Theory Exam 3

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray." If the client touches the sterile field, the nurse will need to discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. The nurse should call for help if a supply is needed. The nurse should not leave the sterile field unobserved.

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

"Respirations of the client with emphysema can be compared to a balloon that has been blown up before." "Emphysema, like a new balloon, takes less effort to empty air out of the alveoli." The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity and leading to decreased compliance.

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?

"Tell me about what you do to take care of your skin."

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.

The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs While all these changes are possible because of age, ineffective cough is most important after surgery. The intervention provided by the nurse is directed toward minimizing pain and maximizing expulsion of secretions, thus minimizing the risk for the development of postsurgical pneumonia.

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?

Administer naloxone Naloxone is an opioid antagonist that reverses the respiratory depressant effects of opioids. If stimulation is ineffective in arousing a client using opioids, naloxone can be used. When the client is alert and the respiratory rate is greater than 9 breaths/min, the opioids may be resumed. A code blue is not appropriate, as there is no indication that the client is without pulse or respiration. However, being prepared for this action is necessary. The nurse will contact the health care provider but first needs to take action to prevent further deterioration of the client's condition. The family must be notified but the most pressing matter is the care of the client.

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia A simple mask may cause anxiety in clients who experience claustrophobia due to the mask covering the nose and mouth. The flow meter for the simple mask is set at 5 L/min or higher to prevent rebreathing exhaled carbon dioxide. The client is not at risk for oxygen toxicity due to the level of oxygen administration with the simple mask. The client's target oxygen saturation would be 88% to 92% (0.88 to 0.92) if the client had chronic obstructive pulmonary disease (COPD). There is no information in the question to indicate the client has COPD.

The nurse is caring for a postoperative adult client who has undergone abdominal surgery. The nurse will provide interventions aimed at preventing what respiratory complication?

Atelectasis For the patient with an abdominal incision, the discomfort of breathing deeply often forces shallow breathing; this is why atelectasis is common in patients after surgery. None of the other listed respiratory conditions are common in the post-operative period or are considered complications of surgery.

A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem?

Bronchospasm When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. Bronchitis and bronchiectasis are chronic respiratory effects and bronchiolitis is infectious.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse?

Contact the health care provider. The nurse should contact the health care provider, as PCA therapy for pain management is contraindicated for clients with sleep apnea. This is due to the fact that oversedation in clients with sleep apnea poses a significant health risk. PCA therapy is also contraindicated in confused clients, infants and very young children, cognitively impaired clients, and clients with asthma.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds?

Crackles Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Heat Massage Pressure The gate theory supports that the signals at the gate in the spinal cord determine which impulses eventually reach the brain. A limited amount of sensory information can be processed by the nervous system at any given moment. When there is too much information sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The theory appears to explain why mechanical and electrical interventions such as heat, pressure, and massage provide effective pain relief.

The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply.

How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain?

A client presents with reports of acute pain. The nurse's assessment indicates the client is likely experiencing moderate, superficial acute pain. What assessment finding would corroborate this conclusion? Select all that apply.

Increased BP, pulse, and RR Sympathetic physiologic responses to moderate superficial acute pain can include increased blood pressure, pulse, and respiratory rate.

A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)?

Initiation of CPR for a client who is found unresponsive The initiation and provision of cardiopulmonary resuscitation is appropriate for all health care providers. Depending on the state's nurse practice act and the organization's policies and procedures, an LPN may or may not be able to perform the other listed actions.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract. During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

A client who has a leg cast tells the nurse that they have pain inside the cast. Which type of stimulus is likely causing this pain?

Mechanical Receptors in the skin may be stimulated by mechanical, thermal, chemical, and electrical agents. Pressure from a cast is a mechanical agent causing pain. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt of a static charge is an electrical stimulant.

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?

Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration If a nurse is conducting a health history interview for a client diagnosed with chronic bronchitis when respiratory distress occurs, the nurse first places the client in a comfortable position, ensures a patent airway, and starts oxygen if prescribed. After ensuring an open airway, the next step is quickly assessing the respiratory rate and quality and then getting assistance in case the client's respiratory status starts to deteriorate. Speaking slowly and calmly to relax the client is valuable but does not help assess the client's respiratory distress or prepare to manage it. The condition may require further intervention so preparation is needed.

The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide?

Provide suggestions of high-protein, high-calorie meals TThe client should have sufficient caloric and protein intake for respiratory muscle strength, so promotion of a high-calorie, high-protein diet is appropriate. Protein shakes and dietary supplements may be appropriate but should complement, rather than replace, meals. Intermittent fasting promotes weight loss, not increased calorie intake.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from the room Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.

Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take?

Reposition the client and gently massage the client's back. The nurse would reposition the client and gently massage the client's back using the gate-control theory of pain. The gate-control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Decreasing the dosage of the pain medication—but giving the doses more frequently—does not follow this theory. Decreasing external stimuli in the room during painful episodes would not address the gate-control theory. Advise the client to sleep following administration of pain medication does not address the gate-control theory.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV) During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

A client is scheduled for an inguinal hernia repair and is concerned about the possibility of developing a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

Surgical asepsis Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment. These measures supersede the importance of reactive treatment, vitamin intake or the use of targeted therapies like monoclonal antibodies.

A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action?

Teach the client to perform deep-breathing and coughing exercises. While using PCA, the nurse should encourage the client to practice coughing and deep breathing to promote ventilation and prevent pooling of secretions.

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply.

Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain The Wong-Baker FACES Pain Rating Scale is useful for assessing children, although children as young as 8 years can use a 0 to 10 numeric scale. The nurse should ask the client to describe the pain but should be aware that a 5-year-old child may not be able to describe the pain. Asking the parents about the client's pain can cloud the nursing process of assessment. Observing the behaviors of the child is important; however, the nurse needs to remember that the client may have diversional activities when coping with pain, such as laughing or talking, which can alter the nurse's assessment of the pain by the client.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response?

behavioral Behavioral (voluntary) responses would include moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb. Physiologic (involuntary) responses would include increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose. Psychological responses would include exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

pneumonia Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease?

Bronchitis Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection?

Contact precautions Contact precautions are used for clients who have incisional wound infections with organisms that can be transmitted by hand or skin-to-skin contact, such as during client care activities or when touching the client's environmental surfaces or care items. Droplet precautions are used for microorganisms transmitted by larger particle droplets, which disperse into air currents and are not applicable for clients with incisional infections. Airborne precautions are used to protect against microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents and are not applicable to incisional infections. Protective isolation may still be used in high-risk situations to prevent infection for people whose body defenses are known to be compromised, which is not applicable to incisional infections.

The nurse performs personal hygiene, including bathing, for an immobile client. What benefit(s) is the client gaining? Select all that apply.

Promotes relaxation and comfort Increases circulation Helps maintain muscle tone and joint mobility Reduces the risk of acquiring multidrug-resistant organisms Bathing promotes relaxation and comfort as well as gives most people a sense of well-being. Bathing also increases circulation (from the friction of a washcloth) and helps maintain muscle tone and joint mobility (from the movement of limbs during the bath). Research demonstrates that daily bathing with chlorhexidine-impregnated washcloths significantly reduces the risk of acquiring multidrug-resistant organisms and the development of hospital-acquired bloodstream infections. A warm bath does not constrict circulation; it increases circulation by dilating blood vessels near the skin surface, allowing more blood to flow to the skin.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug. Paradoxical effects of hypnotics involve a stimulating effect or mental changes.

Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition?

caries The combination of sugar, plaque, and bacteria may eventually erode the tooth enamel, causing caries (cavities). Tartar (hardened plaque) is more difficult to remove and may lead to gingivitis (inflammation of the gums). Pockets of gum inflammation promote periodontal disease, a condition that results in the destruction of the tooth-supporting structures and bones that make up the jaw.