Exam #2

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?

Place the client in the low Fowler's position. Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an 83-year-old woman. The nurse should prioritize which of the following actions?

Keeping the client warm Special attention is given to keeping the client warm because elderly clients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The client is never sterile and restraints are very rarely necessary.

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.

- Dehiscence - Hematoma A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelecstasis, thromobophlebitis, and paralytic ileus are potential complications following surgery. Atelecstasis is a collapse of the alveoli, which interferes with gas exchange. Thromobophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis.

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. - A client who has a chest tube following a pneumothorax B. - A client who has an acute exacerbation of Crohn's disease C. - A client who is postoperative following a laparoscopic appendectomy D. - A client who is recovering from thyroid storm

A. - A client who has a chest tube following a pneumothorax Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider. Incorrect Answers: B. - A client who has Crohn's disease is not at risk for crepitus. Crohn's disease is an inflammatory disorder of the small intestines. C. - A client who is postoperative following a laparoscopic appendectomy is not at risk for crepitus because the surgery is minimally invasive. D. - A client who is recovering from thyroid storm is not at risk for crepitus. Thyroid storm results in a fever, tachycardia, and hypertension from the excessive release of thyroid hormone.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake. Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism.

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. - "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. - "The tubes drain blood from 2 different lung areas." C. - "The lower tube will drain blood, and the higher tube will remove air." D. - "The second tube will take over if blood clots block the first tube."

C. "The lower tube will drain blood, and the higher tube will remove air." The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air. Incorrect Answers: A. - Excessive bleeding indicates a complication that the surgeon must address. B. - Blood typically drains from the base of the lung, not the apex. D. - If a tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish patency or remove and replace the tube.

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. - "I can keep my dentures in during the procedure." B. - "I am allowed only clear liquids prior to the procedure." C. - "A tissue sample might be obtained during the procedure." D. - "A signed consent form is not required for this procedure."

C. - "A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing. Incorrect Answers: A. - The client needs to remove dentures, glasses, or contacts so they can be stored safely until after the procedure is completed. B. - The client should ingest nothing by mouth for 6 hours prior to the procedure to reduce the risk of aspiration. D. - A signed consent form is required prior to a bronchoscopy because it requires sedation, and risk is involved. By signing the consent form, the client is demonstrating an understanding of the procedure and the risks.

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs?

Hypovolemic shock The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The nurse is doing preoperative client education with a 61-year-old male client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client?

Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection. The reduction of smoking will enhance pulmonary function; in the preoperative period, clients who smoke should be urged to stop 30 days before surgery.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the client is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to:

use the incentive spirometer every 2 hours. To clear secretions and prevent pneumonia, the nurse encourages the client to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the client arrives on the clinical unit and continue until the client is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as prescribed would not help to clear secretions or prevent pneumonia.

Which is the of the following factors stimulates the wound healing process?

Sufficient oxygenation Oxygen deficit is a factor in wound healing, oxygenation is needed to increase tissue perfusion and circulation to stimulate the healing process . Hemorrhage nutritional deficiencies such as protein-calorie depletion, and the immobility are factors that decrease wound healing. Immobility leads to thrombosis formation causing tissue necrosis, not healing.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do?

Stand upright for 2 to 3 minutes prior to ambulating. Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The client should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the client's ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. - Respiratory alkalosis B. - Respiratory acidosis C. - Metabolic alkalosis D. - Metabolic acidosis

B. - Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. Incorrect Answers: A. Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. C. Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk of developing metabolic alkalosis. Excessive vomiting also places a client at risk of developing metabolic alkalosis. D. Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk of developing metabolic acidosis.

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. - Aspiration of water B. - Infection of the stoma C. - Bleeding around the stoma D. - Skin breakdown around the stoma

A. - Aspiration of water The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway. Incorrect Answers: B. - Exposure to water alone does not cause infection; infectious microorganisms cause infection. The nurse should instruct the client to examine the stoma every day for any signs of infection. C. - After initial healing, bathing should not cause bleeding around the stoma. Even in the immediate postoperative period, hemorrhage is unlikely. D. - Breakdown of the wound is possible in the postoperative period due to many factors such as poor nutrition. However, brief contact with water during bathing does not cause this complication.

The nurse is caring for an 82-year-old female client in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurse's subsequent assessment?

Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. Postoperative confusion is common in the older adult client, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should be aware of what purpose of the preadmission assessment?

Verifies completion of preoperative diagnostic testing Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the client's suitability for surgery.

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. - Discuss ways the client can reduce the number of cigarettes smoked per day B. - Suggest the client switch from smoking cigarettes to smoking a pipe C. - Inform the client that treatment will be ineffective if smoking continues D. - Discourage the use of nicotine gum

A. - Discuss ways the client can reduce the number of cigarettes smoked per day The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually. Incorrect Answers: B. - Pipe smoking still exposes the client to harmful smoke. C. - The client will benefit from treatment even if smoking continues; however, treatment is more effective if the client stops smoking cigarettes. D. - The nurse should encourage the use of nicotine gum to assist the client in smoking cessation.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. - Stabbing chest pain B. - Calf tenderness C. - Elevated temperature D. - Bradycardia

A. - Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom. Incorrect Answers: B. - This finding is a manifestation of a blood clot in the leg, which can lead to a pulmonary embolism. C. - This finding is a manifestation of an infection. D. - Tachycardia, not bradycardia, is a manifestation of a pulmonary embolism.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next?

Assess the client's oxygen levels. The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if a prescription for medication is needed. A social work consult is inappropriate for addressing restlessness.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?

Atelectasis Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. - "Be sure to take cough medicine to avoid coughing." B. - "Try to drink at least 2 to 3 liters of fluid per day." C. - "Try to reduce your smoking to 2 cigarettes per day." D. - "Be sure to eat 3 full meals each day."

B. - "Try to drink at least 2 to 3 liters of fluid per day." Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions. Incorrect Answers: A. - The nurse should remind the client of the importance of coughing for removing excess mucus. The client should cough after getting out of bed, before mealtime, and before bedtime. C. - The nurse should encourage clients who have emphysema to quit smoking completely. D. - The client should eat 4 to 6 small meals per day to prevent the exhaustion and shortness of breath that can result from ingesting large meals.

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. - "I'll expect a little leg swelling since I won't be that active for a while." B. - "I'll see the doctor every week to change my vena cava filter." C. - "I'll call the doctor if I see any blood in my urine or stool." D. - "I'll have to take the blood thinner for a few more days."

C. - "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately. Incorrect Answers: A. - The client might have to limit activities for a while but should report any leg swelling or tenderness as an indication of clot formation. B. - The vena cava filter remains in place either until the provider determines there is not a high risk for clot formation or permanently. D. - Clients who had a pulmonary embolism typically require anticoagulant therapy for weeks to years after the acute event.

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. - "I'll inhale slowly through pursed lips to help me breathe better." B. - "When I do my pursed-lip breathing, I'll lie down first." C. - "When I breathe out through pursed lips, my airways don't collapse between breaths." D. - "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

C. - "When I breathe out through pursed lips, my airways don't collapse between breaths." Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for clients who have emphysema. The client should use this technique during physical activity and episodes of dyspnea. Incorrect Answers: A. - The client should first inhale slowly through the nose, then exhale slowly through pursed lips. B. - The client should practice pursed-lip breathing while sitting upright or walking. D. - The client should tighten the abdominal muscles when using the pursed-lip breathing technique.

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.) A. - "You will have a chest tube in place after surgery." B. - "We'll frequently help you turn, cough, and breathe deeply after surgery." C. - "You will have to remain in bed for about 2 days after the surgery." D. - "We'll give you oxygen to support your breathing if you need it." E. - "You should expect pain for the first few days after surgery."

Correct answer: (A) (B) (D) After a pneumonectomy, some clients have a clamped chest tube briefly to help reduce mediastinal shift. They do not usually have closed-chest drainage. Helping the client turn, cough, and breathe deeply is standard preventive postoperative care after thoracic surgery. After thoracic surgery, clients typically receive oxygen by nasal cannula or mask for the first 2 days and then as needed. Incorrect Answers: C. - As soon as possible following a pneumonectomy, the nurse should help the client into a semi-Fowler's position or to sit upright in a chair. E. - Although clients do have pain after surgery, the nurse should focus on pain management. To avoid frightening the client unnecessarily, the nurse should inform the client about how the staff will help manage the pain.

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. - "Apply warm compresses to the face." B. - "Take aspirin 650 mg by mouth for mild pain." C. - "Close your mouth when sneezing." D. - "Lie on your back with your head elevated 30° when resting."

D. "Lie on your back with your head elevated 30° when resting." The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions. Incorrect Answers: A. - The client should apply cold compresses to the face to decrease swelling. B. - The client should avoid taking aspirin because it increases the risk of bleeding by decreasing platelet aggregation. C. - The client should open the mouth when sneezing to reduce strain on the incisional site.

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. - Measuring heart rate B. - Palpating peripheral pulses C. - Observing sputum for blood D. - Confirming the gag reflex

D. - Confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk. Incorrect Answers: A. - The nurse should measure the client's heart rate to help determine the client's cardiovascular status; however, this action is not the nurse's priority. B. - The nurse should palpate the client's peripheral pulses to help confirm adequate circulation; however, this action is not the nurse's priority. C. - The nurse should observe the client's sputum for excessive amounts of blood to determine signs of hemorrhage; however, this action is not the nurse's priority.

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?

"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications." The PACU provides care for the client while he or she recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Clients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply.

- Establishing an IV line - Verifying the surgical site with the client - Taking measures to ensure the client's comfort In the holding area, the nurse reviews charts, identifies clients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each client's comfort. A nurse in the preoperative holding area does not prepare medications to be given by anyone else. A grounding device is applied in the OR.

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply.

- Maintain a patent airway. - Frequently monitor neurological status. - Administer blood products per orders. - Apply oxygen per orders. The client is demonstrating signs and symptoms of shock. A client in shock may lose the ability to protect the airway. Frequent neurological assessment can provide information related to a decrease in oxygen to the brain. Administering blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The client should be lying flat or in the Trendelenburg position.

The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and her caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply.

- Provide all discharge instructions in writing. - Provide the nurse's or surgeon's contact information. - Give prescriptions to the client. Before discharging the client, the nurse provides written instructions, prescriptions and the nurse's or surgeon's telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. - Absence of breath sounds B. - Expiratory wheezing C. - Inspiratory stridor D. - Rhonchi

A. - Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. Incorrect Answers: B. - A client who has asthma experiences expiratory wheezing during an acute asthma attack.</p> C. - A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound that is often heard without a stethoscope. D. - A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snoring-like noises produced in the throat.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. - Dry cough B. - Rhinitis C. - Sore throat D. - Swollen lymph nodes

A. - Dry cough A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis. Incorrect Answers: B. - Rhinitis is not a manifestation of inhalation anthrax; however, rhinitis is typically seen with colds and influenza. C. - A sore throat is not a manifestation of inhalation anthrax; however, a sore throat is typically seen with colds and influenza. D. - Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. - Sudden onset of dyspnea B. - Tracheal deviation C. - Bradycardia D. - Difficulty swallowing

A. - Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. Incorrect Answers: B. - Tracheal deviation is an indication of pneumothorax. C. - Tachycardia is a clinical manifestation of pulmonary embolism. D. - Difficulty swallowing is an indication of many conditions, including oral cancer.

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. - Use pursed-lip breathing during periods of dyspnea B. - Limit fluid intake to 1,500 mL per day C. - Practice chest breathing each day D. - Wear home oxygen to maintain an SaO2 of at least 94%

A. - Use pursed-lip breathing during periods of dyspnea The nurse should instruct the client about using pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange. Incorrect Answers: B. - The nurse should instruct the client to drink 2,000 to 3,000 mL of fluids a day to keep respiratory secretions thin and easier to expectorate. C. - The nurse should instruct the client to practice diaphragmatic or abdominal breathing, which reduces the respiratory rate and increases alveolar ventilation. D. - The nurse should instruct the client to maintain an SaO2 of at least 88%. A client with emphysema has chronic hypercarbia, resulting in the need for a lower arterial oxygen level to maintain the drive to breathe. Maintaining an SaO2 of 94% or greater could suppress the client's breathing.

A client is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this client was 10 mL. The tubing of the Foley is confirmed to be patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely. If the client has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted because it known that the Foley is patent.

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible before the surgical procedure Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of pre-admission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. - Eliminating environmental triggers that precipitate attacks B. - Addressing the client's perception of the disease process and what might have triggered past attacks C. - Overviewing the client's medication regimen D. - Explaining manifestations of respiratory infections

B. - Addressing the client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge. Incorrect Answers: A. - Although it is important for the nurse to discuss how to eliminate environmental triggers that precipitate asthma attacks, there is another point to discuss first. C. - Although it is important for the nurse to discuss the client's medication regimen to ensure understanding of how to use each medication, there is another point to discuss first. D. - Although it is important for the nurse to review the manifestations of respiratory infections because the client is at increased risk, there is another point to discuss first.

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. - Insert a large-bore IV catheter B. - Ensure an adequate airway C. - Obtain an accurate medication history D. - Prepare to administer an antagonist

B. Ensure an adequate airway The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opioid toxicity. Incorrect Answers: A. - The client might need fluid administration due to possible hypotension. However, there is another action the nurse should take first. C. - The nurse should obtain an accurate medication history to provide care safely for the client. However, there is another action the nurse should take first.</p> D. - The nurse should prepare to administer an antagonist to reverse the action of the opioid. However, there is another action the nurse should take first.

A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active tuberculosis? A. - Rhinitis B. - Air hunger C. - Night sweats D. - Weight gain

C. - Night sweats Manifestations of active tuberculosis include a fever, coughing, night sweats, anorexia, and fatigue. Incorrect Answers: A. - Rhinitis is common with allergies, the common cold, and influenza but not tuberculosis. B. - Air hunger is a manifestation of pulmonary edema and acute respiratory failure, not tuberculosis. D. - Weight loss is a manifestation of active tuberculosis.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

Offer the client a bedpan or urinal. If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

The nurse just received a postoperative client from the PACU to the medical-surgical unit. The client is an 84-year-old woman who had surgery for a left hip replacement. What concern should the nurse prioritize for this client in the first few hours on the unit?

Close monitoring of neurologic status In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A client who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will take more time to resume.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. - Explain that the client will receive sedation and will not remember the procedure. B. - Verify that the client understands the purpose and nature of the procedure. C. - Offer the client sips of clear liquids until 1 hr before the test. D. - Obtain a pre-procedural sputum specimen. E. - Instruct the client to keep his neck in a neutral position.

Correct answer: (A) (B) For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it. Incorrect Answers: C. - The client should remain NPO for 4 to 8 hours prior to the procedure to minimize aspiration risk. D. - The provider can obtain any necessary sputum specimens during the procedure. E. - The client's neck will be hyperextended to bring the pharynx into alignment with the trachea and to allow insertion of the scope without trauma.

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? A. - "I'm not going to be able to cough for a while after the surgery." B. - "After I recover from the anesthesia, I'll be able to eat regular food again." C. - "After the surgery, my voice will gradually return but might be weak." D. - "I understand that I will have a permanent tracheostomy after the surgery."

D. - "I understand that I will have a permanent tracheostomy after the surgery." With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent. Incorrect Answers: A. - After the surgery, the client should be able to carry out postoperative exercises such as coughing and breathing deeply to help clear secretions. B. - After the surgery, the client will receive enteral nutrition via a feeding tube for 7 to 10 days. C. - After a total laryngectomy, the client will have no natural voice because the surgeon will remove the entire larynx.

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. - Nasal edema B. - Mouth breathing C. - Periorbital ecchymosis D. - Frequent swallowing

D. - Frequent swallowing Frequent swallowing indicates posterior nasal bleeding and possibly hemorrhage. The nurse should notify the surgeon promptly about this finding. Incorrect Answers: A. - Edema of the nose, eyes, and face is an expected finding following rhinoplasty. B. - Mouth breathing is an expected finding following rhinoplasty. The presence of nasal packing hinders the ability to breathe through the nose. C. - Ecchymosis of the nose, eyes, and face is an expected finding following rhinoplasty.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. - Soft blowing B. - Loud bubbling C. - Dry grating D. - Noisy wheezing

D. Noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound. Incorrect Answers: A. - A soft blowing or rustling sound is an expected vesicular lung sound. B. - Loud bubbling or gurgling indicates coarse crackles, which reflect moisture in the lungs. Crackles are not a manifestation of asthma. C. - A dry, grating, creaking, or rubbing sound indicates a pleural friction rub, which is not a manifestation of asthma.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. - The client is unable to speak. B. - The client's airway secretions were last suctioned 2 hr ago. C. - The client coughs and expectorates a large mucous plug. D. - The nurse auscultates coarse crackles in the lung fields.

D. The nurse auscultates coarse crackles in the lung fields The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions. Incorrect Answers: A. - A client who has a tracheostomy with an inflated cuff in place is unable to speak. B. - The nurse should assess the need for suctioning every 2 hours and suction as necessary. C. - The nurse should assess the client's airway after coughing and only suction the client's secretions if the client is not able to cough and expectorate secretions.

The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this client?

Increased risk for postoperative complications Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

Corticosteroids have which effect on wound healing?

Mask the presence of infection Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

The PACU nurse is caring for a male client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

Pain, hypoxia, or bladder distention Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse?

Prednisone Corticosteroids such as prednisone (Deltasone) may impair the normal inflammatory process and may mask infection. Furosemide (Lasix), digoxin (Lanoxin), and allopurinol (Zyloprim) should not be of concern postoperatively.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?

Quickly attempt to determine the cause of hemorrhage. Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the client. The Trendelenberg position would be contraindicated.

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes the first step is to provide the client with information regarding the procedure. Which of the following explanations should the nurse provide to the client?

"During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to." When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.

A surgical client has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). What must the client require for safe and effective use of PCA?

A clear understanding of the need to self-dose The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The client does not adjust the dose and only the client himself or herself should administer a dose. PCAs are normally used for clients who are expected to have moderate to severe pain with a regular need for analgesia.

A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. - Eat high-calorie foods first B. - Increase intake of water at meal times C. - Perform active range-of-motion exercises before meals D. - Keep saltine crackers nearby for snacking

A. - Eat high-calorie foods first Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first. Incorrect Answers: B. - Although a client who has COPD should maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit the intake of water at mealtimes to reduce the feeling of early satiety. C. - The client should rest before meals to decrease dyspnea while eating. D. - The client should keep foods on hand for snacking but should avoid dry and salty foods, which can increase the risk of aspiration and make the client's mouth dry.

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? A. - Increased coughing B. - Diaphragmatic breathing C. - Hemoptysis D. - Kussmaul respirations

A. - Increased coughing The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing. Incorrect Answers: B. - Diaphragmatic breathing is the act of inhaling deeply by flexing the diaphragm. It is not a manifestation of tracheal stenosis. C. - Coughing up blood, otherwise known as hemoptysis, is an abnormal finding following endotracheal extubation that should be reported to the provider. However, it is not a manifestation of tracheal stenosis. D. - Kussmaul respirations are a deep and labored breathing pattern that is most often seen in clients who have metabolic acidosis. It is not a manifestation of tracheal stenosis.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. - Initiate bag-valve-mask ventilation B. - Provide the client with a communication board C. - Obtain a blood sample for ABG analysis D. - Document the ventilator settings

A. - Initiate bag-valve-mask ventilation The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first provide ventilations with a bag-valve-mask device. Incorrect Answers: B. - The nurse should provide a communication board due to the client's inability to speak; however, there is another action the nurse should take first. C. - The nurse should obtain a blood sample for ABG analysis to help determine the status of the client's respiratory system; however, there is another action the nurse should take first. D. - The nurse should routinely document the client's ventilator settings; however, there is another action that the nurse should take first.

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. - Stridor B. - Coughing C. - Hoarseness D. - Extensive oral secretions

A. - Stridor The nurse should identify that stridor (a high-pitched crowing sound heard during inspiration) is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call the rapid response team for assistance before the airway becomes completely obstructed. Incorrect Answers: B. - The nurse should encourage the client to cough after extubation to aid the clearing of secretions. Coughing can be an early manifestation of obstruction, but it does not require the rapid response team unless the client is unable to cough well enough to clear secretions and airway obstruction becomes evident. C. - Hoarseness is expected after extubation and can last for several days. D. - Extensive oral secretions are an expected finding after extubation. The nurse should monitor these secretions for indications of potential airway obstruction.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. - Total lung capacity B. - Vital lung capacity C. - Functional residual capacity D. - Residual volume

A. - Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.</p> Incorrect Answers: B. - Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. C. - Functional residual capacity measures the amount of air in the lungs after normal expiration. D. - Residual volume measures the amount of air in the lungs after forced expiration.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?

Airway patency The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. - Excessive airway secretions B. - A leak within the ventilator's circuitry C. - Decreased lung compliance D. - The client coughing or attempting to talk

B. - A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. Incorrect Answers: A. - The activation of a high-pressure alarm indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions could generate a high-pressure alarm, not a low-pressure alarm. C. - Resistance during the delivery of a specific volume of oxygen to the client triggers the ventilator's high-pressure alarm, not a low-pressure alarm. A possible cause is decreased lung compliance due to disorders such as COPD. D. - When a client is coughing or trying to talk, the ventilator must exert greater force to deliver the preset volume of oxygen. This increased resistance of the airway against the machine can trigger a high-pressure alarm, not a low-pressure alarm.

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. - Lymph nodes B. - Maxillary sinuses C. - Intercostal spaces D. - Salivary glands

B. - Maxillary sinuses Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination. Incorrect Answers: A. - Transillumination cannot help the provider evaluate lymph nodes, which are tiny organs throughout the body that collect tissue fluid. C. - Transillumination cannot help the provider evaluate intercostal spaces, which are the areas between the ribs. D. - Transillumination cannot help the provider evaluate salivary glands, which are tiny organs that secrete saliva to aid the digestive process.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. - Tympanic temperature 38°C (100.4°F) B. - PaO2 50 mmHg C. - Rhonchi D. - Hypopnea

B. - PaO2 50 mmHg This client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. Incorrect Answers: A. - Although the client's temperature is not within the expected reference range, it is not a clinical manifestation of ARDS. C. - A client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces, not in the airway. D. - A client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing; this indicates increased work of breathing.

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. - Increases oxygen intake B. - Promotes carbon dioxide elimination C. - Uses the intercostal muscles D. - Strengthens the diaphragm

B. - Promotes carbon dioxide elimination A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. Incorrect Answers: A. - Pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. The nurse should increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. C. - A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using chest-wall muscles. D. - A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using the diaphragm.

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. - To encourage deep breaths B. - To mobilize secretions in the airways C. - To dilate the bronchioles D. - To stimulate the cough reflex

B. - To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen and promote the drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity. Incorrect Answers: A. - Chest physiotherapy does not encourage deep breaths. However, once airway secretions are mobilized and expectorated, the client might be able to breathe more deeply. C. - Chest physiotherapy does not dilate the bronchioles; however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways. D. - Chest physiotherapy does not stimulate the cough reflex; however, the mobilization of secretions can increase the client's ability to cough up secretions.

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. - "If the test is positive, it means you have an active case of tuberculosis." B. - "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. - "You must return to the clinic to have the test read in 2 or 3 days." D. - "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. - "You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another tuberculin skin test is necessary. Incorrect Answers: A. - A positive test means the client has been exposed to tubercle bacillus, but it does not mean that the client has an active case of tuberculosis. The client should have a chest X-ray to rule out active tuberculosis. B. - A client who has a positive skin test should have a chest X-ray to rule out active tuberculosis. When the client has a positive skin test, subsequent skin tests will always be positive. D. - The nurse will inject 0.1 mL of purified protein derivative intradermally to the dorsal aspect of the client's forearm.

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. - Friction rub B. - Crackles C. - Crepitus D. - Tactile fremitus

C. - Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax. Incorrect Answers: A. - A friction rub is a scratching or squeaking sound heard when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. B. - Crackles (sometimes called rales) are wet, popping sounds heard when auscultating the client's lungs. This condition occurs when fluid is present in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia. D. - Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine, nine." Increased tactile fremitus is a clinical manifestation of pneumonia.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. - Provide chest physiotherapy B. - Perform oropharyngeal suction C. - Encourage deep-breathing and coughing D. - Assist the client with ambulation

C. - Encourage deep-breathing and coughing The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway. Incorrect Answers: A. - The nurse should provide chest physiotherapy to help the client clear secretions; however, there is another action the nurse should take first. B. - Oropharyngeal suction might be necessary if this client is unable to expectorate secretions from the throat or mouth; however, there is another action the nurse should take first. D. - The nurse should assist the client with ambulation to help clear secretions; however, there is another action the nurse should take first.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. - Instruct the client to cough B. - Administer oxygen via face mask C. - Evaluate the client for stridor D. - Keep the client in a semi- to high-Fowler's position

C. - Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation. Incorrect Answers: A. - The nurse should instruct the client to cough immediately to help dislodge and remove the oral secretions that commonly accumulate; however, there is another action the nurse should take first. B. - The nurse should give the client oxygen via face mask or nasal cannula to help maintain oxygen saturation; however, there is another action the nurse should take first. D. - The nurse should keep the client upright to help improve gas exchange and reduce edema of the larynx; however, there is another action the nurse should take first.

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. - Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. - Prepare the client for possible endotracheal intubation and mechanical ventilation C. - Increase the oxygen flow and request an arterial blood gas determination D. - Position the client supine and administer an anti-anxiety medication

C. - Increase the oxygen flow and request an arterial blood gas determination. The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements. Incorrect Answers: A. - Clients who have COPD typically require a nasal cannula with an oxygen flow of 2 to 4 L/min or a Venturi mask delivering up to 40% oxygen. B. - Although the client might require intubation and mechanical ventilation at some point, it is premature to anticipate this measure before trying other therapeutic interventions to help relieve the client's dyspnea.</p> D. - The nurse should assist the client into a high-Fowler's position. Upright positioning allows maximal chest expansion and can help relieve dyspnea. First-line medications for managing dyspnea due to COPD are bronchodilators, cholinergic antagonists, xanthines, and corticosteroids.

A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. - Elevated temperature B. - Swollen cervical lymph nodes C. - Inspiratory stridor D. - Purulent nasal discharge

C. - Inspiratory stridor When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority finding is inspiratory stridor, which is a manifestation of airway obstruction. The nurse should notify the rapid response team and administer humidified oxygen. Incorrect Answers: A. - The nurse should report an elevated temperature and any change in the client's condition; however, another finding is the priority to report. B. - The nurse should report swollen cervical lymph nodes and any change in the client's condition; however, another finding is the priority to report. D. - The nurse should report purulent nasal discharge and any change in the client's condition; however, another finding is the priority to report.

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. - Cover the insertion site with a hydrocolloid dressing after removal B. - Provide pain medication immediately after removal C. - Instruct the client to perform the Valsalva maneuver during removal D. - Delegate removal of the chest tube to a licensed practical nurse (LPN)

C. - Instruct the client to perform the Valsalva maneuver during removal The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space. Incorrect Answers: A. - The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space. B. - The nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube. D. - The nurse should expect a provider or specially trained RN to remove the client's chest tube. The nurse should not delegate this procedure to an LPN, as it is beyond the LPN's scope of practice.

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. - The client will need intensive smoking-cessation education. B. - After surgery, the prognosis for clients with lung cancer is usually good. C. - Lung cancer usually has metastasized before the client presents with symptoms. D. - Oxygen therapy is ineffective following a lobectomy.

C. - Lung cancer usually has metastasized before the client presents with symptoms. The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short-term and long-term care options for the client. Incorrect Answers: A. - Although many clients with lung cancer have been smokers, this is not a certainty because many clients have had exposure to secondhand smoke or other toxins over their lifetime. Incidence remains significant among people who never smoked. However, smoking cessation is a primary prevention intervention. B. - Despite the various treatment options for lung cancer, the prognosis remains poor unless surgery occurs early enough in the disease to remove all traces of cancer. Treatment typically is palliative, not curative. D. - Besides helping correct hypoxemia after a lobectomy, oxygen therapy can help alleviate dyspnea and anxiety.

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. - Pericardial friction rub B. - Weight gain C. - Night sweats D. - Cyanosis of the fingertips

C. - Night sweats Night sweats and fevers are clinical manifestations of tuberculosis. Incorrect Answers: A. - A pericardial friction rub is a clinical manifestation of rheumatic carditis. B. - Anorexia and weight loss are clinical manifestations of tuberculosis. D. - Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. - Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. - Apply ice to the site after obtaining the specimen C. - Perform an Allen's test prior to obtaining the specimen D. - Release the pressure applied to the puncture site 1 min after the needle is withdrawn

C. - Perform an Allen's test prior to obtaining the specimen The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. Incorrect Answers: A. - The nurse should not administer oxygen prior to the blood draw because the test measures the client's arterial blood gases when breathing room air. B. - The nurse should use ice to preserve the arterial blood gas specimen during transportation to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site. D. - The nurse should apply pressure to the puncture site for 5 to 10 minutes after the needle is withdrawn. The high pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. - Respiratory acidosis B. - Metabolic acidosis C. - Respiratory alkalosis D. - Metabolic alkalosis

C. - Respiratory alkalosis Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis. Incorrect Answers: A. - Respiratory acidosis reflects an increase in carbon dioxide resulting from inadequate excretion and an increase in the hydrogen ion level (i.e. decreased pH) of the blood. Common causes of this acid-base imbalance are airway obstruction and respiratory depression.</p> B. - Metabolic acidosis results from a metabolic disturbance such as diabetic ketoacidosis or excessive ingestion of alcohol or salicylates, not a respiratory problem. D. - Metabolic alkalosis results from a metabolic disturbance such as prolonged vomiting or excessive nasogastric suctioning, not a respiratory problem.

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. - Wheezing B. - Bradypnea C. - Tachycardia D. - Diaphoresis

C. - Tachycardia Tachycardia, dyspnea, restlessness, headaches, and increased blood pressure are indications of impending respiratory failure. Incorrect Answers: A. - Wheezing indicates asthma, not respiratory failure. B. - Bradypnea is an indication of respiratory depression. Tachypnea is an indication of respiratory failure. D. - Diaphoresis develops as hypoxemia worsens; therefore, it is a manifestation of worsening, not impending, respiratory failure.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. - Clamp the chest tube if there is continuous bubbling in the water seal chamber B. - Keep the chest tube drainage system at the level of the right atrium C. - Tape all connections between the chest tube and drainage system D. - Empty the collection chamber and record the amount of drainage every 8 hr

C. - Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting. Incorrect Answers: A. - The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless the drainage unit needs to be replaced or an air leak must be located. B. - The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. D. - The nurse should not empty the collection chamber or change the system unless it is almost full.

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) A. - NPO status B. - Alternative methods of communication C. - Endotracheal intubation D. - Changes in body image E. - Swallowing exercises

Correct answer: (A) (B) (D) (E) The client will receive fluids and nutrition via an enteral tube while healing from the surgery. Radical neck dissection interrupts vocal communication, so the nurse should determine with the client and family how the client will prefer to communicate. Extensive resection can result in some disfigurement and permanent tracheostomy; the nurse should help prepare the client for these changes. Swallowing can be challenging after an extensive resection. The client might require the assistance of a speech-language pathologist to provide swallowing exercises and techniques. Incorrect Answer: C. - Following a radical neck dissection, the client will have a laryngectomy or a tracheostomy tube. The client will receive any necessary supplemental ventilation and oxygenation plus suctioning via the laryngectomy or tracheostomy tube, not an endotracheal tube.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. - Assign the client to a private room with negative-pressure airflow. B. - Add contact precautions to the client's plan of care. C. - Wear an N95 respirator when entering the client's room. D. - Ensure the client's environment provides 4 exchanges of fresh air per minute. E. - Institute protective environment precautions as soon as the client arrives on the unit.

Correct answer: (A) (C) This client's history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room. Incorrect Answers: B. - Tuberculosis is a communicable infection that mandates a different type of transmission-based precautions in addition to standard precautions. D. - Tuberculosis mandates the provision of a well-ventilated room with 6-12 exchanges of fresh air per minute. E. - Protective environment precautions are for immunocompromised clients who are at high risk of infection (e.g. clients who had chemotherapy).

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. - Tracheal deviation to the left B. - Temperature of 38.8°C (102°F) C. - Absent breath sounds on the right side D. - Neck vein distention E. - Bradypnea

Correct answer: (A) (C) (D) A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend. Incorrect Answers: B. - An elevated temperature is a sign of an infection and can be associated with the purulent drainage obtained. However, this is not a manifestation of a pneumothorax. E. - Clients who experience a tension pneumothorax exhibit respiratory distress and tachypnea until a chest tube is inserted to re-inflate the lung.

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? A. - "After the surgeon removes the lung, you will not need to cough." B. - "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. - "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." D. - "I will show you how to splint your incision while coughing."

D. - "I will show you how to splint your incision while coughing." A client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint the incision to reduce pain when coughing. Incorrect Answers: A and B. - A client who had a pneumonectomy should cough to clear secretions from the remaining lung. C. - Pain medication reduces pain to a tolerable level. However, it does not necessarily keep the client pain-free. Additionally, telling the client not to worry is a barrier to communication and provides false reassurance.

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. - Tracheostomy placement B. - Thoracentesis C. - CT scan of the chest D. - Chest tube insertion

D. - Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. Incorrect Answers: A. - The client might require mechanical ventilation to stabilize the respiratory status; however, there is no indication at this time for a tracheostomy. B. - A thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, or tuberculosis or for a client who requires microscopic examination of the pleural fluid. C. - While the client will require several portable chest X-rays, there is no immediate indication for a CT scan of the chest.

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. - Removing air from the pleural space B. - Creating access for irrigating the chest cavity C. - Evacuating secretions from the bronchioles and alveoli D. - Draining blood and fluid from the pleural space

D. - Draining blood and fluid from the pleural space. The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space. Incorrect Answers: A. - The upper chest tube removes air from the pleural space. B. - The chest tubes are not used for irrigation following a lobectomy. C. - Secretions are removed from the airways via tracheal suctioning rather than chest tubes.

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. - Place the drainage system at the head of the client's bed B. - Increase the suction to the chest drainage system C. - Place the client on low-flow oxygen via nasal cannula D. - Immerse the end of the chest tube in a bottle of sterile water

D. - Immerse the end of the chest tube in a bottle of sterile water If the chest tube and drainage system have become disconnected, air can enter the pleural space, producing a pneumothorax that can result in severe respiratory distress. To prevent a pneumothorax from developing, a temporary water seal can be established by immersing the end of the chest tube in an open bottle of sterile water. This allows air to escape and not enter the pleural space. A bottle of sterile water should always be readily available at the bedside for a client who has a chest tube. Incorrect Answers: A. - The drainage system should never be placed above the level of the client's chest. The system should be placed below the level of the client's chest to allow gravity to drain the fluid from the chest cavity. B. - Increasing the suction to the chest drainage system will not assist the client's breathing at this time because the chest tube has been disconnected. C. - Applying oxygen will not assist the client's breathing at this time because the chest tube has become disconnected.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. - Simple face mask B. - Nonrebreather mask C. - Bag-valve-mask device D. - Nasal cannula

D. - Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen. Incorrect Answers: A. - A simple face mask provides oxygen at flow rates that can reduce the respiratory drive of a client who has COPD. B. - A nonrebreather mask provides oxygen at flow rates that can reduce the respiratory drive of a client who has COPD. C. - A bag-valve-mask (a manual resuscitation bag) is a handheld device that provides ventilation to a client who is not breathing or who is breathing inadequately.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. - Monitor the client's arterial blood gas results B. - Instruct the client to perform controlled coughing C. - Teach the client how to use pursed-lip breathing D. - Place the client in an upright position

D. - Place the client in an upright position Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow. Incorrect Answers: A. - The nurse should monitor the client's arterial blood gas results to determine oxygenation levels; however, there is another action the nurse should take first. B. - The nurse should instruct the client to perform controlled coughing when not experiencing shortness of breath; however, there is another action the nurse should take first. C. - The nurse should teach the client how to use pursed-lip breathing when not experiencing shortness of breath; however, there is another action the nurse should take first.

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? A. - Pulmonary edema B. - Tension pneumothorax C. - Flail chest D. - Respiratory obstruction

D. - Respiratory obstruction Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine. Incorrect Answers: A. - Manifestations of pulmonary edema can include tachycardia, crackles in the lungs, and frothy pink sputum. B. - Manifestations of a tension pneumothorax can include tracheal deviation, distended neck veins, and absent breath sounds on one side. C. - Manifestations of flail chest can include paradoxical chest movement, dyspnea, and cyanosis.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. - Lying flat on the affected side B. - Prone with the arms raised over the head C. - Supine with the head of the bed elevated D. - Sitting while leaning forward over the bedside table

D. - Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air. Incorrect Answers: A. - Lying flat on the affected side does not allow access for draining the accumulated fluid and air. B. - A prone position does not allow access for draining the accumulated fluid and air. C. - A supine position does not allow access for draining the accumulated fluid and air.

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. - Hallucinations B. - Pruritus C. - Hand and foot syndrome D. - Tinnitus

D. - Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus. Incorrect Answers: A. - Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemia. B. - Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis. C. - Hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic medication used to treat breast and colorectal cancer.

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. - pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. - pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. - pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. - pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg

D. - pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg The nurse should identify that these laboratory values reflect metabolic alkalosis. The pH and bicarbonate values are greater than the expected reference range, and the PaCO2 is within the expected reference range. Incorrect Answers: A. - These laboratory values reflect respiratory acidosis. B. - These laboratory values reflect respiratory alkalosis. C. - These laboratory values reflect metabolic acidosis.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?

To promote optimal lung expansion One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next?

Turn the client completely to one side. Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?

Valsalva maneuver The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.