Funds Basics MedSurg Infectious Disease and Respiratory

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, the nurse should: 1. Suction as needed 2. Apply an ice collar 3. Maintain a high-Fowler position 4. Encourage expectoration of secretions

1 After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery. Although the application of an ice collar may limit edema or pain, it will not maintain patency of an airway that is compromised by secretions. A side-lying position will facilitate better drainage from the mouth. The client may not be reactive or have energy to cough or expectorate; the priority is to prevent secretions from entering the respiratory tract.

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client? 1. Penicillin therapy 2. Major tranquilizers 3. Behavior modification 4. Electroconvulsive therapy

1 Massive doses of penicillin may limit central nervous system damage if treatment is started before neural deterioration from syphilis occurs. Tranquilizers are used to modify behavior, not to treat general paresis. Behavior, not paresis, is treated with behavior modification. Electroconvulsive therapy is used to treat certain psychiatric disorders.

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find: 1. A decrease in CD4 T cells 2. An increase in thymic hormones 3. An increase in immunoglobulin E 4. A decrease in the serum level of glucose-6-phosphate dehydrogenase

1 The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore, 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes are suggestive of AIDS. The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug induced hemolytic anemia and hemolytic disease of the newborn.

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education? 1. Chest tubes will be in place after the procedure 2. The procedure is an endoscopic examination of lymph nodes 3. The procedure will visualize the mainstem bronchus 4. Some pleural fluid will be removed during the procedure

2 A mediastinoscopy is an endoscopic examination of mediastinal lymph nodes through a small suprasternal incision; this generally is done to diagnose mediastinal involvement of pulmonary malignancy or other conditions. Chest tubes are not required unless the lungs are accidentally punctured; the client will have a small incision near the clavicle. A bronchoscopy permits visualization of the mainstem bronchus. Fluid is removed from the pleural space during a thoracentesis.

In today's health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort? 1. Extent of informed consumerism 2. Limited time to engage in teaching 3. Variety of cultural beliefs that exist 4. Deficient motivation of adult learners

2 Because of the variety of factors vying for the nurse's time, efficient use of the time available for teaching is essential to meet the standards of care and legal responsibilities of the nurse. The increased awareness and knowledge of health issues by consumers may provide a foundation on which the teaching plan may be built; informed consumerism should be viewed as positive, not negative. Assessing cultural beliefs is part of the initial and continuing assessment of clients; this should not cause additional stress when teaching. Generally, adults are motivated, independent learners, and the nurse teacher should be a facilitator of learning.

Donning Sterile Gloves. How should the second glove be handled? 1. Grasp inside second glove and place on nondominant hand. 2. Place sterile glove under cuff, and slide hand in glove. 3. Don glove on nondominant hand first, then hold below waist and slide on. 4. Grasp by cuff and place on remaining hand.

2 Sterile gloves can only be handled by sterile equipment or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, as under the waist or in back is contaminated. Grasping by the cuff means the inside of the glove has been touched.

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? 1. No further action is required 2. Additional tests are necessary 3. Repeating the skin test is indicated 4. Results are positive, indicating infection

2 The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive if there is repeated close contact with a person diagnosed with pulmonary tuberculosis or if the client has a disease causing decreased resistance; this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH); also, this client has diabetes mellitus and may be more prone to develop active disease even though cultures indicate a dormant infection. Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive. The test does not indicate whether TB is dormant or active. Additional tests are required.

Which action should the nurse take when caring for a client with malaria? 1. Institute seizure precautions. 2. Prepare for blood transfusions. 3. Maintain isolation precautions. 4. Provide nutrition between paroxysms.

4 Maintaining adequate nutritional and fluid balance is essential to life and must be accomplished during periods when intestinal motility is not excessive so that absorption can occur. Although shaking chills may occur, seizures generally do not occur. Blood transfusions are not used in the treatment of malaria. Maintaining isolation precautions is unnecessary; infection can occur only through direct serum contact or a bite from an infected Anopheles mosquito.

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. The nurse should instruct the client that the purpose of pursed-lip breathing is to: 1. Decrease chest pain. 2. Conserve energy. 3. Increase oxygen saturation. 4. Promote elimination of CO2.

4 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients to slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is: 1. "Repeated phlebotomies may be able to rid you of the virus." 2. "You may be cured of AIDS after prolonged pharmacologic therapy." 3. "Perhaps you should have worn condoms to prevent contracting the virus." 4. "There is no cure for AIDS but there are drugs that can slow down the virus."

4 Stating "There is no cure for AIDS but there are drugs that can slow down the virus" is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications. Phlebotomy is not the treatment used to remove the virus from the client's body. Current pharmacological treatment does not eliminate the virus from the body; it can slow its progress and may even effect a remission (although the medications are never discontinued), but there is no known cure. Stating "Perhaps you should have worn condoms to prevent contracting the virus" is a nontherapeutic, judgmental response that can alienate the client and precipitate feelings of guilt.

A client who has emphysema for many years develops an enlarged liver. The nurse concludes that the enlarged liver is a result of: 1. Liver hypoxia 2. Hepatic acidosis 3. Esophageal varices 4. Portal hypertension

4 The enlarged liver is caused by long-term respiratory acidosis with increased pulmonary pressure that eventually causes right ventricular enlargement and failure (corpulmonale); the elevated pressure causes backup pressure in the hepatic circulation. Liver hypoxia will cause atrophy and necrosis of cells, not enlargement. Right ventricular failure with increased pressure in the ascending vena cava causes increased pressure in the hepatoportal system, resulting in an enlarged liver, not hepatic acidosis. Esophageal varices, dilated tortuous veins of the esophagus, are caused by hepatic portal hypertension; they are not the cause of an enlarged liver.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? 1. Asking about what type of foods the client usually eats 2. Telling the client that the diet must be followed exactly as written 3. Telling the client that the intake of foods on the list must be limited 4. Asking about what the client knows about the diet that was prescribed

4 This question may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.