NUR 407 EXAM #3 EAQ QUESTIONS

The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment?

A mediastinal shift may have occurred

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis?

1) dyspnea 2) diaphoresis 3) tachycardia

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning?

1. Dullness can be percussed over a consolidated lung. 2. Tympanic notes over the lung usually indicate a large pneumothorax 3. Flatness percussed over the lung fields indicates massive pleural effusion

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus should the nurse assess the client?

1. Increased temperature 2. Decreased oxygen saturation level 3. Sudden onset of shortness of breath

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock?

1. Tachycardia 2. Restlessness 3. Decreased Urinary Output

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism?

1. The test involves the administration of a contrast medium. 2. Clients should have their hydration levels assessed. 3. Clients are instructed to lie still on a hard table.

A client is prescribed albuterol to relieve severe asthma. What adverse effect will the nurse instruct the client to anticipate?

1. Tremors 2. Palpitations

A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following?

1. Urinary Output 2. Serum Potassium Level 3. Patency of IV access

An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in a bed with the head of the bed elevated and administers oxygen by means of a face mask. The healthcare provider performs a physical assessment, writes prescriptions, and admits the child to the pediatric unit. Which instruction should the nurse carry out first?

Administer the nebulizer treatment

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client?

Altered mental status

What client response must the nurse monitor to determine the effectiveness of amiodarone?

Decrease in cardiac dysrhythmias

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do?

Discontinue or decrease the oxygen flow rate

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do?

Drain the fluid from the tubing

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation?

Early, unexplained restlessness

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which should the nurse monitor for when assessing for this complication?

Elevated hemoglobin

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status?

Encouraging increased fluid intake

Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction?

Forced expiratory volume/forced vital capacity ratio

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the healthcare provider, which action should the nurse take?

Give oxygen at 2 L per minute via nasal cannula

A client is receiving dexamethasone to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client?

Increased blood glucose

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?

Increased restlessness

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff?

Inflate the cuff before the feeding and for 30 minutes after each feeding

Which statement appropriately describes tidal volume?

It is the volume of air inhaled and exhaled with each breath

An unconscious school-aged child is admitted to the pediatric intensive care unit with a closed head injury. Arterial and central venous pressure lines, an indwelling urinary catheter, and a nasogastric tube are inserted. What is the nurse's primary goal for this child?

Limitation of stimuli that increase intracranial pressure

The nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids?

Maintain blood volume

What teaching must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?

Medications must be continued even when the child is asymptomatic

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what?

Opening collapsed alveoli and keeping them open

The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance test. What information should the nurse consider before replying?

Pancreatic scarring predisposes the child to diabetes.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP)

A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention?

Audible wheezing

A client who is obtunded has a blood pressure of 80/35 mm Hg after a blood transfusion. In an effort to support renal perfusion, the nurse administers dopamine at 2 mcg/kg/min as prescribed. What is the most relevant outcome indicating effectiveness of the medication for this client?

An increased urinary output

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction Occurs

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention?

Assess vital signs

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?

Cold, clammy skin

Three weeks after having a laryngectomy a client asks about what to do if the laryngectomy tube becomes dislodged. An appropriate nursing response is to instruct the client to take which action?

Reinsert another tube as soon as possible

A nurse is caring for a child with a diagnosis of cystic fibrosis. Which schedule of chest physiotherapy (CPT) is best?

Three times a day, halfway between meal