PN 2 Exam #2

You are taking care of a pt who you suspect to have COPD, which early manifestation lead you to believe they have COPD? A. Cough upon waking with sputum B. Arrhythmias C. Clubbed fingers D. Cyanotic digits

A. Rationale: A productive cough with sputum upon waking up in the morning is an early manifestation of COPD. Clubbed fingers are a sign of COPD but this is a later sign once the body compensates by producing extra RBC's which will result in the clubbed fingers.

The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands teaching concerning the DASH diet? A. "I should eat at least four (4) to five (5) servings of vegetables a day". B. "I should eat meat that has a lot of white streaks in it." C. "I should drink no more than two (2) glasses of whole milk a day." D."I should decrease my grain intake to no more than twice a week."

A. "I should eat at least four (4) to five (5) servings of vegetables a day". Rationale: The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? A. "I will eat enough daily fiber to prevent straining at stool." B. "I will try to exercise vigorously to strengthen my heart muscle." C. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." D. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

A. "I will eat enough daily fiber to prevent straining at stool." Rationale: Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

Which dose of oxygen would be safest for a patient with emphysema? A. 35% by face mask. B. 2 L per minute by nasal cannula. C. 100% by non-rebreather face mask. D. 10 L per minute by nasal cannula.

A. 35% by face mask.

Which suggestions should the nurse include when conducting health teaching for clients with arterial insufficiency? Select all that apply. A. Avoid long periods of sitting and standing. B. Keep the legs and feet in a raised position. C. Decrease ambulation to decrease pain. D. Apply moist heat twice a day. E. Increase distances walked to build collateral circulation.

A. Avoid long periods of sitting and standing. E.Increase distances walked to build collateral circulation. Rationale: The client should avoid long periods of standing or sitting to promote adequate blood flow. The client with arterial insufficiency should engage in a walking program as prescribed by the healthcare provider to build collateral circulation and slow progression of the disease. The legs and feet should be below heart level to increase peripheral circulation. Decreasing ambulation inhibits the development of collateral circulation and will not help in disease management. Moist heat is helpful for venous problems, but direct heat to the extremity affected by arterial insufficiency could place the skin at risk for burns because of preexisting local hypoxia and friable tissue

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply. A. Avoid potential environmental asthma triggers such as smoke. B. Use the inhaler 30 minutes before exercising to prevent bronchospasm. C. Wash all bedding in cold water to reduce and destroy dust mites, D. Be sure to get at least 8 hours of rest and sleep every night. E. Avoid foods prepared with monosodium glutamate (MSG). F. Keep a symptom and intervention diary to learn specific trigger for your asthma.

A. Avoid potential environmental asthma triggers such as smoke. B. Use the inhaler 30 minutes before exercising to prevent bronchospasm. D. Be sure to get at least 8 hours of rest and sleep every night. E. Avoid foods prepared with monosodium glutamate (MSG). F. Keep a symptom and intervention diary to learn specific trigger for your asthma. Rationale: Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a pateint with a new diagnosis of asthma.

An ambulance brings a client with audible sucking noises on both inspiration and expiration and diminished breath sounds on the left side. What should the nurse start preparing for? A. Chest tube insertion B. Humidified O2 C. Arterial blood gas draw D. Rapid fluid infusion

A. Chest tube insertion

A Patient asks the nurse how he developed chronic obstructive pulmonary disease (COPD). Which of the following would be the best response for the nurse to make to this client? A. Cigarette smoking is the number one cause of COPD. B. COPD is caused from asthma. C. COPD is caused from working in an industrial environment. D. Once diagnosed with COPD, quitting smoking won't help the disease.

A. Cigarette smoking is the number one cause of COPD. Rationale: The number one risk factor for the development of COPD is cigarette smoking. Individuals with asthma can develop COPD; however, it is not the number one cause of the illness. COPD can develop from working in an industrial environment; however, the chance of that occurring is small. Once diagnosed with COPD, quitting smoking will help, and the client should be encouraged to do so to stop the progression of the disease.

Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes? A. Endocarditis B. Acute Renal failure C. Chronic thrombophlebitis D. Myocardial Infarction

A. Endocarditis

A provider is conducting a seminar to staff and to the community of some of the causes of community acquired pneumonia. She states there are a few to be aware of. What are they? Select all that apply A. Influenza B. Mycoplasma C. Streptococcus pneumoniae D. HIV

A. Influenza B. Mycoplasma C. Streptococcus pneumoniae

The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply. A. Notify the healthcare provider (HCP) if the client gains more than 2 lb in one day. B. Keep the head of the bed elevated when sleeping. C. Take the loop diuretic once a day before going to sleep. D. Teach the client which foods are high in sodium and should be avoided. E. Perform isotonic exercises at least once a day.

A. Notify the healthcare provider (HCP) if the client gains more than 2 lb in one day. B. Keep the head of the bed elevated when sleeping. D. Teach the client which foods are high in sodium and should be avoided. E. Perform isotonic exercises at least once a day. Rationale: A 2-lb weight gain indicates the client is retaining fluid and should contact the HCP. This is an appropriate teaching intervention; keeping the head of the bed elevated will help the client breathe easier; therefore, this is an appropriate teaching intervention; sodium retains water. Telling the client to avoid eating foods high in sodium is an appropriate teaching intervention; isotonic exercise, such as walking or swimming, helps tone the muscles, and discussing this with the client is an appropriate teaching intervention.

When planning care for a client receiving treatment for cardiac dysrhythmias, an appropriate client outcome would be: A. The client will avoid use of caffeine during therapy. B. The client will maintain heart rate below 60 beats per minute. C. The client will limit fluid intake to 1000 ml/day. D. The client will limit cigarettes to 15/day.

A. The client will avoid use of caffeine during therapy. RATIONALE: Causes of dysrhythmias include electrolyte imbalance, hyperthyroidism, anxiety, caffeine ingestion, and tobacco use. The client should be taught to avoid caffeine and tobacco.

An elderly female patient arrives in the emergency department complaining of fatigue, nausea, vague complaint of intermittent chest discomfort, and not sleeping well. The nurse would interpret these findings as symptoms of: A. Cardiac disease. B. Pancreatic disease. C. Normal changes of aging. D. Signs of anemia.

A.Cardiac disease. Rationale: Many elderly women complain of vague symptoms when having a myocardial infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia would present with fatigue but not with nausea or chest discomfort.

A Patient is admitted with complaints of SOB of 2 weeks duration. Which of the following laboratory findings would support the finding that the patient is at risk for an alteration in perfusion? A. Increased Hematocrit B. Decreased BUN C. Increased Blood sugar D. Increased sedimentation rate

A.Increased Hematocrit Rationale: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production. This can lead to an alteration in the client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Increases in blood sugar and sedimentation rate are not a direct measure of oxygen.

A client has just been admitted to the intensive care unit after having a left lower lobectomy via video-assisted thorascopic surgery. Which of these prescriptions will the nurse implement first? a.Titrate oxygen flow rate to keep O2 saturation at or greater than 93%. b.Administer 2 g of cephazolin IV now. c.Give morphine sulfate 4 to 6 mg IV for pain. d.Transfuse 1 unit of packed red blood cells (PRBCs) over 2 hours.

ANSWER A, Rationale: Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important. Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important, but is secondary to airway, breathing, and circulation. PRBCs to maintain the oxygen-carrying capacity of the blood will be performed after oxygenation. Pain medication and antibiotic administration will be performed last.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? a.Right pneumothorax b.Pulmonary embolism c.Displaced endotracheal tube Acute respiratory distress syndrome

ANSWER A, Rationale: Pneumothorax is characterized by relentless, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. And endotracheal tube that is inserted too far can cause absent breath sounds, but lack of breath sounds most likely would be on the left side because of the degrees of curvature of the right and left mainstem bronchi.

The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit? a.Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask b.Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour c.Client with emphysema who requires instruction about correct use of oxygen at home d.Client with lung cancer who has just been transferred from the intensive care unit after a left lower lobectomy yesterday

ANSWER A, Rationale: The charge nurse would assign the asthma client to the float pediatric nurse. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis. Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population. Although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? a.Obtain baseline vital signs and oxygen saturation b.Obtain a sputum culture c.Obtain a complete history from the client d.Provide a pneumococcal vaccine

ANSWER A. The first action the nurse should take using the nursing process is to assess the client, which is essential in planning client-centered care

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concertation, which oxygen delivery system would the nurse prepare for the client? a.Face tent b.Venturi mask c.Aerosol mask Tracheostomy collar

ANSWER B, Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as COPD, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? a.Gender b.Environmental allergies c.Alcohol use Race

ANSWER B. Environmental allergies are a risk factor associated with asthma. A client who has environmental allergies typically has other allergic problems, such as rhinitis or a skin rash.

A client with tuberculosis is being started on anti-tuberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? a.Electrolyte levels b.Coagulation times c.Liver enzyme levels Serum creatinine levels

ANSWER C, Rationale: Isoniazid therapy can cause elevation of hepatic enzyme levels and hepatitis. Therefore liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer is the client is older than 50 years old or abuses alcohol. The lab test for A, B, and D are not necessary.

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? a."This medication can increase my blood sugar levels". b."This medication can decrease my immune response". c."I can have an increase in my heat rate while taking this medication". d."I can have mouth sores while taking this medication".

ANSWER C. Bronchodilators, such as albuterol, can cause tachycardia

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? a.Dry cough b.Hematuria c.Bronchospasm Blood-streaked sputum

ANSWER C. If a biopsy was performed during a bronchoscopy, blood streaked sputum is expected for a several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a.Sitting up in bed b.Side-lying in bed c.Sitting in a recliner chair Sitting up and leaning on an overbed table.

ANSWER D. Rationale: Positions that will assist with breathing include sitting up and leaning on an overbed table, sitting up and resting elbows on the knees, and standing and leaning against the wall.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? A.The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B.The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C.The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL (10.1 mmol/L) D.The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg

ANSWER D. The questionable assignment made by the charge nurse is assigning the LPN/LVN with 20 years' experience to care for a client with a headache whose BP is 210/150 mm Hg. The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. This client must be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications. A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN. The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

The nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Select all that apply. a.Client who has dysphagia b.Client who has AIDS c.Client who was vaccinated for pneumococcus and influenza 6 months ago d.Client who is postoperative and has received local anesthesia e.Client who has a closed head injury and is receiving ventilation f.Client who has myasthenia gravis

ANSWERS : A. The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration B. The client who has AIDS is immunocompromised, which increases the risk of opportunistic infection, such as pneumonia E. Mechanical ventilation is invasive and increases the risk of pneumonia F. A client who has myasthenia gravis has generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. a.Hypocapnia b.A hyperinflated chest noted on the chest x-ray c.Decreased oxygen saturation with mild exercise d.A widened diaphragm noted on the chest x-ray e.Pulmonary function tests that demonstrate increased vital capacity

ANSWERS B, C. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respirations. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? Select all that apply. a.SaO2 95% b.Wheezing c.Retraction of sternal muscles d.Premature ventricular complexes (PVCs)

ANSWERS: B. Wheezing is a manifestation indicating the client's respiratory status is declining C. Retraction of sternal muscles is a manifestation that the client's respiratory status is declining D. PVC's are a manifestation that the client's respiratory status is declining

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? SELECT ALL THAT APPLY a.Activities should be resumed gradually. b.Avoid contact with other individuals, except family members, for at least 6 months c.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated d.Respiratory isolation is not necessary because family members already have been exposed e.Cover mouth and nose when coughing or sneezing and put used tissues is plastic bags. f.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

ANSWERS: A, C, D, and E. Rationale: The nurse should provide the client and family with information about TB and concerns about contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent reoccurrence of infection should be consumed. Respiratory isolation is not necessary because family members have already been exposed. Instruct client about thorough hand washing, to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

A client recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the client has correct understanding of the use of an inhaler with a spacer when the client states which of these? SELECT ALL THAT APPLY a."I don't have to wait a minute between the two puffs if I use a spacer." b."If the spacer makes a whistling sound, I am breathing in too rapidly." c."I should rinse my mouth and then swallow the water to get all of the medicine." d."I should shake the canister when I want to see whether it is empty." e."I should hold my breath for at least ten seconds after inhaling the medication."

ANSWERS: B, E Rationale: Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client should hold the breath for at least 10 seconds, however attempting to hold the breath for a minute is unnecessary and could pose a threat to oxygenation. The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. An empty inhaler will float on its side in water while a full inhaler will sink. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff.

Risk factors for decreased perfusion can be modifiable or nonmodifiable. Which factors are nonmodifiable? Select all that apply. A. Obesity B. Age C. Genetics D. Smoking E. Gender

B. Age C. Genetics E. Gender Rationale: Obesity and smoking can both be modifiable risk factors because they can be fixed with a change in life style. The correct answers- Age, genetics, and gender are nonmodifiable because they cannot be changed

Which of the following assessment findings would suggest to the nurse that a Patient is at risk for alterations in perfusion? A. Blood pressure 110/68 mmHgB. Apical heart rate 80; radial beats per minute 68C. Respiratory rate 20 per minuteD. Temperature 98.8°F

B. Apical heart rate 80; radial beats per minute 68. The number of radial beats per minute is 12 beats slower than the apical rate of 80 per minute. This indicates weak contractions of the left ventricle and could lead to alterations in perfusion. The other assessment findings are within normal limits.

A patient who has a diagnosis of chronic bronchitis is experiencing an acute exacerbation. Assessments include increasing dyspnea and a cough producing thick, purulent mucus. Which class of medications should the healthcare provider to administer first? A. Leukotriene Inhibitor B. Beta-2-Agonist C. Nonsteroidal Anti-inflammatory Agent D. Mucolytic

B. Beta-2-Agonist Rationale: During acute exacerbation of Chronic Bronchitis, the airways narrow and fill with mucus. A Beta-2-Agonist opens up the airways.

The swishing, turbulent sound heard through the stethoscope or Doppler probe as a result of blood trying to passed through a narrow artery is called? A. Arterial Pitch B. Bruit C. Murmur D. Arterial Closure

B. Bruit Rationale: This is common in a patient who has vascular disease, this sound is considered abnormal.

A client with myocardial infraction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds

B. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveal crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is crawling sound associated with laryngospasm or edema of the upper airway.

A client is diagnosed with left sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. a. Peripheral edema b. Crackles in both lungs c. Breathlessness d. Ascites e. Tachypnea

B. Crackles in both lungs C. Breathlessness E. Tachypnea

A nurse is taking care of a patient who is receiving digoxin for the treatment of heart failure. Which signs and symptoms should the nurse be concerned about upon assessment? A. Fatigue and rhabdomyolosis B. Nausea, abdominal discomfort, and visual disturbances C. Irritability and weight gain D. Constricted pupils and increased appetite

B. Nausea, abdominal discomfort, and visual disturbances Rationale: With digoxin toxicity, the first signs and symptoms of toxicity are nausea, abdominal pain, vomiting, and visual disturbances such as halos around lights. Main symptoms of digoxin toxicity affects your stomach, breathing, and vision.

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5mL/min by nasal cannula. Which finding concerns the nurse immediately? A. Fine bibasilar crackles B. Respiratory rate of 8 breaths/min C. The patient sitting up and leaning over the nightstand D. A large barrel chest

B. Respiratory rate of 8 breaths/min Rationale: For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in decreased respiratory rate If the nurse does not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema.

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? A. Blood Pressure B. Status of airway C. Oxygen flow rate D. Level of consciousness

B. Status of airway ● Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and levels of consciousness, and dysrhythmia detection.

The nurse has completed an assessment on a client with decreased cardiac output. Which findings should receive highest priority? A. BP 110/60, atrial fibrillation with HR 82, bibasilar crackles B. Confusion, urine output 15mL over the last 2 hours, orthopnea. C. SPO2 92% on 2L nasal cannula, respirations 20, 1+ edema of lower extremities. D. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

B.Confusion, urine output 15mL over the last 2 hours, orthopnea. Rationale: A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable

A patient is diagnosed with primary hypertension. When taking the patient's history, the healthcare provider anticipates the patient will report which of the following? A. "Every once in awhile I wake up at night covered in sweat." B. Sometimes I get pain in my lower legs when I take my daily walk. C. "I have not noticed any significant changes in my health." D. "I'm starting to get out of breath when I go up a flight of stairs."

C. "I have not noticed any significant changes in my health." Rationale: Primary hypertension is related to risk factors including age, culture, genetics and lifestyle. If caused by a new health condition, this would be secondary hypertension.

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? A. "Oxygen has a calming effect" B. "Oxygen will prevent the development of any thrombus." C. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." D. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

C. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." Rationale: The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. weight loss and dry skin B. flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure(CVP)

C. An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as over hydration or fluid or fluid over load and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, Tachypnea, Tachycardia, elevated blood pressure, bounding pulse, elevated cvp, weight gain, edema, neck and hand vein distention, altered level consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit

The nurse assessing a Patient admitted for a total hip replacement is concerned the Patient would be at risk for thrombus formation because of which of the following? A. Age 45 years B. Former cigarette smoker C. Body mass index (BMI) 35.8 D. Blood pressure 132/88 mmHg

C. Body mass index (BMI) 35.8 Rationale: Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code. B. Call the health care provider. C. Check the client's status and lead placement. D. Press the recorder button on the electrocardiogram console.

C. Check the client's status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole, electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.

A new healthcare provider is working on the telemetry unit of a hospital and notes in a patient's chart that he has cyanosis. When asking the new nurse what cyanosis means, the nurse best response would be: A. Cyanosis is a normal occurrence when the blood is highly oxygenated B. Cyanosis is an indication of low blood pressure C. Cyanosis occurs when the blood is not oxygenated causing the skin and mucous membranes to turn blue D. Cyanosis is a condition that occurs from the extremities being exposed to cold temperatures

C. Cyanosis occurs when the blood is not oxygenated causing the skin and mucous membranes to turn blue

The nurse teaches a patient with HTN that uncontrolled hypertension may damage organs in the body primarily by which of the following mechanisms? A. HTN causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. B. HTN increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions. C. HTN promotes atherosclerosis and damage to the walls of the arteries. D. HTN causes thickening of capillary membranes, leading to hypoxia of organ systems.

C. HTN promotes atherosclerosis and damage to the walls of the arteries.

A patient is admitted with a possible deep vein thrombosis. Nursing interventions should be implemented to prevent which complication?A. Myocardial infarctionB. Renal failureC. Pulmonary embolismD. Pneumonia

C. Pulmonary embolismRationale: The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development. There is less likelihood that the thrombosis would cause myocardial infarction, renal failure, or pneumonia.

Select the client who is at greatest risk for impaired vascular perfusion. A. A 76 year old female client who has a history of alcohol abuse. B. A 76 year old female client who has a history of radon gas exposure. C. A 64 year old male client who has a history of cigarette smoking. D. A 64 year old male client who has hypotension.

Correct Response: D. A 64 year old male client who has hypotension is at greatest risk for impaired vascular perfusion. Other risk factors associated with impaired vascular and tissue perfusion are: Hypervolemia Hypovolemia Low hemoglobin An immobilized limb Hypoxia Decreased cardiac output Diabetes Impaired oxygen transportation Hypoventilation Alcohol abuse, cigarette smoking and exposures to radon place people at risk for cancer, rather than impaired perfusion.

The healthcare provider is providing teaching on pleural effusions. The healthcare provider understands that teaching has been effective when the patient states: A. "A pleural effusion is accumulation of fluid in the airways of the lungs." B. "A pleural effusion is an accumulation of fluid in the alveoli." C. "A pleural effusion is an accumulation of blood in the airspace. D. "A pleural effusion is an accumulation of fluid in the pleural cavity."

D. "A pleural effusion is an accumulation of fluid in the pleural cavity."

The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse? A. "I have to go to the bathroom a lot during the morning." B. "I get up very slowly when I have been sitting for a while." C. "I do not salt my food when I am cooking it but I add it at the table." D. "I drink grapefruit juice every morning with my breakfast."

D. "I drink grapefruit juice every morning with my breakfast." Rationale: Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants intervention by the nurse.

The healthcare provider understands that teaching has been effective when the patient verbalizes the following regarding influenza vaccinations: A. "If I have already had the vaccine last year, it is not recommended that I get it again this year." B. "Since the vaccine is a live virus, I can expect to be ill for 4-7 days after receiving my vaccine." C. "Influenza vaccines are a cure for the flu." D. "The vaccine is an inactivated virus, but may cause some mild cold- like symptoms."

D. "The vaccine is an inactivated virus, but may cause some mild cold- like symptoms."

Upon monitoring a diagnostic test done for a patient admitted with heart failure, which specific finding is most consistent with this diagnosis? A. Potassium level of 3.4 mEq/L B. Chest X-ray indications showing consolidation of right upper lobe C. WBC level of 10,050/mm3 D. B-type natriuretic peptide of 560 pg/mL

D. B-type natriuretic peptide of 560 pg/mL Rationale: B-type natriuretic peptide (BNP) is made and released by ventricles when the patient has fluid overload as a result of heart failure; normal values for BNP is < 100 pg/mL. Hypokalemia may be due to diuretic therapy but may also occur do to other conditions.

In providing community education on prevention of peripheral arterial disease (PAD), the nurse should include which major risk factors? Select all that apply. A. Dysrhythmias B. Low-protein intake C. Exposure to cool weather D. Cigarette smoking E. Hypertension

D. Cigarette smoking E.Hypertension Rationale: Cigarette smoking promotes vasoconstriction and is a major risk factor for PAD. Hypertension is a major risk factor for the development of PAD. The presence of dysrhythmias is not a risk factor for PAD. Low protein intake is not a risk factor for PAD, although hyperlipidemia from the high fat intake or familial tendency is a risk factor. Exposure to cool weather is not a risk factor for PAD, although it could worsen the symptoms when the disease is already present

The type of heart failure where the cardiac output remains as normal or above normal causing an increase for metabolic needs is referred to as? A. Diastolic Heart Failure B. Systolic Heart Failure C. Right sided Heart Failure D. High output Heart Failure

D. High output Heart Failure Rationale: Metabolic needs or hyperkinetic conditions such as high fever, anemia and hyperthyroidism are associated along with high output heart failure

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign or acute respiratory distress syndrome (ARDS)? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retraction D. Increased respiratory rate

D. Increased respiratory rate

The nurse auscultates the blood pressure of a 71 year old patient admitted with pneumonia and finds it to be 160/70 mm Hg. Which of the following does the nurse consider to be an age-related change that contributes to this finding? A. Decreased adrenergic sensitivity B. Increased parasympathetic activity C. Stenosis of the heart valves D. Loss of elasticity in arterial vessels.

D. Loss of elasticity in arterial vessels.

A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings? A. Acute pericarditis B. Deep vein thrombosis (DVT) C. Peripheral artery disease D. Right ventricular failure

D. Right ventricular failure Rationale: Pulmonary valve dysfunction decreases blood flow to the lungs. Pulmonary valve dysfunction increases the workload of the right ventricle. A sign of right ventricular failure is peripheral edema.

The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? A. Being overweight. B. Sedentary lifestyle. C. High-fat, high cholesterol diet. D. Smoking cigarettes.

D. Smoking cigarettes. Rationale: Tobacco use is the strongest factor in the development of athersclerotic lesions.

A patient who has experienced atrial fibrillation for the past 33 days is admitted to the cardiac care unit. In addition to administering an antidysrhythmia medication, the healthcare provider should anticipate which of these orders? A. prepare the patient for AV node ablation B. prepare for immediate cardioversion C. give atropine IV push D. initiate a heparin infusion

D. initiate a heparin infusion Rationale: Because blood tends to pool and clot in the fibrillating atria, patients with atrial fibrillation are at high risk for embolic stroke, so heparin will be given.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? A. "I should notify my doctor if my feet or legs start to swell." B. "My doctor told me to call his office if my pulse rate decreases below 60." C. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." D. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

D."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with his or her spouse.

When assessing the arterial blood gases of a patient with a 20 year history of chronic bronchitis, which of these conditions would the clinician expect? A. Metabolic Alkalosis, Compensated B. Metabolic Acidosis, Uncompensated C. Respiratory Acidosis, Uncompensated D. Respiratory Acidosis, Compensated

D.Respiratory Acidosis, Compensated Rationale: The kidneys respond to acidosis by conserving bicarbonate, keeping the pH in a low-normal range, resulting in a state of compensated respiratory acidosis.

Your educating a patient how to use a peak flow meter to help monitor the status of their asthma. Which statement by the patient demonstrates they understand how to use the device? A. "This device will help keep my lungs strong so I don't have another asthma attack." B. "I will inhale as hard as I can while using the device." C. "I will use this device at the same time, either in the morning or before bedtime, and compare the readings with my personal best reading." D. "I will notify the doctor if my peak flow rating is 90% or more than my personal best peak flow."

The answer is C. This option is correct. Option A is wrong because this device monitors how controlled a patient's asthma is and if it is getting worst. It doesn't make the lung stronger. Option B is wrong because the patient exhales as hard as they can onto the device. Option D is wrong because a flow rate of 90% of the personal best peak flow is a good reading.

You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient: A. Easily fatigued with physical activity B. Reduced peak flow meter reading C. Chest retractions D. Cyanosis E. Wheezing with activity F. Nighttime coughing G. No relief with short-acting bronchodilator inhaler

The answers are A, B, E, and F. These are all early warning signs an asthma attack is imminent. Options C, D, and G are signs and symptoms of an active asthma attack that requires medical treatment.

A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when: (SATA) A. She has 3 negative sputum cultures B. Her signs and symptoms improve C. She has completed the full medication regime D. Her chest x-ray is normal E. She has been on tuberculosis medications for about 3 weeks

The answers are A, B, and E. These are all criteria for when a patient with active TB can return to public life (school, work, running errands). Until then they are still contagious and must stay home in isolation.

Select all the correct options that represent the pathophysiology of an asthma attack. (SATA) A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation. B. The mucosa lining experiences severe inflammation. C. The goblet cells within the mucosa lining produce excessive amounts of mucous. D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.

The answers are B and C. Option A is wrong because the smooth muscle surrounding the BRONCHI AND BRONCHIOLES CONSTRICTS (not alveoli), limiting oxygenation. Option D is wrong become the patient does NOT experience respiratory alkalosis but respiratory ACIDOSIS. During an asthma attack, the patient is unable to exhale fully and air trapping occurs. Therefore, gas exchange does NOT occur, leaving carbon dioxide to build up in the blood and NO oxygen to enter the bloodstream. The CO2 builds up in the system and oxygen saturations drop....hence acidosis. Remember CO2 is acidic.

You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education? SATA A. Cough for a minimum of 6 weeks B. Night sweats C. Weight gain D. Hemoptysis E. Chills F. Fever G.Chest pain

The answers are B, D, E, F, and G. Option A is wrong because a cough should be present for 3 weeks or more (NOT 6 weeks). Option C is wrong because the patient will experience weight LOSS (not gain).

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction? a) A cardiac output of 2 L/min is normal. b) A cardiac output of 4 L/min is normal. c) A cardiac output of 6 L/min is normal. d) A cardiac output of 7 L/min is normal.

a) A cardiac output of 2 L/min is normal. Rationale: The cardiac cycle consists of contraction and relaxation of the heart muscle. In adults, the cardiac output ranges from 4 to 7 L/min. Therefore, option 1 identifies a low cardiac output.

Assessing a patient who has a history of asthma and is in an acute attack what might we see? Select All That Apply a. Abnormal ABG results b. Wheezing and or an increased respiratory rate c. Pink frothy sputum d. Pitting edema

a. Abnormal ABG results b. Wheezing and or an increased respiratory rate Rationale: CO2 may be increases due to the increased respiratory rate

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the healthcare provider and prepares to implement which priority interventions? (Select all that apply) a. Administering oxygen b. Inserting a Foley Catheter c. Administering furosemide d. Administering morphine sulfate intravenously e. Transporting the client to the coronary care unit f. Placing the client in a low Fowler's side-lying position

a. Administering oxygen b. Inserting a Foley Catheter c. Administering furosemide d. Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide a. Increased blood pressureb. Increased urine outputc. Decreased paind. Decreased premature ventricular contractions

b. Increased urine output

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: a. Familial tendency toward peripheral vascular disease b. Smoking History c. Recent exposures to all allergens d. History of insect bites

b.Smoking History Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? a. Flat neck veins b. Nausea and vomiting c. Hypotension and dizziness d. Clubbed fingertips and headache

c. Hypotension and dizziness

In a patient with a diagnosis of COPD which of the following statements tells the nurse that further teaching about helping manage this condition? a. I will find ways to cope with my anxiety about having trouble breathing b. When I feel short of breath and my SPO2 is high 80s low 90s this is normal for my condition c. I can continue smoking because it has no effect on my condition d. I may see a weight loss as my condition worsens

c. I can continue smoking because it has no effect on my condition Rationale: when a patient states that they smoke it should be encouraged to quit

The nurse is taking care of an elderly male client who has SOB, cough, and fluid in his pleural space. The physician asks the nurse to assist in the performance of a therapeutic and diagnostic thoracentesis. Which of the following nursing interventions should the nurse perform to assist this client? a. Make certain the consents are signed, witnessed, and filed in the chart. b. Offer oral fluids, because the client will not be able to take a drink during the procedure. c. Help the client to lie flat with pillow under his feet for comfort during the procedure. d. Help the client to sit up and place his arms over a bedside table, encouraging him to remain still during the procedure.

d.Help the client to sit up and place his arms over a bedside table, encouraging him to remain still during the procedure. Rationale: Placing the client in a sitting position over the bed side table is the most comfortable and allows the best opportunity to remove fluid at the base of the chest. Fluids should not be offered right before a procedure to avoid nausea and vomiting if pain is experienced.

A client with CF (Cystic Fibrosis) who is 2 months postoperative from a bilateral lung transplant wants to begin riding his bicycle again, as his pulmonary specialist has said he can do, but his wife is concerned that this will "wear out" his new lungs faster. How will the nurse advise this couple? A.Remind the wife that activity does not damage or "wear out" the lungs and that exercise will reduce the risk of other health complications. B.Tell the wife that, because the client has a reduced life expectancy, she should allow him to do whatever he wants. C.Remind the client that this is the "honeymoon phase" of recovery and that he will not feel well for very long Advise the client to protect his lungs at all costs

•Answer A

With which client does the nurse anticipate complications form obstructive sleep apnea following abdominal surgery? A.28-year-old who is 80 lbs (36.4 kg) overweight and has a short neck B.48-year-old who has type 1 diabetes and chronic sinusitis C.58-year-old who has had gastroesophageal reflux disease for 10 years D.78-year-old who wears upper and lower dentures and has asthma

•Answer A

A client with pulmonary artery hypertension on a continuous IV epoprostenol infusion is in the emergency department with symptoms of possible sepsis. The primary health care provider prescribes a broad-spectrum antibiotic to be administered IV immediately. What is the nurse's best action? A.Request a prescription for an oral antibiotic B.Start a peripheral IV line and administer the antibiotic C.Administer the IV antibiotic through the continuous infusion's side port D.Stop the epoprostenol infusion for 15 minutes to administer the IV antibiotic

•Answer B

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? A.Pneumothorax B.Pneumonia C.Pleural Effusion Emphysema

•Answer B

When reviewing the laboratory values for a client admitted with pneumonia, which result will cause the nurse to collaborate quickly with the primary health care provider? A.White blood cell (WBC) count of 14,526mm B.PaO2 68 mm Hg C.PaCO2 46 mm Hg Blood glucose 146 mg/dL

•Answer B

Which information is most important for a nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy? A."Report darkening or reddening of the urine while taking Rifampin." B."Do not drink alcohol in any quantity while taking Isoniazid." C."Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide." D."Temporary visual changes while taking ethambutol are not serious."

•Answer B

A client newly diagnosed with moderate asthma asks whether he can just take salmeterol instead of salmeterol and albuterol, because he has read that they are both beta agonists. What is the nurse's best advice? A.Yes, both of these drugs have the same action, and you only need one B.Yes, because they both need to be used daily whether you are having symptoms or not; just take a little more of the salmeterol and don't take any of the albuterol C.No; albuterol is used to relieve the symptoms during an actual asthma attack, and salmeterol is used to prevent an attack. Both are needed. D.No; albuterol is taken through the use of an aerosol inhaler, and salmeterol is an oral drug (tablet) that is activated in the stomach. Both are needed

•Answer C

The nurse notes that a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy at 2 L/min and had an oxygen saturation of 88% 1 hour ago now has dyspnea and an oxygen saturation of 80%. Should the nurse increase the FiO2? A.No; increasing the FiO2 will severely depress the respiratory rate by blunting the hypoxic drive. B.No; an oxygen saturation of 80% is acceptable for a client with COPD C.Yes; hypoxia must be treated despite the risk for oxygen-induced hypercapnia D.Yes; the expected outcome for any client with hypoxia is to achieve a saturation of at least 97%

•Answer C

Which description of respiratory physiologic features is correct? A.The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange B.The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound C.Any problems with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung D.The left lung is responsible for approximately 60% of gas exchange, and the right lung is responsible for 60% of pulmonary perfusion.

•Answer C - About 60% to 65% of lung function occurs in the right lung. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung

The chest tube of a client who is 12 hours postoperative from a lobectomy separates from the drainage system. What is the nurse's best first action? A.Immediately call the surgeon or rapid response team B.Notify respiratory therapy to set up a new drainage system C.Cover the insertion site with a sterile occlusive dressing and tape down on three sides D.Place the end of the disconnected tube into a container of sterile water positioned below the chest

•Answer D

Which interventions are important for the nurse to teach a client with severe chronic obstructive pulmonary disease (COPD) to help ensure adequate nutrition? Select all that apply. A.Avoid eating gas-producing foods B.Cough to clear mucus right before eating C.Drink plenty of fluid with every meal D.Eat smaller meals more frequently E.Rest immediately following a meal F.Eat more raw fruits and vegetables G.Use your bronchodilator about 30 minutes before each meal

•Answers A, B, D, G

What must the nurse include for discharge education for a client who is newly prescribed to use oxygen therapy at home? Select all that apply. A.The consequences of smoking while using oxygen B.The need to limit potted plants in the home C.The types of oxygen delivery devices available for home use D.The use of oxygen when performing ADLs E.The need to travel only in specially designated cars F.Performing proper skin care under the device and its straps

•Answers A, C, D, F

Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? Select all that apply. A.Onset of or when the client first noticed dyspnea B.Results of most recent pulmonary function test C.Conditions that relieve the dyspnea sensation D.Whether or not dyspnea interferes with ADLs E.Inspection of the external nose and its symmetry F.Whether stridor is present with dyspnea

•Answers A, C, D, F

Which interventions are most appropriate for the nurse to teach a client with a nasal fracture to reduce bleeding from the injury? Select all that apply. A.Avoid blowing or picking the nose B.Drink at least 2000 mL of fluid daily C.Take the antibiotics for as long as they are prescribed D.Take in only liquids and eat no solid food for at least a week E.Change the drip (moustache) dressing as soon as it becomes wet F.Use acetaminophen for pain rather than aspirin or other NSAIDs

•Answers A, F

A nurse is providing community education on seasonal influenza. What information will the nurse include in this presentation? Select all that apply. A.Adults older than 65 years should get the Prevnar-13 vaccination annually B.All adults older than 49 years should receive a Fluzone immunization annually C.Sneeze into a disposable tissue or into your sleeve instead of your hand D.Avoid large crowds during spring and summer to limit the chance for getting the flu E.Wash your hands frequently and after blowing your nose, coughing, or sneezing F.Call your primary health care provider for an antiviral prescription within 3 days of getting symptoms

•Answers B, C, E

A client about to undergo radiation therapy for head and neck cancer (pharyngeal) asks what side effects are expected from this therapy. Which side effects does the nurse teach the client to expect? Select all that apply. A.Scalp and eyebrow alopecia B.Taste sensation loss or changes C.Increased risk for sinus infections D.Increased risk for skin breakdown E.Moderate weight gain Increased risk for cavities

•Answers B, D, F