General Evolve HESI Elsevier

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? 1 Pleural friction rub 2 Tracheoesophageal fistula 3 Rupture of a subpleural bleb 4 Puncture wound of the chest wall

Rupture of a subpleural bleb The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air. Pleural friction rub results in pain on inspiration, not a pneumothorax. A tracheoesophageal fistula causes aspiration of food and saliva, resulting in respiratory distress. The client has no history of trauma.

A tracheostomy is performed on a client in respiratory distress. How should the nurse position the patient following the procedure? 1 Supine 2 Orthopneic 3 High-Fowler Correct4 Semi-Fowler

Semi-Fowler

The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply. Incorrect 1 "I will eat a bland diet." Correct 2 "I will not drink fluids when I eat meals." Correct 3 "I will eat small, frequent meals instead of three large meals a day." 4 "I will eat a low-protein, high-carbohydrate diet." Correct 5 "I will avoid sweetened and spicy foods."

"I will not drink fluids when I eat meals." "I will eat small, frequent meals instead of three large meals a day." "I will avoid sweetened and spicy foods."

After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client states, "I feel like I am walking like a drunken seaman." The nurse withholds the drug and promptly reports the problem to the health care provider. Which part of the body does the nurse determine is being affected as indicated by the symptom reported by the client? 1 Pyramidal tracts 2 Cerebellar tissue 3 Peripheral motor end-plates 4 Eighth cranial nerve's vestibular branch

Eighth cranial nerve's vestibular branch Streptomycin sulfate is ototoxic and may cause damage to auditory and vestibular portions of the eighth cranial nerve. Pyramidal tracts, cerebellar tissue, and peripheral motor end-plates are not affected by streptomycin. Test-Taking Tip: Bring to your test prep a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess this client? Incorrect1 Aphasia 2 Dyspnea 3 Dysphagia Correct4 Hoarseness

Hoarseness Hoarseness is caused by the inability of the vocal cords to move adequately during speech when a tumor exists. Aphasia refers to an expressive or receptive communication deficit as a result of cerebral disease; it is not related to laryngeal cancer. Dyspnea is a late, not early, adaptation that occurs with laryngeal cancer when a tumor is large enough to obstruct air flow. Dysphagia is a late, not early, adaptation that occurs when the tumor is large enough to compress the esophagus.

A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, the nurse instructs the client to: Correct1 Eat small meals six times a day to limit oxygen needs 2 Drink large amounts of fluid to help liquefy secretions 3 Lie down after eating to conserve energy needed for digestion

Increase the intake of protein to decrease intravascular hydrostatic pressure Eating small meals will decrease the amount of oxygen necessary for ingestion and digestion at any one time; a small volume of food in the stomach will not impede the downward movement of the diaphragm during inhalation. Although fluids can help liquefy secretions, they should not be encouraged for a client with heart failure. Lying down increases intraabdominal pressure, pushing a full stomach against the diaphragm and limiting respiratory excursion. Protein maintains or increases hydrostatic pressure; it does not decrease it.

A nurse is notified that a victim of a gunshot wound to the right side of the chest is being transported to the emergency department. To prepare for the client, the priority nursing intervention is to: 1 Reserve an operating room 2 Obtain equipment for a tracheotomy 3 Arrange for a portable x-ray examination

Obtain equipment for chest tube insertion The priority is to stabilize the respiratory status; a chest tube should be inserted. Open pneumothorax is the most likely result of penetrating chest trauma. It occurs when there's a large defect in the chest wall that allows air to move freely between the pleural space and the atmosphere. If not managed quickly and appropriately, an open pneumothorax can lead to hypoxia and hypercarbia. Chest tube insertion is the typical treatment for an open pneumothorax. The client must be stabilized before surgery; this may be necessary later. To maintain the airway an endotracheal tube will be inserted. Arranging for a portable x-ray examination is secondary to stabilizing respirations.

Within the first 2½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first? 1 Obtain the vital signs. 2 Notify the health care provider. 3 Chart the amount on the intake & output (I&O) record. 4 Continue to monitor the amount for another 2½ hours

Obtain the vital signs

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises? 1 Spend more time inhaling than exhaling to blow off carbon dioxide Correct2 Perform diaphragmatic exercises to improve contraction of the diaphragm 3 Perform sit-ups to strengthen abdominal muscles to improve breathing 4 Use abdominal exercises to limit the use of accessory muscles of respiration

Perform diaphragmatic exercises to improve contraction of the diaphragm With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable. Longer expiration, not inhalation, facilitates removal of carbon dioxide. Sit-ups are too strenuous for clients with emphysema. The abdominal muscles are accessory muscles of respiration, and their contraction and relaxation are enhanced in diaphragmatic breathing.

Methods for temporary pacing include: Select all that apply 1 Transcutaneous pacing. 2 Transvenous pacing. 3 Implantable cardioverter defibrillators (ICDs). 4 Epicardial pacing. 5 Biventricular pacing.

Transcutaneous pacing Transvenous pacing. Epicardial pacing