To decrease the potential for brain damage

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: You selected: to continue I.V. administration of other scheduled medications. Incorrect

Correct response: she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Silica b) Coal dust c) Pollen d) Asbestos

A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Consume majority of fluid intake prior to bed. b) Wear tight-fitting clothing. c) Begin estrogen replacement. d) Tense and relax muscles in lower extremities.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) test stimulates a reddened response in some clients and requires a second test in 3 months. c) presence of a wheal at the injection site in 2 days indicates active tuberculosis. d) skin test doesn't differentiate between active and dormant tuberculosis infection.

A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy regimen? a) Within 48 hours after initiation of bacteriocidal drugs b) Results vary with each client, so it is difficult to predict c) After completion of 6 months of bacteriocidal drugs d) Two to 3 weeks after initiation of bacteriocidal drugs

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? A) Elevating the head of the bed 30 degrees B) Turning the client every 2 hours C) Maintaining a cool room temperature D) Encouraging increased fluid intake

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to: A) pollen. B) silica. C) coal dust. D) asbestos.

A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? a) "Getting the flu can complicate pneumonia." b) "Influenza vaccine will prevent typical pneumonias." c) "Influenza is the major cause of death in the United States." d) "Viruses, like influenza, are the most common cause of pneumonia."

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? a) A negative reaction always excludes the diagnosis of TB. b) The PPD can be read within 12 hours after the injection. c) A positive reaction indicates that the client has active tuberculosis (TB). d) A positive reaction indicates that the client has been exposed to the disease.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Sore throat and abdominal pain b) Nonproductive cough and normal temperature c) Hemoptysis and dysuria d) Dyspnea and wheezing

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Decreased cardiac output b) Anxiety c) Ineffective tissue perfusion (cardiopulmonary) d) Impaired gas exchange

A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? a) Uncertain b) Positive c) Borderline d) Negative

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: a) follow up with the physician in 2 weeks. b) turn and reposition himself every 2 hours. c) maintain fluid intake of 40 oz (1,200 ml) per day. d) continue to take antibiotics for the entire 10 days.

The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Fever b) Headache c) Weight loss d) Shortness of breath

The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? a) Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. b) Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. c) Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.

The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer? a) Symptoms are often minimized by clients. b) There are no early symptoms of lung cancer. c) Symptoms often mimic other infectious diseases. d) Symptoms often do not appear until the disease is well established.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Flail chest b) Cardiac tamponade c) Pulmonary contusion d) Tension pneumothorax

Which action should the nurse take first in caring for a client during an acute asthma attack? A) Send for STAT chest x-ray. B) Initiate oxygen therapy and reassess pulse oximetry in 10 minutes. C) Obtain arterial blood gases. D) Administer bronchodilator as ordered.

Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions b) Do not allow visitors with respiratory infections c) Place suspected patients together d) Encourage breathing exercises

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? a) Constipation usually develops b) It is spread by fecal contamination c) Hypothermia will occur d) It is the most contagious during the second week of illness

Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women? a) Large cell carcinoma b) Squamous cell carcinoma c) Small cell carcinoma d) Adenocarcinoma

Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? a) Fungal b) Streptococcal c) TB d) Pneumocystis

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin E b) Vitamin D c) Vitamin C d) Vitamin B6

You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Bronchitis b) Lung cancer c) Tracheobronchitis d) Acute respiratory distress syndrome

Which of the following would be a pulse pressure indicative of shock? a) 130/90 b) 120/90 c) 100/60 d) 90/70

D (90/70)

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain. a. a dopamine infusion. b. a hypothermia blanket. c. lactated Ringer's solution. d. two 16-gauge IV catheters.

D (A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.)

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a) A slow and imperceptible pulse b) A weak and thready pulse c) A slow but steady pulse d) A rapid, bounding pulse

D (A rapid, bounding pulse)

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? a) Diabetes mellitus b) Unstable angina pectoris c) Hypertension d) Aortic insufficiency

D (Aortic insufficiency)

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

D (Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.)

Which of the following is a clinical characteristic of neurogenic shock? a) Cool skin b) Tachycardia c) Moist skin d) Bradycardia

D (Bradycardia)

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Multiple sclerosis b) Myocardial infarction c) Diabetes d) Head injury

D (Head injury)

Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock? a) Semi-Fowler's b) Prone c) Supine d) Modified Trendelenburg

D (Modified Trendelenburg)

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? A. Codeine B. Demerol C. Dilaudid D. Morphine

D (Morphine)

As the body tries to adjust to accommodate injury (and thus avoid shock), many physical responses are expected. When the pathophysiological compensations are not sufficient, which stage of shock does the client experience? a) Compensation stage b) Catecholamine stage c) Irreversible stage d) Progressive stage

D (Progressive stage)

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur.

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

(see full question) The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction?

You selected: "I can apply powder under the liner to help with sweating."

Which Glasgow Coma Scale score is indicative of a severe head injury?

You selected: 7

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

You selected: A small amount of yellow drainage at the left pin insertion site

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

You selected: Absence of reflexes along with flaccid extremities

A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?

You selected: Acute

You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

You selected: Autonomic dysreflexia

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

You selected: Basilar skull fracture

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

You selected: Body temperature

At which level of cord injury does a patient have full head and neck control?

You selected: C5

At which of the following spinal cord injury levels does the patient have full head and neck control?

You selected: C5

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

You selected: Change in level of consciousness (LOC)

(see full question) The nurse has documented a patient diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as which of the following?

You selected: Coma

(see full question) The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

You selected: Conception is not impaired; the birth process is determined with the physician.

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

You selected: Decerebrate

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

You selected: Ecchymosis over the mastoid

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

You selected: Edema to the head with bruising of the mastoid process

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except:

You selected: Glasgow Coma Scale of 6

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

You selected: Ineffective airway clearance related to brain injury

The nurse is caring for a patient with a head injury. The patient is experiencing CSF rhinorrhea. Which of the following orders should the nurse question?

You selected: Insertion of a nasogastric (NG) tube

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

You selected: Irrigates the wound to remove debris

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?

You selected: Look for signs of increased intracranial pressure

You selected: Meticulous cleanliness

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

You selected: Monitoring the patency of an indwelling urinary catheter

(see full question) The nurse is conducting a health fair on spinal cord injury (SCI) at a local high school. The nurse relays that which of the following is the most common cause of SCI?

You selected: Motor vehicle crashes

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

You selected: Neurologic examination

Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP?

You selected: Pupils are showing progressive dilation.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

You selected: Raise the head of the bed and place the patient in a sitting position

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

You selected: Risk for injury related to neurologic deficit

Which of the following are characteristics of autonomic dysreflexia?

You selected: Severe hypertension, slow heart rate, pounding headache, sweating

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

You selected: Spasticity

Which of the following are the immediate complications of spinal cord injury?

You selected: Spinal shock

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

You selected: Subdural

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

You selected: Subdural hematoma

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

You selected: Suction the airway.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

You selected: T6

(see full question) The nurse is caring for a patient with TBI (traumatic brain injury). The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern?

You selected: Temperature increase from 98.0°F to 99.6°F

The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

You selected: The client has cerebral spinal fluid (CSF) leaking from the ear.You selected: The client has cerebral spinal fluid (CSF) leaking from the ear.

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

You selected: vomits. Correct

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

You selected: • Bradycardia • Hypertension • Bradypnea

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "I'll stay in isolation for 6 weeks." b) "This disease may come back later if I am under stress." c) "I'll have to take the medication for up to a year." d) "I'll always have a positive test for tuberculosis."

a) "I'll stay in isolation for 6 weeks." Explanation: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease. pg.587

A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is: a) 1.4 L. b) unspecified. c) 2 L. d) 3 L.

a) 1.4 L. Explanation: Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily. pg.582

Approximately what percentage of people who are initially infected with TB develop active disease? a) 10% b) 40% c) 20% d) 30%

a) 10% Explanation: Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate. pg.587

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Apply a compression dressing to the area. b) Record the observation. c) Measure the patient's pulse oximetry. d) Report the finding to the physician immediately.

a) Apply a compression dressing to the area. Explanation: Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. During surgery the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. pg.616

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a) Fibrotic changes in lungs b) Hemorrhage c) Damage to surrounding tissues d) Lung contusion

a) Fibrotic changes in lungs Explanation: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries. pg.606

What are the conditions that make up Virchow's triad? Select all that apply. a) Hypocoagulability b) Disruption of the vessel lining c) Edema d) Hypercoagulability e) Venostasis

a) Hypercoagulability b) Disruption of the vessel lining e) Venostasis Explanation: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad. pg.846

The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma b) Squamous cell carcinoma c) Bronchoalveolar carcinoma d) Adenocarcinoma

a) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.606

You've been invited to speak to the Hospital Guild of the hospital where you practice nursing. You've been asked to address "Communicable Diseases of Winter" and are speaking to a large group of volunteer women, most of whom are older than 60 years. What practices should you encourage in these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. a) Receiving vaccinations b) Techniques for incentive spirometry c) Hand antisepsis d) Using prescribed opioids

a) Receiving vaccinations c) Hand antisepsis b) Techniques for incentive spirometry Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. Teaching the Guild members the proper method and times to wash their hands go a long way in disease prevention. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae. pg.571

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: a) acute respiratory distress syndrome (ARDS). b) chronic obstructive pulmonary disease (COPD). c) bronchial asthma. d) renal failure.

a) acute respiratory distress syndrome (ARDS). Explanation: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation. pg.596

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) empyema. b) Pneumocystis carinii pneumonia. c) infected chest tube wound site. d) lobar pneumonia.

a) empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage. pg.594

A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." b) "You must consume a diet rich in protein, such as chicken, fish, and beans." c) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." d) "You must consume a diet low in fat by limiting dairy products and concentrated sweets."

b) "You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess. pg.592

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner? a) Apply vented dressing. b) Apply airtight dressing. c) Apply direct pressure to the wound. d) Clean the wound and leave open to the air.

b) Apply airtight dressing. Explanation: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted. pg.613

The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and assist in the diagnosis of an occupational lung disease? a) Cough and dyspnea b) Black-streaked sputum c) Tenacious secretions d) Barrel chest

b) Black-streaked sputum Explanation: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time. pg.606

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? a) Cardiac tamponade b) Flail chest c) Simple pneumothorax d) Pulmonary contusion

b) Flail chest Explanation: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. pg.611

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Intubate the patient and control breathing with mechanical ventilation c) Schedule the patient for pulmonary surgery d) Increase oxygen administration

b) Intubate the patient and control breathing with mechanical ventilation Explanation: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate. pg.597

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Measure the patient's pulse oximetry b) Record the observation c) Report the finding to the physician immediately d) Apply a compression dressing to the area

b) Record the observation Explanation: Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. pg.614

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) bruising. b) redness and induration. c) drainage. d) tissue sloughing.

b) redness and induration. Explanation: The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus. pg.588

What dietary recommendations should a nurse provide a patient with a lung abscess? a) A diet low in calories b) A carbohydrate-dense diet c) A diet rich in protein d) A diet with limited fat

c) A diet rich in protein Explanation: For a patient with pleural effusion, a diet rich in protein and calories is pivotal. A carbohydrate-dense diet or diets with limited fat are not advisable for a patient with lung abscess. pg.591

Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall? a) Viral pneumonia b) Mycoplasmata pneumonia c) Legionnaires' disease d) Streptococcal (pneumococcal) pneumonia

c) Legionnaires' disease Explanation: Legionnaires' disease accounts for 15% of community-acquired pneumonias. Streptococcal pneumonia demonstrates the highest occurrence in winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter. Viral pneumonia demonstrates the greatest incidence during winter months. pg.574

A patient suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which of the following interventions to improve oxygenation and provide comfort for the patient? a) Assist the patient up to a chair b) Force fluids for the next 24 hours c) Position the patient in the prone position d) Administer small doses of pancuronium (Pavulon)

c) Position the patient in the prone position Explanation: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs. pg.597

Which of the following terms refers to lung tissue that has become more solid in nature due to a collapse of alveoli or an infectious process? a) Bronchiectasis b) Empyema c) Atelectasis d) Consolidation

d) Consolidation Explanation: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space. pg.578

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a) Crackles b) Wheezes c) Rhonchi d) Decreased breath sounds

d) Decreased breath sounds Explanation: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis. pg.593

An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Mottling of the skin upon inspection b) Resonance upon percussion c) Wheezing upon auscultation d) Decreased chest wall excursion upon palpation

d) Decreased chest wall excursion upon palpation Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. pg.593

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Activity intolerance b) Impaired oral mucous membranes c) Imbalanced nutrition: Less than body requirements d) Impaired gas exchange

d) Impaired gas exchange Explanation: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client. pg.582

Which of the following types of lung cancer is characterized as fast growing and tending to arise peripherally? a) Bronchoalveolar carcinoma b) Adenocarcinoma c) Squamous cell carcinoma d) Large cell carcinoma

d) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.605

A 62-year-old female client arrives at the office complaining of dyspnea and fatigue. She tells the nurse that she's had a persistent productive cough for the last few months, which she attributes to a bout with the flu. The nurse suspects that this client may have which of the following? a) Pleurisy b) Lung abscess c) Pleural effusion d) Lung cancer

d) Lung cancer Explanation: Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. The sputum is examined for malignant cells. Chest x-rays may or may not show a tumor. With pleurisy, the client's respirations become shallow secondary to excruciating pain. The client may have a dry cough, fatigue easily, and experience dyspnea. Fever, pain, and dyspnea are the most common symptoms of pleural effusion. Signs and symptoms of lung abscess include chills, fever, weight loss, chest pain, and a productive cough. pg.607

A 29-year-old client presents to the ED complaining of dyspnea on exertion and overall weakness. Her pulmonary arterial pressure is 40/15 mm Hg. These symptoms indicate that the client may have which of the following conditions? a) Atelectasis b) Restrictive lung disease c) Asthma d) Pulmonary arterial hypertension

d) Pulmonary arterial hypertension pg.599

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? a) Tracheobronchitis b) Viral pneumonia c) Cardiovascular disease d) Staphylococcal pneumonia

d) Staphylococcal pneumonia Explanation: Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease. Staphylococcal pneumonia is the most serious complication. Although tracheobronchitis is a complication of the flu, it is not the most serious one. Although cardiovascular disease is a complication of the flu, it is not the most serious one. Bacterial, not viral, pneumonia is a possible complication of the flu, although not its most serious one. pg.577

A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Bloody, productive cough b) Diminished breath sounds c) Decreased respiratory rate d) Sucking sound at the site of injury

d) Sucking sound at the site of injury Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds pg.614

A 68-year-old male client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The nurse knows that the surgical team places this catheter: a) To administer IV medication b) To ventilate the client c) To remove fluid from the lungs d) To remove air from the pleural space

d) To remove air from the pleural space Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery—one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid. Chest tubes are placed to remove anteriorly air from the pleural space following thoracic surgery. The anesthesiologist ventilates the client during surgery. Postsurgery, a chest tube is placed anteriorly to remove air from the pleural space. pg.527

Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Elevate the head of the bed b) Use a prescribed analgesic c) Use a heat application d) Turn onto the affected side

d) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain. pg.593

Following thoracic surgery, the care plan for a client at risk for impaired gas exchange would include which of the following? Select all that apply. a) Elevate head of bed 30°-40° as tolerated. b) Reinforce preoperative breathing exercises. c) Administer pain medications. d) Maintain accurate record of intravenous intake. e) Monitor vital signs frequently.

e) Monitor vital signs frequently. b) Reinforce preoperative breathing exercises. a) Elevate head of bed 30°-40° as tolerated. Explanation: Nursing management for a client with the goal of maintaining optimal gas exchange includes assessing vital signs frequently, reinforcing preoperative instructions about deep breathing, coughing, and incentive spirometry, and elevating the head of the bed as tolerated. pg.528

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

• Respiratory irregularities • Slow bounding pulse • Widened pulse pressure

(see full question) Which of the following are risk factors for SCI? Select all that apply.

• Young age • Alcohol use • Drug abuse

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