Exam 1

Multiple Choice 17. The nurse is caring for a client who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? A. Cardiac monitoring B. Monitoring the implanted device signal C. Pain assessment D. Monitoring the client's level of consciousness (LOC)

A Rationale: Following catheter ablation therapy, the client is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? A. Early ambulation B. Increased dietary intake of protein C. Maintaining the client in a supine position D. Administering aspirin with warfarin

A Rationale: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding. PTS: 1 REF: p. 535 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is caring for a client with a history of endocarditis. Which topic would the nurse prioritize during health promotion education? A. Oral hygiene B. Physical activity C. Dietary guidelines D. Fluid intake

A Rationale: For clients with endocarditis, regular professional oral care combined with personal oral care may reduce the risk of bacteremia. In most cases, diet and fluid intake do not need to be altered. Physical activity has broad benefits, but it does not directly prevent complications of endocarditis. PTS: 1 REF: p. 786 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. Which classification of clients would be at greatest risk for hospital-acquired endocarditis? A. Hemodialysis clients B. Clients on immunoglobulins C. Clients who undergo intermittent urinary catheterization D. Children under the age of 12

A Rationale: Hospital-acquired infective endocarditis occurs most often in clients with debilitating disease or indwelling catheters and in clients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Clients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Clients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis. PTS: 1 REF: p. 785 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 33. The nurse is caring for a client who is in the recovery room following the implantation of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse assess and document? A. ECG to compare time of onset of VT and onset of device's shock B. ECG so health care provider can see what type of dysrhythmia the client has C. Client's level of consciousness (LOC) at the time of the dysrhythmia D. Client's activity at time of dysrhythmia

A Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset. PTS: 1 REF: p. 721 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

A Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration. PTS: 1 REF: p. 594 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax? A. Diminished or absent breath sounds on the affected side B. Paradoxical chest wall movement with respirations C. Sudden loss of consciousness D. Muffled heart sounds

A Rationale: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade. PTS: 1 REF: p. 581 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? A. Maintaining a patent airway B. Preventing the need for suctioning C. Maintaining the sterility of the client's airway D. Increasing the client's lung compliance

A Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent. PTS: 1 REF: p. 566 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. A client is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the client's pacemaker? A. Monitoring for pacemaker malfunction or battery failure B. Determining when it is appropriate to remove the pacemaker C. Making necessary changes to the pacemaker settings D. Selecting alternatives to future pacemaker use

A Rationale: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are health care provider responsibilities. PTS: 1 REF: p. 715 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? A. Incentive spirometry B. Intermittent positive-pressure breathing (IPPB) C. Positive end-expiratory pressure (PEEP) D. Bronchoscopy

A Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used. PTS: 1 REF: p. 530 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

A Rationale: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 40. The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 13. While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care? A. Administer an analgesic before coughing and deep breathing. B. Ambulate the client at least three times daily. C. Arrange for a soft-textured diet and increased fluid intake. D. Encourage the client to speak as little as possible.

A Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Because deep breathing and coughing prevent atelectasis, the client should be given an analgesic prior to performing these respiratory exercises. A soft diet is not necessarily indicated, and there is no need for the client to avoid speaking. Ambulation has multiple benefits, but pain management is not among them. PTS: 1 REF: p. 554 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable vital signs and arterial blood gases (ABGs) B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGs D. Normal level of consciousness

A Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have a normal level of consciousness. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? A. Defibrillation B. ECG monitoring C. Implantation of a cardioverter defibrillator D. Angioplasty

A Rationale: Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia. PTS: 1 REF: p. 707 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? A. Initiate chest physiotherapy. B. Immobilize the ribs with an abdominal binder. C. Prepare the client for surgery. D. Immediately sedate and intubate the client.

A Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury. PTS: 1 REF: p. 591 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this client is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B. Administer atropine as a continuous infusion until symptoms resolve. C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D. Administer atropine 1.0 mg sublingually.

A Rationale: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 36. A postoperative cardiac client experiences signs and symptoms of cardiac tamponade. Which action by the nurse would be most appropriate? A. Prepare to assist with pericardiocentesis. B. Reposition the client into a prone position. C. Administer a dose of metoprolol as prescribed. D. Administer a bolus of normal saline as prescribed.

A Rationale: Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not relieve the pressure on the heart and prone positioning would likely exacerbate symptoms. PTS: 1 REF: p. 788 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 22: Management of Patients with Arrhythmias and Conduction Problems 1. The nurse is caring for a client who has had an ECG. The nurse notices that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A. Recognize that the view of the electrical current changes in relation to the lead placement. B. Recognize that the electrophysiological conduction of the heart differs with lead placement. C. Inform the technician that the ECG equipment has malfunctioned. D. Inform the health care provider that the client is experiencing a new onset of dysrhythmia.

A Rationale: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias. PTS: 1 REF: p. 692 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 13. The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication? A. Epinephrine 1 mg IV push B. Lidocaine 100 mg IV push C. Amiodarone 300 mg IV push D. Sodium bicarbonate 1 amp IV push

A Rationale: Epinephrine should be given as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists. PTS: 1 REF: p. 714 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex

B Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa. PTS: 1 REF: p. 559 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A. "Cardioversion is done on a beating heart; defibrillation is not." B. "The difference is the timing of the delivery of the electric current." C. "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D. "Cardioversion is always attempted before defibrillation because it has fewer risks."

B Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart? A. P wave B. T wave C. U wave D. QRS complex

B Rationale: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 21. The nurse is caring for a client with complex cardiac history. How should the nurse best explain the process of depolarization to a colleague? A. Mechanical contraction of the heart muscles B. Electrical stimulation of the heart muscles C. Electrical relaxation of the heart muscles. D. Mechanical relaxation of the heart muscles

B Rationale: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole. PTS: 1 REF: p. 691 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Choice 5. A client with pericarditis has just been admitted to the critical care unit. The nurse planning the client's care should prioritize which nursing diagnosis? A. Anxiety related to pericarditis B. Acute pain related to pericarditis C. Ineffective tissue perfusion related to pericarditis D. Ineffective breathing pattern related to pericarditis

B Rationale: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment. PTS: 1 REF: p. 789 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Perform chest auscultation. D. Monitor incentive spirometry volumes.

B Rationale: The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status. PTS: 1 REF: p. 540 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? A. Facilitation of long-term intubation B. Restoration of adequate gas exchange C. Attainment of effective coping D. Self-management of oxygen therapy

B Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated. PTS: 1 REF: p. 556 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A. Sputum production B. Shortness of breath C. Throat discomfort D. Epistaxis

B Rationale: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in the health care facility and at home involves monitoring the client for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication. PTS: 1 REF: p. 492 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test? A. Echocardiography B. Blood cultures C. Cardiac aspiration D. Full blood count

B Rationale: To help determine the causative organisms and the most effective antibiotic treatment for the client, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test. PTS: 1 REF: p. 786 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the treatment has what main goal? A. Decrease SA node conduction. B. Control ventricular heart rate. C. Improve oxygenation. D. Maintain anticoagulation.

B Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin. PTS: 1 REF: p. 700 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A. Apply the paddles directly to the client's skin. B. Use a conducting medium between the paddles and the skin. C. Always use a petroleum-based gel between the paddles and the skin. D. Any available liquid can be used between the paddles and the skin.

B Rationale: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 13. A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath after a prolonged episode of coughing. On assessment, the nurse notes an oxygen saturation of 84%, asymmetrical chest movement, and decreased breath sounds on the right side. Which condition should the nurse suspect and which interventions should the nurse implement based on these signs and symptoms? A. Expected response to coughing; give supplemental oxygen and encourage deep breathing exercises B. Pneumothorax; give supplemental oxygen and continue to monitor the client C. Oxygen toxicity; lower any supplemental oxygen and continue to monitor the client D. Chronic atelectasis; give supplemental oxygen and encourage deep breathing exercises

B Rationale: Development of a pneumothorax, a potentially life-threatening complication of COPD, may be spontaneous or related to severe coughing or large intrathoracic pressure changes. The combination of asymmetry of chest movement, differences in breath sounds, and a decreased pulse oximetry are indications of pneumothorax. In response, the nurse should administer supplemental oxygen and continue close bedside monitoring of this client. The signs and symptoms described are not normal findings after coughing or due to chronic atelectasis (alveolar collapse). While a decrease in saturation is expected after coughing, due to irritation of airways and decreased ability to fully oxygenate, the saturation was lower than expected. Oxygen toxicity occurs when too high of a concentration of oxygen is given over a period of time, which triggers a severe inflammatory response. Because no specific duration or amount of oxygen was listed and a hallmark of this condition is substernal discomfort and progressive respiratory difficulties, this was an unlikely choice. PTS: 1 REF: p. 623 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply. A. Coping B. Level of consciousness C. Oral intake D. Arterial blood gases E. Vital signs

B, D, E Rationale: Trauma clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment but would become more important later during recovery. PTS: 1 REF: p. 590 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is caring for a client who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A. Assessing the client's mobility B. Facilitating transthoracic echocardiography C. Vigilant monitoring of the client's ECG D. Close monitoring of the client's peripheral perfusion

C Rationale: After a permanent electronic device (pacemaker or ICD) is inserted, the client's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and mobility because the consequences of abnormalities are more serious. Echocardiography is not indicated. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A client is undergoing testing to assess for a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? A. Increased tactile fremitus, egophony, and the chest wall dull on percussion B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion

C Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion. PTS: 1 REF: p. 484 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A 62-year-old client with atrial fibrillation and a CHA2DS2-VASC score of 3 is being discharged home today. Based on this score, which additional medications or medications would be prescribed for this client? A. No antithrombotic therapy, oral anticoagulant or aspirin B. Low molecular weight heparin or intravenous heparin C. Warfarin, direct thrombin inhibitor, or factor Xa inhibitor D. Antiarrhythmic agents and aspirin

C Rationale: Clients with atrial fibrillation are assessed for the risk of stroke using the mnemonic CHA2DS2-VASC with age, sex, and medical history determining a score. With a score of zero, clients may choose no antithrombotic therapy. With a score of 1, the client may choose no therapy, oral anticoagulant or aspirin. With a score of 2 or greater in men or 3 or greater in women, clients may choose warfarin, direct thrombin, or factor Xa inhibitor. Heparin can be used as a short-term or immediate anticoagulation medication and is not used as part of this scoring process. And intravenous heparin is not typically used in a home setting for prevention. The antiarrhythmic medication treats atrial fibrillation and is not part of the scoring process. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 20. A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? A. Pneumoconiosis B. Pleural effusion C. Acute respiratory failure D. Pneumonia

C Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms. PTS: 1 REF: p. 556 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is planning discharge teaching for a client with a newly inserted permanent pacemaker. What is the priority teaching point for this client? A. Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B. Avoid cooking with a microwave oven. C. Avoid exposure to strong electromagnetic fields D. Avoid walking through store and library antitheft devices.

C Rationale: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows clients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so clients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 24: Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders 1. A client with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the client to exhibit which heart rhythm? A. Ventricular fibrillation (VF) B. Ventricular tachycardia (VT) C. Atrial fibrillation D. Sinus bradycardia

C Rationale: In clients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation caused by strain on the atrium. Bradycardia, VF, and VT are not characteristic of this valvular disorder. PTS: 1 REF: p. 768 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, which nursing diagnosis is most appropriate? A. Risk for acute pain B. Risk for unilateral neglect C. Risk for activity intolerance D. Risk for fluid volume excess

C Rationale: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A. P wave B. T wave C. QRS complex D. U wave

C Rationale: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 29. The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A. Increased blood pressure B. Bounding peripheral pulses C. Changes in level of consciousness D. Skin flushing

C Rationale: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected. PTS: 1 REF: p. 710 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. PTS: 1 REF: p. 596 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

C Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 31. The nurse is caring for a client with acute pericarditis. Which nursing management would be instituted to minimize complications? A. The nurse keeps the client isolated to prevent nosocomial infections. B. The nurse encourages coughing and deep breathing. C. The nurse helps the client with activities until the pain and fever subside. D. The nurse encourages increased fluid intake until the infection resolves.

C Rationale: To minimize complications, the nurse helps the client with activity restrictions until the pain and fever subside. As the client's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the client isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary. PTS: 1 REF: p. 789 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse would discuss the importance of antibiotic prophylaxis prior to which event? A. Exposure to immunocompromised individuals B. Future hospital admissions C. Dental procedures D. Live vaccinations

C Rationale: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed. PTS: 1 REF: p. 786 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. A client with a history of rheumatic heart disease knows that the client is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which drug? A. Enoxaparin B. Metoprolol C. Azathioprine D. Amoxicillin

D Rationale: Although rare, bacterial endocarditis may be life threatening. A key strategy is primary prevention in high-risk clients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic. PTS: 1 REF: p. 785 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. An ECG has been ordered for a newly admitted client. What should the nurse do prior to electrode placement? A. Clean the skin with povidone-iodine solution. B. Ensure that the area for electrode placement is dry. C. Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D. Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

D Rationale: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used. PTS: 1 REF: p. 692 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. The nurse is assessing a client who had a pacemaker implanted 4 weeks ago. During the client's most recent follow-up appointment, the nurse identifies data that suggest the client may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A. Decisional conflict related to pacemaker implantation B. Deficient knowledge related to pacemaker implantation C. Spiritual distress related to pacemaker implantation D. Ineffective coping related to pacemaker implantation

D Rationale: Depression and isolation may be symptoms of ineffective coping with the implantation. These psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be needed to determine a spiritual component to the client's challenges. PTS: 1 REF: p. 721 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 33. A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

D Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? A. Maintain firm contact between paddles and the client's skin. B. Apply a layer of water as a conducting agent. C. Call "all clear" once before discharging the defibrillator. D. Ensure the defibrillator is in the sync mode.

A Rationale: When defibrillating an adult client, the nurse should maintain good contact between the paddles and the client's skin. To prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear'' should be called three times before discharging the paddles. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiologic state? A. The client's tissue demands may be met, but the client will be unable to respond to physiological stressors. B. The client's short-term oxygen needs will be met, but the client will be unable to expel sufficient CO2. C. The client will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D. The client will experience respiratory alkalosis with no ability to compensate.

A Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiologic stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results. PTS: 1 REF: p. 470 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client's sternum. This client's health record should note the presence of what chest deformity? A. A barrel chest B. A funnel chest C. A pigeon chest D. Kyphoscoliosis

B Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax. PTS: 1 REF: p. 477 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 37. The nurse is auscultating the breath sounds of a client with pericarditis. Which finding is most consistent with this diagnosis? A. Wheezes B. Friction rub C. Fine crackles D. Coarse crackles

B Rationale: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis. PTS: 1 REF: p. 789 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders 1. A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism

B Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing. PTS: 1 REF: p. 527 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is performing a respiratory assessment of a client who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A. An appropriate perfusion-diffusion ratio B. An adequate ventilation-perfusion ratio C. Adequate diffusion of gas in shunted blood D. Appropriate blood nitrogen concentration

B Rationale: Adequate gas exchange depends on an adequate ventilation-perfusion ratio. There is no perfusion-diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen. PTS: 1 REF: p. 468 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 29. A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. Which other supportive measure should be initiated in this client? A. Psychological counseling B. Nutritional support C. High-protein oral diet D. Occupational therapy

B Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS. PTS: 1 REF: p. 572 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B Rationale: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client? A. Chest pain B. Bleeding at the implantation site C. Malignant hyperthermia D. Bradycardia

B Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration. PTS: 1 REF: p. 717 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? A. Carboxyhemoglobin level B. Brain natriuretic peptide (BNP) level C. C-reactive protein (CRP) level D. Complete blood count

B Rationale: Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem. PTS: 1 REF: p. 572 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? A. Core body temperature B. Heart rate and rhythm C. Blood pressure D. Oxygen saturation level

B Rationale: For clients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. The nurse caring for a client whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this client? A. Implanted pacemaker B. Transcutaneous pacemaker C. ICD D. Asynchronous defibrillator

B Rationale: If a client suddenly develops bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief. PTS: 1 REF: p. 716 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A. Place gel pads over the apex and posterior chest for better conduction. B. Ensure no one is touching the client at the time shock is delivered. C. Continue to ventilate the client via endotracheal tube during the procedure. D. Allow at least 3 minutes between shocks.

B Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the client's skin to prevent leaking. Second, ensure that no one is in contact with the client or with anything that is touching the client when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the client. Ventilation should be stopped during defibrillation. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A. A chest tube B. A tracheostomy C. An endotracheal tube D. A feeding tube

B Rationale: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction. PTS: 1 REF: p. 598 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client with an ICD calls the cardiologist's office and talks to the nurse. The client is concerned about being defibrillated too often. The nurse tells the client to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what issue? A. Infection B. Failure to capture C. Premature battery depletion D. Oversensing of dysrhythmias

D Rationale: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common. PTS: 1 REF: p. 718 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A client is being treated for a pulmonary embolism, and the medical nurse is aware that the client experienced an acute disturbance in pulmonary perfusion. This involved an alteration in which aspect of normal physiology? A. Maintenance of constant osmotic pressure in the alveoli B. Maintenance of muscle tone in the diaphragm C. pH balance in the pulmonary veins and arteries D. Adequate flow of blood through the pulmonary circulation.

D Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure. PTS: 1 REF: p. 466 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. A group of nurses is participating in orientation to a telemetry unit. The nurse who is providing the education should tell the class that ST segments: A. are the part of an ECG that reflects systole. B. are the part of an ECG used to calculate ventricular rate and rhythm. C. are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D. represent early ventricular repolarization.

D Rationale: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 32. The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate? A. Keep the client in a low Fowler position. B. Perform tracheostomy care at least once per day. C. Maintain continuous bed rest. D. Monitor cuff pressure every 8 hours.

D Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours, not once per day, because of the risk of infection. The client should be encouraged to ambulate, if possible, not maintain continuous bed rest, and a low Fowler position is not indicated. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client is scheduled to have excess pleural fluid aspirated with a needle to relieve dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? A. It allows for full expansion of the lungs within the thoracic cavity. B. It prevents the lungs from collapsing within the thoracic cavity. C. It limits lung expansion within the thoracic cavity. D. It lubricates the movement of the thorax and lungs.

D Rationale: The pleural fluid, located between two membranes known as the visceral pleura (which cover the lungs) and the parietal pleura (which line the thorax), serves to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleural fluid does not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity. PTS: 1 REF: p. 465 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 31. The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A. Cognition is decreased. B. Daily arterial blood gases (ABGs) are necessary. C. Slight tracheal bleeding is anticipated. D. The cough reflex is depressed.

D Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze