Elsevier Adaptive Quizzing: Respiration
Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. One, some, or all responses may be correct. 1. Diarrhea 2. Anorexia 3. Weight gain 4. Hemoptysis 5. Night sweats
Answer: 2. Anorexia 4. Hemoptysis 5. Night sweats Rationale: Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. Signs include a persistent cough, anorexia, hemoptysis, night sweats, shortness of breath, and a high body temperature. Diarrhea and weight gain are not associated with tuberculosis.
Which sign in t he newborn infant would reflect an Apgar score of 1 in the category of respiration? 1. Good cry 2. Grimacce 3. Absent respiration 4. Slow, weak cry
Answer: 4. Slow, weak cry Rationale: A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system.
A client diagnosed with tuberculosis is taking isoniazide. The prevent a food and medication interaction, the nurse will advise to avoid which food item? 1. Hot dogs 2. Red wine 3. Sour cream 4. Grapefruit juice
Answer: 2. Red wine Rationale: Clients taking isoniazide should avoid foods containing tyramine such as red wine, tuna fish, and hard cheese. Hot dogs, sour cream, and grapefruit juice do not contain tyramine and are not contraindicated. Grapefruit juice slows metabolism of many medications, but isoniazid is not one of them.
Which complication is prevented by coaching a client in the second stage of labor to take a breath at least every 6 seconds while pushing with each contraction? 1. Fetal hypoxia 2. Perineal lacerations 3. Carpopedal spasms 4. Maternal hypertension
Answer: 1. Fetal hypoxia Rationale: Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.
To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? 1. Hilum 2. Carina 3. Alveoli 4. Epiglottis
Answer: 2. Carina Rationale: Located at the level of manubriosternal junction, the carina is also referred to as the angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the largynx during swallowing.
Which technique would the nurse employ for an obstetrical client with foreign body airway obstruction? 1. Back blows 2. Chest thrusts 3. Suprapubic thrusts 4. Abdominal thrusts
Answer: 2. Chest thrusts Rationale: Chest thrusts are performed for an obstetrical client with a foreign airway obstruction. Back blows, suprapubic thrusts, or abdominal thrusts are not used to dislodge a foreign body causing airway obstruction.
Which is prevented by providing warm, humidified oxygen to a preterm infant? 1. Apnea 2. Cold stress 3. Respiratory distress 4. Bronchopulmonary dysplasia
Answer: 2. Cold stress Rationale: By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.
Which manifestation is an adverse effect of intravenous lorazepam? Select all that apply. One, some, or all responses may be correct. 1. Amnesia 2. Drowsiness 3. Sleep driving 4. Blurred vision 5. Respiratory depression
Answer: 1. Amnesia 2. Drowsiness 3. Sleep driving 4. Blurred vision 5. Respiratory depression Rationale: Benzodiazepines such as lorazepam have a range of side effects, many of which are related to central nervous system depression. Anterograde amnesia, drowsiness, sleep driving, blurred vision, and respiratory depression are all potential adverse effects of lorazepam.
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement? 1. Auscultate the lungs 2. Obtain arterial blood gases. 3. Notify the health care provider. 4. Apply pressure to the abdomen.
Answer: 1. Auscultate the lungs Rationale: Always assess the client first to determine if the lung sounds are indicative of fluid overload. When respiratory distress occurs, possibly from pressure of the dialysate on the diaphragm, respiratory status and vital signs should be assessed. The health care provider should be notified and arterial blood gases should be obtained after immediate action is taken. Never apply pressure to the abdomen, as that could worsen the respiratory status.
Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. One, some, or all responses may be correct. 1. Burns 2. Skin cancer 3. Osteomyelitis 4. Diabetic ulcers 5. Myocardial infarction
Answer: 1. Burns 3. Osteomyelitis 4. Diabetic ulcers Rationale: Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue's oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy. Skin cancer and myocardial infarctions are not treated using hyperbaric oxygen therapy.
Which child is the best roommate option for child admitted in a vasoocclusive sickle cell crisis? 1. Child with thalassemia 2. Child with osteomyelitis 3. Child with viral pneumonia 4. Child with acute pharyngitis
Answer: 1. Child with thalassemia Rationale: Thalassemia is a hemolytic anemia that is not communicable; roommates with infectious diseases should be avoided because a child with sickle cell anemia is susceptible to infection. Osteomyelitis is an infection of the bone, pneumonia is an infection of the lung, and pharyngitis is an upper respiratory tract infection; therefore, none of these children is a suitable roommate.
Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. One, some, or all responses may be correct. 1. Dyspnea 2. Dry cough 3. Diaphoresis 4. Mild chest pain 5. High temperature
Answer: 1. Dyspnea 3. Diaphoresis 5. High temperature Rationale: The fulminant stage of inhalation of anthrax is manifested by dyspnea, diaphoresis, and a high body temperature. The prodromal stage of inhalation of anthrax is manifested by a dry cough and mild chest pain.
Which is the priority nursing intervention to prevent thrombus formation in a child with sickle cell anemia? 1. Encouraging fluids 2. Encouraging bed rest 3. Administering oxygen (O2) 4. Administering prescribed anticoagulants
Answer: 1. Encouraging fluids Rationale: Dehydration, stress, infection, and electrolyte imbalance can trigger the sickling process. Red blood cells (RBCs) change to the sickle shape when deoxygenated because of polymerization of the abnormal hemoglobin. This process damages the RBC membrane, which causes the cells to become entangled in the blood vessels, depriving the tissues that are distal to the occlusion of O2, resulting in ischemia and infarction, which can in turn cause organ damage. The child's condition determines the activity level; although bed rest may be required during a pain episode, at other times it is not necessary. Administering O2 will not prevent thrombus formation. Anticoagulants do not help prevent thrombus formation in sickle cell anemia.
Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct.. 1. Facial edema 2. Septal deviation 3. Clear nasal drainage 4. Oxygen saturation 89% 5. Bilateral periorbital bruising
Answer: 1. Facial edema 2. Septal deviation 3. Clear nasal drainage 4. Oxygen saturation 89% 5. Bilateral periorbital bruising Rationale: Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. 'Raccoon eye' or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.
Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Orthopnea 3. Pitting edema 4. Dry hacking cough 5. 4-pound weight gain
Answer: 1. Fatigue 2. Orthopnea 3. Pitting edema 4. Dry hacking cough 5. 4-pound weight gain Rationale: Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1. Initiate oxygen via a nasal cannula 2. Administer the prescribed morphine 3. Prepare the client for endotracheal intubation 4. Place a nitroglycerin tablet under the client's tongue
Answer: 1. Initiate oxygen via a nasal cannula Rationale: Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is no the priority intervention and requires a prescription.
Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? 1. It helps prevent drying of membranes. 2. It provides a mode of giving inhalant medications. 3. It increases the surface tension of the respiratory tract. 4. It provides an environment free of pathogenic organisms.
Answer: 1. It helps prevent drying of membranes. Rationale: Humidified oxygen helps reduce inflammation and edema of the upper respiratory tract. Inhalant medications are administered with the use of a nebulizer. The mist has no effect on surface tension in the respiratory tract. Eliminating pathogenic organisms is not the purpose of humidified oxygen.
A client with type 1 diabetes has dry, hot, flushed skin; a fruity odor to the breath; and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? 1. Ketoacidosis 2. Somogyi phenomenon 3. Hypoglycemic reaction 4. Hyperosmolar nonketotic coma
Answer: 1. Ketoacidosis Rationale: Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.
Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. 1. Mold 2. Cold air 3. Pet dander 4. Air pollution 5. Cigarette smoke
Answer: 1. Mold 2. Cold air 3. Pet dander 4. Air pollution 5. Cigarette smoke Rationale: Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.
Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct. 1. Opioids 2. Alcohol 3. Barbiturates 4. Antidepressants 5. First-generation antipsychotics
Answer: 1. Opioids 2. Alcohol 3. Barbiturates Rationale: Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines.
Which is a risk factor of necrotizing enterocolitis in the preterm infant? 1. Polycythemia 2. Hypoglycemia 3. Ventilatory support 4. Antibiotic administration
Answer: 1. Polycythemia Rationale: Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the GI mucosa, commonly complicated by bowel necrosis and perforation. Polycythemia places the preterm infant at risk for necrotizing enterocolitis. Hypoglycemia and ventilatory support are not risk factors associated with necrotizing enterocolitis. Gut infections can lead to NEC, but the use of antibiotics does not.
Which agent of terrorism can cause death within a few minutes? 1. Sarin gas 2. Uranium 3. Iodine-131 4. Mustard gas
Answer: 1. Sarin gas Rationale: Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by paralyzing respiratory muscles. Uranium and iodine-131 can be dangerous in close proximities but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause death within a few minutes.
A child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. Which is the most appropriate nursing intervention? 1. Stopping the bath and replacing the mask 2. Performing postural drainage and clapping the chest 3. Placing the child in the orthopneic position and calling the health care provider (HCP) 4. Suctioning the child's nasal passages and waiting for the dyspnea to subside
Answer: 1. Stopping the bath and replacing the mask Rationale: Interrupting the bath and providing humidified air will reduce energy requirements, allow the child to rest, and lessen the demand for O2. Although postural drainage loosens secretions in the lungs, it should not be used when the child is in distress. The orthopneic position will not reduce energy and O2 demands; the HCP should be called if appropriate nursing measures do not relieve the dyspnea. Suctioning is not performed unless respiratory distress is severe; it increases restlessness and energy demand.
Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct. 1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting
Answer: 1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting Rationale: Findings indicative of abnormal breathing in newborns include stridor, mottling, bradypnea, nasal flaring, and expiratory grunting.
A client hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care? 1. The disease process and breathing exercises 2. How to control or prevent respiratory infections 3. Using aerosol therapy, especially nebulizers 4. Priorities when performing everyday activities
Answer: 1. The disease process and breathing exercises Rationale: Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.
A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1. The ribcage is not compressed and released during birth. 2. The sudden temperature change at birth causes aspiration. 3. there is usually oxygen deprivation after a cesarean birth. 4. There is no gravity during the birth to promote drainage from the lungs.
Answer: 1. The ribcage is not compressed and released during birth. Rationale: The release after compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? 1. Their gag reflex has returned. 2. They are confused due to anesthesia. 3. They are nauseated and want to vomit. 4. Their airway is becoming obstructed.
Answer: 1. Their gag reflex has returned. Rationale: The ability to spit out the oral airway indicates that the normal gag reflex has returned and the client can protect her or his airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit out the airway does not mean that the client is nauseated. An oral airway is meant to keep the airway patent; it may not obstruct the airway.
Which assessment finding is consistent with bronchospasm? 1. Wheezing 2. Rhonchi 3. Pleural friction rub 4. Low-pitched crackles
Answer: 1. Wheezing Rationale: Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is caused by airway narrowing, which occurs with bronchospasm, for example. Rhonchi are associated with obstruction by a foreign body or thick mucus. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.
Which arterial blood gas results are associated with diabetic ketoacidosis? 1. pH: 7.28; PCO2: 28; HCO3: 18 2. pH: 7.30; PCO2: 54; HCO3: 28 3. pH: 7.50; PCO2: 49; HCO3: 32 4. pH: 7.52; PCO2: 26; HCO3: 20
Answer: 1. pH: 7.28; PCO2: 28; HCO3: 18 Rationale: Diabetic ketoacidosis would be associated with metabolic acidosis, which is reflect by a low pH and bicarbonate; a low PCO2 indicates compensatory hyperventilation. A low pH and elevated PCO2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO2 indicates compensatory hypoventilation. An elevated pH and low PCO2 reflect hyperventilation and respiratory alkalosis.
Which statement by the nurse regarding anesthetic drugs in pediatric clients requires correction? 1. 'Pediatric clients are more affected by anesthesia than adults.' 2. 'During general anesthesia, the upper airway obstruction risk is less in pediatrics.' 3. 'Cardiac abnormalities are more common in pediatric clients receiving anesthesia.' 4. 'The central nervous system of pediatric clients is more sensitive to the effects of anesthetics.'
Answer: 2. 'During general anesthesia, the upper airway obstruction risk is less in pediatrics.' Rationale: Neonates have a respiratory structure that is small in diameter, and they have a high metabolic rate. Because of this, the chance of upper airway obstruction during general anesthesia is quite high. In pediatric clients, medication accumulation and toxicity also increase because the child's liver and kidney functions are immature. Thus children are more affected by anesthesia than adults. A child's cardiac system is not fully developed, which causes problems with the excretion and metabolism of anesthetics and leads to cardiac abnormalities. Because the blood-brain barrier is underdeveloped in pediatric clients, the central nervous system is more affect by anesthetics.
Which would be the respiratory rate in a 2-year-old child? 1. 20 breaths/min 2. 30 breaths/min 3. 40 breaths/min 4. 50 breaths/min
Answer: 2. 30 breaths/min Rationale: The normal range for the respiratory rate in a 2-year-old child (toddler) is between 25 and 32 breaths/min. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40 breaths/min. The normal respiratory rate in infants is 50 breaths/min.
Pilocarpine is used as part of the diagnostic process process of a toddler suspected of cystic fibrosis. The nurse knows that the pilocarpine would stimulate which process? 1. Secretion of mucus 2. Activity of sweat glands 3. Excretion of pancreatic enzymes 4. Release of bile from the gallbladder.
Answer: 2. Activity of sweat glands Rationale: Pilocarpine is a cholinergic that is applied to the skin to stimulate sweat production; the sweat is then tested to confirm the diagnosis of cystic fibrosis. Pilocarpine does not stimulate the secretion of mucus, the excretion of pancreatic enzymes, or the release of bile from the gallbladder.
A client's respiratory tract infection, which started with a common cold, has progressed to whooping cough. The client reports 'coughing fits' lasting several minutes. Which organism is responsible for the client's condition? 1. Bacillus anthracis 2. Bordetella pertussis 3. Streptococcus pneumoniae 4. Mycobacterium tuberculosis
Answer: 2. Bordetella pertussis Rationale: Bordetella ppertussis causes whooping cough. Pertussis is a respiratory tract infection beginning with the common cold and progresses to whooping cough. The client also develops coughing episodes lasting for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.
The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client? 1. Apnea 2. Bradypnea 3. Tachypnea 4. Hyperpnea
Answer: 2. Bradypnea Rationale: In bradypnea the breathing rate is regular, but is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.
Which factor would elevate the oxygen saturation during an assessment? 1. Nail polishes 2. Carbon monoxide 3. Intravascular dyes 4. Skin pigmentation
Answer: 2. Carbon monoxide Rationale: Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.
Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? 1. Prevents bronchial spasm 2. Decreases air trapping in lung 3. Improves alveolar surface area 4. Strengthens diaphragmatic contraction
Answer: 2. Decreases air trapping in lung Rationale: Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.
Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? 1. Is able to obtain pulse oximeter readings 2. Demonstrates use of a metered-dose inhaler 3. Knows the health care provider's office hours 4. Can identify triggers that may cause wheezing
Answer: 2. Demonstrates use of a metered-dose inhaler Rationale: Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have. Home management typically includes self-monitoring of the peak expiratory flow rate rather than pulse oximetry. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Although it is important to be able to identify triggers that may cause wheezing, knowing these cannot prevent all wheezing; therefore, being able to abort wheezing with a bronchodilator is the greater priority.
Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)? 1. Nausea 2. Dyspnea 3. Orthopnea 4. Paresthesia
Answer: 2. Dyspnea Rationale: FES is clinically manifested by dyspnea because of low levels of arterial oxygen. Nausea and orthopnea are not seen in FES. However, tachypnea, headache, and lethargy are seen in clients with FES. Paresthesia occurs with compartment syndrome. Orthopnea - the sensation of breathlessness in the recumbent position, relieved by sitting or standing Paresthesia - burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/h. One hour later, the client begins screaming, 'I can't breathe!' How would the nurse respond? 1. Discontinue the IV and notify the health care provider. 2. Elevate the head of the client's bed and obtain vital signs. 3. Assess the client for allergies and change the IV to an intermittent lock. 4. Contact the health care provider to request a prescription for a sedative.
Answer: 2. Elevate the head of the client's bed and obtain vital signs. Rationale: Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Discontinuing the IV access line is unsafe because IV medications may need to be administered and restarting the IV will cause unnecessary discomfort and expense; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.
When caring for a client in late hypovolemic shock, which complication will the nurse anticipate? 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased PCO2 levels
Answer: 2. Metabolic acidosis Rationale: Decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock, metabolic or respiratory acidosis occurs. The PCO2 level will increase in profound shock.
A chronically ill, older client lives with their daughter. The client reports the daughter, who has three small children, seems run-down, coughs a lot, and sleeps all the time. Which statement supports the need for the nurse to pursue the daughter's condition as a potential cause finding? 1. Tuberculosis has been rising dramatically in the general population. 2. Older adults with chronic illness are more susceptible to tuberculosis. 3. There is a high incidence of tuberculosis in children less than 12 years of age. 4. Death from tuberculosis has been decreasing in the United States and Canada.
Answer: 2. Older adults with chronic illness are more susceptible to tuberculosis. Rationale: The client's chronic illness and older age increase vulnerability; the daughter's condition should be explored in greater detail. Tuberculosis is only one of man potential causes of the daughter's clinical condition. Children who have not yet reached puberty and adolescence have the lowest incidence of tuberculosis. Morbidity and mortality resulting from tuberculosis are increasing, not decreasing.
Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. 1. Palpate the chest and back for masses. 2. Question the client about shortness of breath. 3. Check the hematocrit and hemoglobin values 4. Inspect the skin and nails for integrity and color. 5. Ask the client about color and quantity of sputum.
Answer: 2. Question the client about shortness of breath. 5. Ask the client about color and quantity of sputum. Rationale: Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.
Which complication of cystic fibrosis is related to frequent stools and tenacious mucus? 1. Anal fissures 2. Rectal prolapse 3. Intussusception 4. Meconium ileus
Answer: 2. Rectal prolapse Rationale: Rectal prolapse, a common gastrointestinal complication of cystic fibrosis, results from the wasting of perirectal supporting tissues because of malnutrition. Anal fissures usually do not occur with cystic fibrosis. Intussusception is not associated with cystic fibrosis. Meconium ileus is associated with cystic fibrosis in newborns; it prevents the passage of meconium.
Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? 1. Duration of cry 2. Respiratory distress 3. Frequency of voiding 4. Poor nutritional intake
Answer: 2. Respiratory distress Rationale: Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. If the infant is in respiratory distress, the nutritional intake is not important.
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1. Bradycardia 2. Restlessness 3. Constricted pupils 4. Clubbing of the fingers
Answer: 2. Restlessness Rationale: Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.
A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? 1. Bradycardia 2. Restlessness 3. Constricted pupils 4. Clubbing of the fingers
Answer: 2. Restlessness Rationale: Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.
Which complication is the priority for the nurse to assess in a child with smoke inhalation? 1. Systemic infection 2. Tracheobronchial edema 3. Post-traumatic stress disorder 4. Generalized adaptation to stress
Answer: 2. Tracheobronchial edema Rationale: Heat and inhaled smoke-related irritants may cause fluid to shift from the intravascular compartment into the interstitial compartment, resulting in edema, which obstructs the airway. Although monitoring for infection is important, a patient airway is the priority. Although monitoring for post-traumatic stress disorder is important because the condition could occur later, maintaining a patient airway is the priority. Although monitoring for physical and emotional responses to stress is important, maintaining a patient airway is the priority.
How would the nurse position a client to practice supraglottic swallowing after tracheostomy? 1. In bed 2. Upright 3. Lying down 4. Position of comfort
Answer: 2. Upright Rationale: The safest position for supraglottic swallowing is sitting upright. Clients should be out of bed, if possible. Clients are at risk for aspiration if swallowing while supine. Comfort is always a goal of positioning clients, but upright is the priority for safe swallowing.
After auscultating the chest, how will the nurse document findings of bilateral, high-pitched continuous whistling sounds heard during each expiration? 1. Crackles 2. Wheezes 3. Rhonchus 4. Pleural friction rub
Answer: 2. Wheezes Rationale: Wheezing, an adventitious breath sounds, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.
The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? 1. Vesicular 2. Bronchial 3. Adventitious 4. Bronchovesicular
Answer: 3. Adventitious Rationale: Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.
Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? 1. Hemorrhage 2. Thyrotoxic crisis 3. Airway obstruction 4. Hypocalcemic tetany
Answer: 3. Airway obstruction Rationale: Maintaining airway patency is always the priority to permit gas exchange necessary to maintain life. Although important, hemorrhage, thyrotoxic crisis, and hypocalcemic tetany do not exceed patency of the airway in priority.
The nurse is caring a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? 1. Red blood cell count 2. Sputum culture 3. Arterial blood gas 4. Total hemoglobin
Answer: 3. Arterial blood gas Rationale: Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
The nurse assesses the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? 1. Client with shock 2. Client with anemia 3. Client with epilepsy 4. Client with peripheral vascular disease
Answer: 3. Client with epilepsy Rationale: A client with epilepsy does not have any circulatory inadequacy. The capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.
The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? 1. Vesicular 2. Bronchial 3. Crackles 4. Rhonchi
Answer: 3. Crackles Rationale: Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a lower pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.
A client's breath has a sweet, fruity odor. Which condition is affecting this client? 1. Gum disease 2. Uremic acidosis 3. Diabetic acidosis 4. Infection inside a cast
Answer: 3. Diabetic acidosis Rationale: A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.
Which type of breathing pattern is manifested with hypercarbia? 1. Eupnea 2. Tachypnea 3. Hypoventilation 4. Kussmaul respiration
Answer: 3. Hypoventilation Rationale: Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul respiration.
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? 1. It relieves bronchial spasms. 2. It increases the depth of respirations. 3. It loosens pulmonary secretions. 4. It expels carbon dioxide from the lungs.
Answer: 3. It loosens pulmonary secretions. Rationale: Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.
Why should the use of baby powder on an infant be avoided? 1. Skin irritation 2. Skin infection 3. Lung irritaiton 4. Respiratory infection
Answer: 3. Lung irritaiton Rationale: The use of baby powder or cornstarch should be avoided on an infant because it is associated with lung irritation. The use of baby powder or cornstarch is not directly associated with skin irritation or with skin or respiratory infections.
Which nursing intervention has the highest priority for a client who was in a motor bike accident and has a severe neck injury? 1. Assessing for crepitus 2. Assessing for bleeding 3. Maintaining a patent airway 4. Performing neurological assessment
Answer: 3. Maintaining a patent airway Rationale: The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurological assessment for mental status, sensory level, and motor function, which holds a medium priority.
After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? 1. Partial pressure of oxygen (PaO2) of 72; peripheral capillary oxygen saturation (SpO2) of 96 2. PaO2 of 60; SpO2 of 90 3. PaO2 of 55; SpO2 of 88 4. PaO2 of 70; SpO2 of 92
Answer: 3. PaO2 of 55; SpO2 of 88 Rationale: A PaO2 of 55 and SpO2 of 88 indicate hypoxemia and that long-term oxygen therapy is needed. The values PaO2 72 and SpO2 96 indicate adequate oxygenation. The values PaO2 60 and SpO2 90 are adequate and the client would not require oxygen therapy. The values PaO2 70 and SpO2 92 are adequate and do not indicate a need for oxygen therapy.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gas results require nursing attention because they indication which condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
Answer: 3. Respiratory acidosis Rationale: The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2, and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
A client takes morphine sulfate for severe metastatic bone pain. The nurse will assess the client for which adverse effect? 1. Diarrhea 2. Addiction 3. Respiratory depression 4. Diuresis
Answer: 3. Respiratory depression Rationale: Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Urinary retention, not diuresis, is a common side effect of morphine.
A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. Which response from the nurse would be the best? 1. 'I don't know; however, I will ask your health care provider for a prescription as soon as possible.' 2. 'Antibiotics are used to treat viruses, and your cultures indicate the presence of a bacterial infection.' 3. 'Antibiotics are ineffective for treating the bacteria that caused your upper respiratory infections.' 4. 'Upper respiratory infections are generally caused by viruses and would not be treated with antibiotics.'
Answer: 4. 'Upper respiratory infections are generally caused by viruses and would not be treated with antibiotics.' Rationale: Generally, upper respiratory infections are viral; therefore antibiotics would not be used. Overuse of antibiotics result in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.
An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? 1. Death from TB is on the increase in older populations. 2. The roommate is causing increased anxiety and stress in the client. 3. TB adversely affects older adults with chronic illness. 4. Most likely, the roommate prevents the client from getting proper sleep.
Answer: 3. TB adversely affects older adults with chronic illness. Rationale: The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from TB is declining because of improved medication therapy. (Canada: According to the Public Health Agency of Canada, 1607 new active and retreatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.
A child with cystic fibrosis (CF) has recurrent episodes of bronchitis, and the parents ask why this happens. Which reason would the nurse include in the reply? 1. Associated heart defects cause heart failure and respiratory depression. 2. Neuromuscular irritability causes spasm and constriction of the bronchi. 3. Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. 4. The increased salt content in saliva irritates the mucous membranes, resulting in inflammation of the nasopharynx.
Answer: 3. Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. Rationale: CF is characterized by an overproduction of viscous mucus by exocrine glands in the lungs. The mucus traps bacteria and foreign debris that adhere to the lining and cannot be expelled by the cilia, resulting in obstruction of the airway and the development of a favorable environment for the growth of microorganisms, leading to infection. Cardiac defects are not associated with CF. Neuromuscular irritability of the bronchi does not occur in CF. Although there is increased sodium and chloride in the saliva, they do not irritate or inflame the mucous membranes.
Parents whose child has cystic fibrosis (CF) have no history of CF in their family and ask how their child inherited this disorder. How would the nurse clarify the way in which the disease was inherited? 1. It is a mutated gene. 2. It involves an X-linked gene. 3. The inheritance is autosomal recessive. 4. The inheritance is autosomal dominant.
Answer: 3. The inheritance is autosomal recessive. Rationale: Both parents are carriers; the gene for CF is recessive, not dominant, and the parents do not have the disease. The gene for CF is not a mutant gene, nor is it located on the X or Y chromosome.
A client with coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? 1. To prevent dyspnea 2. To prevent cyanosis 3. To increase oxygen concentration to heart cells 4. To increase oxygen tension in the circulating blood
Answer: 3. To increase oxygen concentration to heart cells Rationale: Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.
A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease? 1. Anemia 2. Pneumonia 3. Tuberculosis 4. Leukocytosis
Answer: 3. Tuberculosis Rationale: Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased whited blood cells; it does not cause hemoptysis.
How would the nurse position a client with epistaxis? 1. Supine 2. Side-lying 3. Upright leaning forward 4. Sitting with the head tipped backward
Answer: 3. Upright leaning forward Rationale: A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the risk for aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the risk for aspiration or swallowing blood.
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? 1. Fine crackles 2. Adventitious sounds 3. Vesicular breath sounds 4. Diminished breath sounds
Answer: 3. Vesicular breath sounds Rationale: Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. 'Adventitious sounds' is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? 1. Adventitious sounds 2. Fine crackling sounds 3. Vesicular breath sounds 4. Diminished breath sounds
Answer: 3. Vesicular breath sounds Rationale: Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. 'Adventitious' is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? 1. Deep and retracting 2. Shallow and thoracic 3. Stertorous and regular 4. Abdominal and irregular
Answer: 4. Abdominal and irregular Rationale: A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? 1. Dull sound on percussion 2. Vocal fremitus on palpation 3. Rales with rhonchi on auscultation 4. Absence of breath sounds on auscultation
Answer: 4. Absence of breath sounds on auscultation Rationale: The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.
The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. After stopping the infusion, which priority action will the nurse take? 1. Notify the primary health care provider immediately about the client's condition. 2. Take the client's blood pressure. 3. obtain the client's pulse oximetry. 4. Assess the client's respiratory status.
Answer: 4. Assess the client's respiratory status. Rationale: The client is experiencing an allergic reaction. Severe allergic reactions commonly cause respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the primary health care provider. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.
During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic infusion? 1. Check the client's temperature. 2. Take the client's blood pressure. 3. Obtain the client's pulse oximetry. 4. Assess the client's respiratory status.
Answer: 4. Assess the client's respiratory status. Rationale: The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.
Which clinical findings support the diagnosis of diabetic ketoacidosis (DKA)? 1. Nervousness and tachycardia 2. Erythema toxicum rash and pruritus 3. Diaphoresis and altered mental state 4. Deep respirations and fruity odor to the breath
Answer: 4. Deep respirations and fruity odor to the breath Rationale: Deep respirations and a fruity odor to the breath are classic signs of DKA, because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremors, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.
The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? 1. Teaching how to make a room allergy-free 2. Referring to a support group for individuals with asthma 3. Arranging with the college to ensure a speedy return to classes 4. Evaluating whether the necessary lifestyle changes are understood
Answer: 4. Evaluating whether the necessary lifestyle changes are understood Rationale: Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.
Which insect or arthropod is the most common allergen for children with asthma? 1. Spider 2. Centipede 3. Carpenter ant 4. Household cockroach
Answer: 4. Household cockroach Rationale: Research has identified that the presence of the common household cockroach can trigger an asthma exacerbation in children with asthma. Spiders, centipedes, and carpenter ants have not been identified as triggers in children who are prone to asthmatic attacks.
Which is the cause of frequent upper respiratory tract infections in toddlers? 1. Stress 2. Unhealthy diet 3. Lack of exercise 4. Immature immune system
Answer: 4. Immature immune system Rationale: Infants and toddlers are at risk for upper respiratory tract infections as a result of frequent exposure to other children, an immature immune system, and exposure to second-hand smoke. Stress, unhealthy diet, and lack of exercise predispose young- and middle-age adults to multiple cardiopulmonary risk factors.
A client with a diagnosis of myocardial infarction asks the nurse, 'What is causing the pain I am having?' Which explanation would the nurse give? 1. Compression of the heart muscle 2. Release of myocardial isoenzymes 3. Rapid vasodilation of the coronary arteries 4. Inadequate oxygenation of the myocardium
Answer: 4. Inadequate oxygenation of the myocardium Rationale: Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.
Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1. Emptying the drainage system when full 2. Keeping the drainage system at heart level 3. Notifying the health care provider of drainage greater than 50 mL/h 4. Marking the time on the drainage unit every shift 5. Laying the drainage system on its side during transport
Answer: 4. Marking the time on the drainage unit every shift Rationale: The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. Emptying the system would break sterility. The drainage system should remain below chest level to prevent fluid from backing up into the lungs. The nurse would notify the health care provider if drainage is greater than 100 mL/h. The nurse would keep the drainage system upright.
Which is the optimal area for the nurse to assess adequate tissue oxygenation in an African-American neonate? 1. Heels and buttocks 2. Upper tips of the ears 3. Nail beds on the hands and feet 4. Mucous membranes of the mouth
Answer: 4. Mucous membranes of the mouth Rationale: Lack of skin pigmentation on the surfaces of the mucous membranes makes this the best area in which to assess this neonate's tissue oxygenation. Heels and buttocks are usually highly pigmented areas, and the buttocks often have Mongolian spots. The tips of the ears will indicated skin color later in life. Because most neonates' hands and feet exhibit acrocyanosis, the nail beds may be cyanotic as well.
The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? 1. Decreases chest pain 2. Conserves energy 3. Increases oxygen saturation 4. Promotes elimination of CO2
Answer: 4. Promotes elimination of CO2 Rationale: Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.
After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding? 1. Dull 2. Flat 3. Tympanic 4. Resonance
Answer: 4. Resonance Rationale: Resonance is a low-pitched hollow sound normally heard over the air-filled lungs during percussion in healthy individuals. Dullness is a medium-pitched 'thud-like' sound that might be heard with problems like lung consolidation due to pneumonia. Flatness is a high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds are high-pitched and musical; tympany might be heard over a pneumothorax.
A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? 1. Ventricular fibrillation and decreased perfusion 2. Dysfunction of the vagus nerve with hiccups 3. Retention of sensation but paralysis of the lower extremities 4. Respiratory paralysis and cessation of diaphragmatic contractions
Answer: 4. Respiratory paralysis and cessation of diaphragmatic contractions Rationale: The phrenic nerve innervates the diaphragm. A crushing spinal cord injury above the cervical plexuses, the level of phrenic nerve origin, results in respiratory paralysis. Cardiac activity will not be affected; the heart is regulated by the autonomic nervous system fibers originating in the medulla. Activities regulated by the vagus nerve will be unaffected; the vagus nerve originates in the medulla, which is superior to the cervical region; the phrenic nerves originate from the cervical plexuses. In a crushing spinal cord injury, both motor and sensory conduction are affected.
Which disease is caused by coronaviruses? 1. Pertussis 2. Inhalation anthrax 3. Coccidioidomycosis 4. Severe acute respiratory syndrome
Answer: 4. Severe acute respiratory syndrome Rationale: Severe acute respiratory syndrome is a respiratory infection caused by coronaviruses. Pertussis is caused by the bacterium Bordetella pertussis. Inhalation anthrax is caused by Bacillus anthracis. Coccidioidomycosis is caused by Coccidioides.
Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy? 1. Urinary retention 2. Signs of restlessness 3. Decreased blood pressure 4. Signs of respiratory obstruction
Answer: 4. Signs of respiratory obstruction Rationale: The first and most important observation should be for respiratory obstruction. If this occurs, treatment must be instituted immediately. Urinary retention is a later concern; urinary retention will not occur in the immediate postoperative period. Signs of restlessness may result from anesthesia; however, it is not life threatening and usually passes. The blood pressure is not significantly affected by this type of surgery; however, surgery itself can influence blood pressure. If the blood pressure significantly increases, other symptoms of thyroid crisis (storm) will be present.
A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition would the nurse expect? 1. Hypoventilation 2. Biot respiration 3. Kussmaul's respiration 4. Cheyne-Stokes respiration
Kussmaul's respiration is an alteration in the berathing process characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration
