Exam 3 Respiratory #40-79
55.The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion. B. Check pupillary response to light. C. Assess the capillary refill. D. Check client's response to questions about place and time.
A) answer Rationale: When using the airway, breathing, circulation approach to client care, the nurse should plan on evaluating the client's respiratory effort and function. This involves listening to breath sounds, evaluating chest expansion, and assessing the client for chest trauma or abnormalities that would compromise breathing. B)Rationale: The nurse should check pupillary response to light as part of a neurological assessment. However, this is not the nurse's priority action. C)Rationale: The nurse should assess capillary refill to identify any vascular compromise. However, there is another action the nurse should take first. D)Rationale: The nurse should question the client regarding place and time to determine the client's level of orientation. However, another action is priority.
69.A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? A. Intracranial pressure B. Spinal cord perfusion C. Renal function D. Hemodynamic status
D) answer Rationale: A pulmonary artery catheter is inserted into the pulmonary arteryhemodynamic status by measuring pulmonary artery pressures and cardiac output. A)Rationale: A pulmonary artery catheter is inserted into the pulmonary artery pressures and cardiac output. B)Rationale: A pulmonary artery catheter is inserted into the pulmonary artery pressures and cardiac output. C)Rationale: A pulmonary artery catheter is inserted into the pulmonary artery pressures and cardiac output.
45.A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension
C) answer Rationale The nurse should expect agitation due to neurological changes from poor oxygen exchange. A) Rationale: The nurse would not expect the client to be nauseated during an asthma attack. B) RationaleThe nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack D) Rationale The nurse should expect hypertension due to increased work load of the heart from decreased oxygenation.2
77.A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A) answer Rationale: A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL). B) Rationale: Hyperventilation, from acute pain or anxiety, can causes respiratory alkalosis. In the presence of respiratory alkalosis, the client's blood gas values meet the following criteria: a pH greater than 7.45, a PaCO2 less than 35 mm Hg, and a HCO3 of 22 to 26 mEq/mL. C) Rationale: Ketoacidosis can cause metabolic acidosis. In the presence of metabolic acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 that is normal if uncompensated (35 to 45 mm/Hg), and a HCO3 less than 22 mEq/mL. D) Rationale: Persistent vomiting can cause metabolic alkalosis. In the presence of metabolic acidosis, the client's blood gas values meet the following criteria: a pH greater than 7.45, a PaCO2 that is normal if uncompensated (35 to 45 mm/Hg), and a HCO3 that is greater than 26 mEq/mL.
48.A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A. Continuous bubbling in the water-seal chamber B. Occasional bubbling in the water-seal chamber C. Constant bubbling in the suction-control chamber D. Fluctuations in the fluid level in the water-seal chamber
A) answer Rationale: Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. B)Rationale: The nurse should expect continuous bubbling in the water-seal chamber initially and occasional bubbling after that. The bubbles indicate the removal of air from the pleural space, which is the expected result. C)Rationale: The nurse should expect constant, gentle bubbling in the suction control chamber. D)Rationale: The nurse should expect to see fluctuation with inspiration and exhalation, as this reflects the expected pressure changes in the pleural space during respiration.
75.A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds
A) answer Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy. B) Rationale: Squeaky, musical sounds caused by air whoosh through narrowed airways are a manifestation of bronchospasms. C) Rationale: Popping sounds caused by moving into deflated airways are a manifestation of atelectasis and pneumonia. D) Rationale: Snoring sounds, known as rhonchi, are heard when a client has thick, tenacious secretions.
72.A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? A. Lethargy B. High-grade fever C. Weight gain D. Dry cough
A) answer Rationale: Manifestations of pulmonary tuberculosis include lethargy and fatigue. B) Rationale: A low-grade fever is a manifestation of pulmonary tuberculosis. C) Rationale: Weight loss is a manifestation of pulmonary tuberculosis. D) Rationale: A productive cough is a manifestation of pulmonary tuberculosis. The client who has pulmonary tuberculosis often has purulent sputum streaked with blood.
59.A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A) answer Rationale: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids. B)Rationale: Alkalosis occurs when there is an imbalance in the amount or strength of the bases. In cases of respiratory alkalosis, this occurs because of an excessive loss of carbon dioxide through hyperventilation. It can occur in clients as a response to fear, anxiety or pain, from a fever or salicylate (aspirin) overdose. C)Rationale: Metabolic acidosis results due to an increase in the amount of acid or a decrease in the amount of base available. It is seen in starvation, diabetic ketoacidosis, renal failure, dehydration, and diarrhea. D)Rationale: Metabolic alkalosis results from an increase in the amount of bases seen in massive blood transfusion, or the administration of sodium bicarbonate, or a bicarbonate containing antacid. It can also occur related to an acid deficit, seen with prolonged vomiting, the use of thiazide diuretics, or prolonged gastric suctioning.
73.A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat
A) answer Rationale: Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately. B) Rationale: Copious oral secretions following extubation is an expected finding. The nurse should remind the client to cough to facilitate removal of secretions in the throat. C) Rationale: Hoarseness is an expected finding following extubation. D) Rationale: Sore throat is an expected finding following extubation.
78.A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority? A. Provide the client with supplemental oxygen at 5 L/min via facemask. B. Place the client in high-Fowler's position with their legs in a dependent position. C. Give the client sublingual nitroglycerin. D. Administer morphine sulfate IV.
A) answer Rationale: The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to provide supplemental oxygen at 5 L/min via simple facemask to promote effective gas exchange and tissue perfusion and to prevent rebreathing of exhaled air. The client is exhibiting signs of respiratory distress, such as dyspnea at rest, crackles, and anxiousness. Therefore, this is the nurse's priority intervention because it would helps manage hypoxia related to pulmonary edema. B) Rationale: The nurse should place the client in high-Fowler's position with their legs in a dependent position to decrease venous blood return to the heart. However, there is another intervention that is the nurse's priority. C) Rationale: The nurse should give the client sublingual nitroglycerin to decrease the preload and afterload. However, there is another intervention that is the nurse's priority. D) Rationale: The nurse should administer morphine sulfate IV to decrease the preload and afterload and decrease the client's anxiety. However, there is another intervention that is the nurse's priority.
46.A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A. Auscultate lung fields. B. Assess pulse and respirations. C. Assess characteristics of her sputum. D. Instruct to slowly exhale with pursed lips.
A) answer Rationale: The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure. B) Rationale: The nurse should assess vital signs every shift and during the procedure to determine the client's tolerance to positioning, but this is not the first actions the nurse should take. C) Rationale: The nurse should assess the characteristics of the sputum following the procedure, but this is not the first action the nurse should take. D) Rationale: The nurse should instruct the client to slowly exhale with pursed lips and use diaphragmatic breathing techniques to expel mucus during and following the procedure, but this is not the first action the nurse should take.
52.A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign. C. Administer an IV vasopressor medication. D. Monitor the client for headache.
A) answer Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation. B)Rationale: The nurse should check the client for a positive Chvostek's sign to monitor for hypocalcemia secondary to fat embolism syndrome; however, there is another action the nurse should take first. C) Rationale: The nurse should administer an IV vasopressor medication to prevent hypotension secondary to fat embolism syndrome; however, there is another action the nurse should take first. D) Rationale: The nurse should monitor the client for headache secondary to fat embolism syndrome to provide appropriate pain relief; however, there is another action the nurse should take first.
58.A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright
A) answer Rationale: This describes Cheyne-Stokes respirations, an indication that the client is approaching death. B)Rationale: This describes Biot's (cluster) respirations, an alteration that accompanies some central nervous system disorders. C)Rationale: This describes Kussmaul's respiration, a compensatory mechanism for metabolic acidosis during which the client attempts to get rid of excess acid in the form of carbon dioxide. D)Rationale: This describes orthopnea, a compensatory mechanism to ease breathing in clients who have chronic obstructive pulmonary disease.
57.A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? A. Airway protection B. Decreasing intracranial pressure C. Stabilizing cardiac arrhythmias D. Preventing musculoskeletal disability
A) answer Rationale: When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway. B)Rationale: After managing the airway, breathing, and circulation, the nurse would assess and manage any disabilities. This involves a baseline assessment of the client's neurologic status. C)Rationale: When using the airway, breathing, circulation approach to client care, the nurse would stabilize cardiac rhythms. However, it is not the priority focus of care. D)Rationale: Preventing musculoskeletal disability is is completed during the secondary survey of the client who has trauma, following a head-to-toe assessment. It is not the priority focus of the nurse when using the airway, breathing, circulation approach to client care.
71.A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) to measure pulmonary artery to measure pulmonary artery to measure pulmonary artery and monitors a client's A. Night sweats B. Low-grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum
A, B, E) answer Rationale: Night sweats is correct. Night sweats are a manifestation of tuberculosis.</br></br>Low-grade fever is correct. Low-grade fever is a manifestation of tuberculosis.</br></br>Weight gain is incorrect. Weight loss, not weight gain, is a manifestation of tuberculosis.</br></br>Flushed cheeks is incorrect. Flushed cheeks are a manifestation of pneumonia, not tuberculosis.</br></br>Blood in the sputum is correct. Blood-streaked sputum is a manifestation of tuberculosis.
65.A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A. Instruct the woman to call 911. B. Ask the partner if he can speak. C. Use the jaw-thrust maneuver. D. Perform chest compressions.
B) answer Rationale: Before intervening, the nurse should determine if the partner's airway is blocked. Therefore, the nurse should ask the partner if he can speak. If he can speak, breathe, or cough, air is moving through his airway. A)Rationale: Because the woman is screaming, the nurse should ask someone else in the restaurant to call 911 and give the essential details to the dispatcher C) Rationale: The nurse should perform the jaw-thrust maneuver to open a client's airway prior to administering rescue breaths or attempting to get air into the client. D)Rationale: The nurse should perform chest compressions for a client who is experiencing cardiac arrest, not for a client who is choking.
56.A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? A. Insert an IV line. B. Count the respiratory rate. C. Administer oxygen. D. Prepare equipment for intubation.
B) answer Rationale: Checking the client's respiratory status is the priority action when following the nursing process approach to client care. A)Rationale: The nurse should insert an IV line to provide fluids and medications. However, it is not the priority action when following the nursing process approach to client care. C)Rationale: The nurse should administer oxygen to the client using a high-flow, non-rebreather mask to prevent hypoxia. However, it is not the priority action when following the nursing process approach to client care. D)Rationale: Preparing equipment for intubation ensures the client will maintain an open airway in the event of respiratory failure. However, it is not the priority action when following the nursing process approach to client care.
74.A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis B. Flail chest C. Hemothorax D. Pneumothorax
B) answer Rationale: Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out. A) Rationale: Atelectasis is a collapse of the alveoli. With atelectasis, the exchange of oxygen and carbon dioxide is diminished. Crackles, fever and productive cough are manifestations of atelectasis. C) Rationale: Hemothorax is blood in the pleural space and involves decreased movement of the involved chest wall. Manifestations of a large hemothorax include diminished breath sounds and dull percussion sounds. D) Rationale: Pneumothorax is air in the pleural space and involves decreased movement of the involved chest wall. Manifestations of pneumothorax include diminished breath sounds and hyperresonance upon percussion.
43.A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% B. No fluctuations in the water seal chamber C. No reports of pleuritic chest pain D. Occasional bubbling in the water-seal chamber
B) answer Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning. A) Rationale: A client can have an oxygen saturation of 95% with or without lung re-expansion. C) Rationale: The client might not report pain if his pain management is effective, not because his lung has re-expanded. D) Rationale: Occasional bubbling indicates the removal of air from the pleural space, indicating that the lung is not fully re-expanded.
63.A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.
B) answer Rationale: The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation. A)Rationale: It is important to manage the client's pain because this can reduce oxygen consumption and limit the harmful effects of catecholamines, which are released when the client experiences pain; however, another intervention should be implemented by the nurse first. C)Rationale: Crystalloids are administered via continuous IV bolus to maintain cardiac output and prevent shock; however, another intervention is the priority action for the nurse to take. D) Rationale: The client who develops a pulmonary embolism is likely to have cardiac manifestation as a result of decreased tissue perfusion. It will be important to monitor the client's cardiac rhythm for T-wave and ST-segment changes as well as right ventricular failure or myocardial infarction. There is, however, another intervention that is the priority.
70.A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest
B) answer Rationale: The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs. A) Rationale: The nurse should anticipate the client's arterial blood gasses will reveal respiratory acidosis because there is increased arterial carbon dioxide. C) Rationale: This oxygen saturation level is within the expected reference range. The nurse should anticipate a decreased oxygen saturation level. D) Rationale: The nurse should anticipate petechiae on the chest and the abdomen for a client who has pulmonary embolism.
54.A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? A. Insert an oral airway. tube. B. Administer the abdominal thrust maneuver. C. Turn the client to the side. D. Perform a blind finger sweep.
B) answer Rationale: The nurse should immediately begin applying abdominal thrusts to a conscious client who an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. A)Rationale: Insertion of an oral airway is appropriate if the client is unconscious and the obstruction is due to the tongue obstructing the airway or from excessive secretions. Inserting an oral airway conscious client will cause the client to gag and will not relieve the obstruction. C)Rationale: Turning the client to the side is an appropriate intervention if the client is unconscious and breathing to prevent aspiration of any vomitus that occurs. D)Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction and is contraindicated.
41.A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? A. Clamp the tube when the client is ambulating. B. Keep the collection device below the level of the client's chest. C. Coil the tubes carefully to prevent kinking. D. Lay the client flat to avoid leaks in the tubing.
B) answer Rationale: The nurse should keep the drainage system lower than the client's chest to facilitate drainage from the chest cavity. A) Rationale: The nurse should clamp the client's chest tube only when replacing the drainage system or when checking for air leaks. C) Rationale: The nurse should keep the tubing as straight as possible, without any kinks or dependent loops. This can impair the function of the chest tube. D) Rationale: Upright positioning allows optimal lung expansion. The nurse should elevate the head of the client's bed at least 30°.
61.A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub
B) answer Rationale: The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain. A)Rationale: Atelectasis refers to the closure or collapse of the alveoli resulting in hypoxia. A client may develop cyanosis as a result. C)Rationale: Because of the decreased oxygen exchange caused by the atelectasis, the client will be tachypneic in an effort to meet the body's oxygen needs. D)Rationale: A friction rub is a grating or creaking sound heard when a client has inflammation of the pleura. For the client who has atelectasis, auscultation may reveal decreased breath sounds and crackles.
68.A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A) Urinary output 25 mL/hr B) Difficulty swallowing C) Heart rate 122/min D) Pain of 6 on a scale of 0 to 10
B) answer Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this is can be an indication that the client's airway is obstructed. A)Rationale: The nurse should report a urinary output of 25 mL/hr because it is below the expected reference range of 30 to 50 mL/hr; however, this is not the priority finding to report. C)Rationale: The nurse should report a heart rate of 122/min because it is above the expected reference range; however, this is not the priority finding to report. D) Rationale: The nurse should report pain of a 6 on a scale of 0 to10 to obtain a prescription for pain relief; however, this is not the priority finding to report.
51.A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make? A. "We can teach you some relaxation techniques to minimize your pain." B. "Keep wire cutters with you at all times." C. "Use a water pick device to keep your teeth clean." D. "Consume a high-protein, liquid diet."
B) answer Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to include is to tell the client to keep wire cutters available at all times. When the jaw is wired shut, the client is likely to aspirate if vomiting occurs. The client should use the wire cutters to clip the wires to keep the mouth clear of emesis, and should notify the provider so the jaw can be re-wired. A)Rationale: The nurse should manage the client's pain by including pharmacological and nonpharmacological relief interventions; however, there is another statement that the nurse should identify as the priority. C)Rationale: The nurse should teach the client about appropriate oral hygiene to prevent infection in the mouth, which could complicate healing. However, there is another statement that the nurse should identify as the priority. D)Rationale: The nurse should tell the client to consume a liquid diet that includes protein and other nutrients necessary for wound healing; however, there is another statement that the nurse should identify as the priority.
50.A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A. Urticaria B. Stridor C. Vomiting D. Hypotension
B) answer RationaleWhen using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance. A)RationaleThe nurse should administer an antihistamine or corticosteroid to minimize the client's itching or skin inflammation; however, there is another finding the nurse should address first. C)RationaleThe nurse should administer an antiemetic medication for the client; however, there is another finding the nurse should address first. D)RationaleThe nurse should raise the client's feet and legs to promote venous return of blood to the torso and maintain vital organs perfusion; however, there is another finding the nurse should address first.
62.A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine
C) answer Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots. A)Rationale: Furosemide, a diuretic, is often used in the treatment of pulmonary edema; however, it is not used for the client who has a pulmonary embolism. B)Rationale: Glucocorticoids such as dexamethasone decrease inflammation and is used to treat a wide variety of disorders, including inflammatory bowel disease and cerebral edema. It is not, however, useful in treating a pulmonary emboli. D) Rationale: Atropine, an anticholinergic, is used in the treatment of bradycardia. The client who has a pulmonary embolism will be tachycardic.
40. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature
C) answer Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately. A) Rationale: A small amount of serosanguineous drainage at the puncture site is expected after a thoracentesis. B) Rationale: Mild discomfort at the puncture site is expected after a thoracentesis. D) Rationale: Infection is possible after any invasive procedure; however, it takes time to develop and increases the body temperature.
76.A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."
C) answer Rationale: Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals. A) Rationale: The client should first inhale slowly through the nose, then exhale slowly through pursed lips. B)Rationale: The client is at risk for respiratory infections. Therefore, the client should avoid crowds and should get an annual vaccination against influenza. D) Rationale: The client should practice abdominal (diaphragmatic) breathing exercises daily while lying on his back with his knees flexed. The client should focus on using the diaphragm to achieve maximum inhalation and to slow his respiratory rate.
53.A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. Movement of the ET tube into the right main bronchus D. Infection of the vocal cords
C) answer Rationale: During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube A)Rationale: The ET tube is positioned over the client's tongue, so the tongue cannot obstruct it. The nurse should expect decreased SaO2 if the ET tube is obstructed. B)Rationale: The nurse should suspect passage of the ET tube into the esophagus if the client's breath sounds are heard over the abdomen and the abdomen becomes distended. D)Rationale: The nurse should suspect infection if the client exhibits findings such as hyperthermia and increased WBC.
47.A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. B. Assess for an increase in temperature. C. Check the oximeter. D. Monitor for manifestations for increased intracranial pressure.
C) answer Rationale: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to maintain a patent airway. Checking the oximeter is the first indicator of poor oxygen exchange which can cause cerebral edema. A)Rationale: The nurse should monitor for a CSF leak from the evacuation site; however, it is not the priority action. B)Rationale: The nurse should assess for an increase in temperature; however, it is not the priority action. D)Rationale: The nurse should monitor for manifestations for increased intracranial pressure; however, it is not the priority action.
79.A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C) answer Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway. A) Rationale: Following a bronchoscopy, an older adult client is at risk for confusion due to medications use for sedation. However, there is another assessment that is the nurse's priority. B) Rationale: The client is at risk for hypoxia following a bronchoscopy and the nurse should auscultate the client's breath sounds. However, there is another assessment that is the nurse's priority. D) Rationale: The client is at risk for hypotension due to the medications used for sedation during the procedure. However, there is another assessment that is the nurse's priority.
42.A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C) answer Rationale: With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. A) Rationale: With uncompensated metabolic acidosis, the pH is less than 7.35 and the PaCO2 is less than 35 mm Hg or within the expected reference range. B) Rationale: With uncompensated metabolic alkalosis, the pH is greater than 7.45 and the PaCO2 is greater than 45 mm Hg or within the expected reference range. D) Rationale: With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO2 is less than 45 mm Hg.
67.A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel
D) answer Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped. A)Rationale: Pectus carinatum is an overgrowth of cartilage that causes the sternum to protrude forward, creating a pigeon-shaped chest. B)Rationale: Pectus excavatum is a congenital chest deformity that causes a funnel or concave chest shape. C)Rationale: A kyphotic chest results from a curvature of the spine that produces a hunchback effect.
49.A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport B. A client who has a prescription for discharge C. A client who received oral pain medication 30 min ago D. A client who told an assistive personnel he is short of breath
D) answer Rationale: A client who has shortness of breath is unstable; therefore, this is the client the nurse should plan to see first. A)Rationale: A client who is scheduled for an abdominal x-ray and is awaiting transport is stable. The nurse should see the client before allowing her to leave the unit; however, there is another client the nurse should see first. B)Rationale: A client who has a prescription for discharge is stable; therefore, there is another client the nurse should see first. C)Rationale: A client who received oral pain medication 30 minutes ago is stable; therefore, there is another client the nurse should see first. The nurse should expect oral analgesia to reach peak effect after 1 hr.
64.A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions
D) answer Rationale: Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs. A)Rationale: A client who is hypoxic is more likely to have tachycardia than bradycardia. B)Rationale: Clients who have hypoxia generally have rapid, shallow respirations and are dyspneic. C)Rationale: The client who is hypoxic is increasingly restless and may state feeling light-headed.
60.A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.
D) answer Rationale: Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds. A)Rationale: ARDS is an acute respiratory failure in which the client remains hypoxic despite the administration of 100% oxygen. Clients who have ARDS require high concentrations of oxygen, usually by mask or ventilator. B)Rationale: Diuretics and fluid restrictions help minimize pulmonary edema, which is part of ARDS. C)Rationale: Clients who have ARDS are at high risk for malnutrition. The client is often sedated and paralyzed to provide mechanical ventilation and decrease oxygen needs. The nutritional needs of the client will be met through enteral or parenteral means.
66.A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.
D) answer Rationale: Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD. A)Rationale: Unless the client has another medical disorder that warrants fluid restriction, he should drink 2 to 3 L of fluid each day. B)Rationale: Clients who have COPD should consume a high-calorie, high-protein diet to prevent weight loss. C)Rationale: Clients who have COPD have poor exercise tolerance in the early morning due to the pulmonary secretions that accumulate while the client has been recumbent during the night.
44.A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction. B. Strip the client's chest tube. C. Clamp the client's chest tube. D. Reposition the client.
D) answer Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube. A) RationaleThe nurse increasing the wall suction does not affect the amount of negative pressure of the chest tube and would not relieve the client's chest burning. B)Rationale: The nurse stripping the chest tube increases negative pressure and may damage lung tissue and would not resolve the client's chest burning. C) Rationale: The nurse clamping the chest tube briefly to change the chamber or check for an air leak is recommended but would not resolve the client's chest burning.
