Ed 1355 Exam 3 practice problems

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as:

Cheyne-Stokes respiration.

The nurse is aware that the best position for a client with impaired gas exchange is what?

High-fowlers

A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH, 7.52; partial pressure of carbon dioxide, 38 mm Hg (5.1 kPa); bicarbonate, 34 mg/L (34 mmol/L). The nurse should plan care based on the fact that these findings indicate which of the following acid-base imbalances?

Metabolic alkalosis.

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute Rationale: albuterol is used as a bronchodilator

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:

moderate pain that worsens on inspiration.

A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:

nervousness Rationale: other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps AT HIGH DOSES: hypokalemia

A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance?

respiratory acidosis

To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest that the couple:

use pillows to raise the affected partner's head and upper torso.

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer:

vitamin K1 (phytonadione).

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:

a drop in the client's heart rate.

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions?

"I should try to eat several small meals during the day."

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply.

-Report hemoptysis, stridor, or dyspnea immediately. -Keep suction equipment available. -Assess cough and gag reflexes after the procedure.

A client is being prepared for a bronchoscopy. Which of the following preoperative activities would be appropriate for the nurse to delegate to the nursing assistant?

Placing the client on NPO status.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which statement is true concerning oxygen administration to a client with COPD?

High oxygen concentrations may inhibit the hypoxic stimulus to breathe.

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.

Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?

Teach the client to splint the rib cage when coughing.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

Which finding would suggest pneumothorax in a trauma victim?

absent breath sounds Rationale: lung will collapse

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first?

albuterol nebulizer

An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important?

applying an oximeter and initiating respiratory therapy

Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. The priority for care is first to:

maintain adequate oxygenation

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:

may induce bronchospasm

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg Rationale: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35