M/S PT#2
A patient has a sodium level of 130. What is this condition called? Hyponatremia. Hypercalcemia. Hypernatremia. Normal sodium level.
Hyponatremia. A normal sodium level is 136-145 mEq/L, a sodium level of 130 is below the normal sodium level.
Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? osmotic pressure. intake and output. skin turgor. cardiac rate and rhythm.
cardiac rate and rhythm.
A patient who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. The nurse should instruct the patient to: avoid brushing the teeth until the nasal packing is removed. take aspirin to control nasal discomfort. avoid activities that elicit Valsalva's maneuver. apply heat to the nasal area to control swelling.
avoid activities that elicit Valsalva's maneuver. The patient should be instructed to avoid any activities that cause Valsalva's maneuver (i.e., constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture lines. The patient should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the patient's appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.
A patient is receiving streptomycin in the treatment regiment of tuberculosis. The nurse should assess for: IV infiltration. hearing loss. difficulty swallowing. decreased serum creatinine.
hearing loss. Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin is given via intramuscular injection.
Dietary recommendations for a patient with a hypotonic fluid excess should include: decreased sodium intake. increased fluid intake. intake of potassium-rich foods. increased sodium intake.
increased sodium intake.
Which is a priority goal for the patient with chronic obstructive pulmonary disease (COPD)? minimizing chest pain. increasing carbon dioxide level in the blood. treating infectious agents. maintaining functional ability.
maintaining functional ability.
The nurse is teaching a patient who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the patient indicate(s) that he has understood the nurses instructions? Select all that apply. "I can use regular plate and utensils whenever I eat." "I will need to dispose of my old clothing when I return home." "I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them properly." "It is important that I isolate myself from family when possible."
"I can use regular plate and utensils whenever I eat." "I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them properly."
Which statement indicates that the patient who has undergone repair of the nasal septum has understood the discharge instructions? "Coughing every 2 hours is important to prevent respiratory complications." "It is important to blow my nose each day to remove the dried secretions." "I will take stool softeners and modify my diet to prevent constipation." "I should not shower until my packing is removed."
"I will take stool softeners and modify my diet to prevent constipation." Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The patient should take measures to prevent coughing. The patient should avoid blowing the nose for 48 hours after the packing is removed.
The nurse evaluates which of the following patients to be at risk for developing hypernatremia? 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH). 50-year-old with pneumonia, diaphoresis, and high fevers. 62-year-old with congestive heart failure taking loop diuretics. 39-year-old with diarrhea and vomiting.
50-year-old with pneumonia, diaphoresis, and high fevers. Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Patients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.
Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination? A 36-year-old woman with 3 children, A 60-year-old woman with osteoarthritis, A 50-year-old woman caring for a spouse with cancer, A 60-year-old man with a hiatal hernia.
A 50-year-old woman caring for a spouse with cancer, Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described.
The nurse is admitting a patient with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of: Nasogastric drainage. Malabsorption syndrome. Acute renal failure. Laxative abuse.
Acute renal failure.
The nurse is performing tracheal suctioning. Which action is essential to prevent hypoxemia during suctioning? Administer 100% oxygen before suctioning. Removal of oral and nasal secretions. Auscultate the lungs. Encouraging the client to deep breathe and cough.
Administer 100% oxygen before suctioning.
A 74 year-old female patient presents to the emergency room with tented skin turgor, dry mucous membranes,and decreased urinary output. Which would be the most appropriate intervention? Monitoring serum albumin and total protein levels. Administer oral rehydration fluids. Assessing color, odor, and amount of sputum. Clustering necessary activities throughout the day.
Administer oral rehydration fluids.
An oxygen delivery system is prescribed for a male patient with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? Face tent. Venturi mask. Tracheostomy collar Aerosol mask.
Aerosol mask. The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the patient with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
For a patient with asthma, the healthcare provider (HCP) prescribes albuterol, two puffs twice a day, and beclomethasone, two puffs twice a day. The nurse instructs the patient to administer: Albuterol on awakening and alternate the medication every 4 hours. Beclomethasone inhaler first and follow with albuterol. Albuterol first and follow with beclomethasone two times a day. Medications 1 hour apart, two times a day.
Albuterol first and follow with beclomethasone two times a day. The nurse instructs the patient to administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue.
A patient with COPD reports steady weight loss and being "too tired from just breathing to eat." Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this patient? Activity intolerance related to dyspnea. Weight loss related to COPD. Ineffective breathing pattern related to alveolar hypoventilation. Altered nutrition: Less than body requirements related to fatigue.
Altered nutrition: Less than body requirements related to fatigue. The patient's problem is altered nutrition—specifically, less than required. The cause, as stated by the patient, is the fatigue associated with the disease process. Activity intolerance is a likely diagnosis but is not related to the patient's nutritional problems. Weight loss is not a nursing diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the patient.
After nasal surgery, the patient expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? Use a bedside humidifier while sleeping. Take analgesics every 4 hours around the clock. Use corticosteroid nasal spray as needed to control symptoms. Apply cold compresses to the area.
Apply cold compresses to the area. Applying cold compresses helps to decrease facial swelling and pain from edema. Analgesics may decrease pain, but they do not decrease edema. A corticosteroid nasal spray would not be administered postoperatively because it can impair healing. Use of a bedside humidifier promotes comfort by providing moisture for nasal mucosa, but it does not decrease edema.
Following nasal surgery, what should the nurse do first? Inspect the area for periorbital ecchymosis. Assess respiratory status. Measure intake and output. Assess the patient's pain.
Assess respiratory status.
Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery? Bronchitis. Atelectasis. Pneumonia. Pneumothorax.
Atelectasis. Atelectasis develops when there's interference with the normal negative pressure that promotes lung expansion. Patients in the postoperative phase often splint their breathing because of pain and positioning, which causes hypoxia. It's uncommon for any of the other respiratory disorders to develop.
A patient with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor: Urine output. Bowel movements. Blood Pressure. ECG for tall, peaked T waves.
Bowel movements. Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If the patient does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.
A 58-year-old patient with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? Emphysema. Adult respiratory distress syndrome (ARDS). Chronic obstructive bronchitis. Asthma.
Chronic obstructive bronchitis. Because of his extensive smoking history and symptoms, the patient most likely has chronic obstructive bronchitis. Patients with ARDS have acute symptoms of and typically need large amounts of oxygen. Patients with asthma and emphysema tend not to have a chronic cough or peripheral edema.
The term "blue bloater" refers to which of the following conditions? Adult respiratory distress syndrome (ARDS). Chronic obstructive bronchitis. Emphysema. Asthma
Chronic obstructive bronchitis. Patients with chronic obstructive bronchitis often present with peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Patients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Patients with asthma don't exhibit characteristics of chronic disease, and patients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and wasting).
The nurse assesses the respiratory status of a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which findings are expected? Prolonged inspiration. Coarse crackles and rhonchi. Normal chest movement. Normal breath sounds.
Coarse crackles and rhonchi. Exacerbation of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become over distended.
A nursing instructor is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism? Use of masks, gowns, and gloves when caring for clients with infection. Correct handwashing technique. Cleanup of blood spills with sodium hydrochloride. Maintenance of asepsis with indwelling catheter insertion.
Correct handwashing technique.
The term "pink puffer" refers to the patient with which of the following conditions? ARDS. Emphysema. Asthma Chronic obstructive bronchitis.
Emphysema. Because of the large amount of energy it takes to breathe, patients with emphysema are usually cachectic. They're pink and usually breathe through pursed lips, hence the term "puffer". Patients with ARDS are usually acutely short of breath. Patients with asthma don't have any particular characteristics, and patients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
A nurse is assessing a patient with chronic airflow limitation and notes that the patient has a "barrel chest." The nurse interprets that this patient has which of the following forms of chronic airflow limitation? Emphysema. Chronic obstructive bronchitis. Bronchial asthma. Bronchial asthma and bronchitis.
Emphysema. The patient with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as "barrel chest." The patient also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
A 55 year-old male patient presents to the emergency department due to hyperventilation. Which nursing intervention is the most appropriate for the patient who is subsequently developing respiratory alkalosis? Preparing to administer sodium bicarbonate. Administer low-flow oxygen therapy. Administering intravenous sodium chloride. Encouraging slow, deep breaths.
Encouraging slow, deep breaths. The patient who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.
When assessing a patient for obstructive sleep apnea (OSA), the nurse understands the most common symptom is: Excessive daytime sleepiness. Headache. Early awakening. Impaired reasoning.
Excessive daytime sleepiness. Excessive daytime sleepiness is the most common complaint of people with OSA. Persons with severe OSA may report taking daytime naps and experiencing a disruption in their daily activities because of sleepiness.
Eight hours following bowel surgery, the nurse observes that the patient's urine output has decreased from 50 to 20 mL/hour. The nurse should assess the patient further for: Hypertension. Hemorrhage. Bowel obstruction. Adverse effect of opioid analgesics.
Hemorrhage. When the urine output is <30 mL/hour, the nurse should assess for potential causes such as hypovolemia or hemorrhage. The nurse should assess and evaluate the patient's vital signs, intake and output, dressing, and available laboratory values and notify the healthcare provider. Bowel obstruction, although possible after surgery is characterized most notably by abdominal distention and absent bowel sounds, not decreased urine output. The nurse would not expect the patient to have hypertension, but rather hypotension.
The nurse assesses a patient to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. The nurse reports this assessment as consistent with which of the following? Hypocalcemia. Hypokalemia. Hypernatremia. Hypermagnesemia.
Hypocalcemia.
A patient with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? Hypermagnesemia. Hyponatremia. Hyperkalemia. Hypocalcemia.
Hypocalcemia. Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 10.5 mg/dl.
A patient has a sodium level of 119. Which of the following is NOT related to this finding? Hypotonic fluid infusion (overload) Low salt diet Inadequate water intake Over secretion of ADH (antidiuretic hormone)
Inadequate water intake
Which of the following physical assessment findings would the nurse expect to find in a patient with advanced COPD? Increased chest excursions with respiration. Increased anteroposterior chest diameter. Collapsed neck veins. Underdeveloped neck muscles.
Increased anteroposterior chest diameter. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the patient may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.
A 82 year-old female patient is diagnosed with hypomagnesemia, which nursing intervention would be appropriate? Teaching the patient the importance of early ambulation, Avoiding the use of tight tourniquet when drawing blood. Instituting seizure precautions to prevent injury. Instructing the patient on the importance of preventing infection.
Instituting seizure precautions to prevent injury. A normal magnesium level is 1.8-2.6 mEq/L. Hypomagnesemia is a magnesium level less than 1.8 mEq/L. Instituting seizure precaution is an appropriate intervention, because the patient with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.
What is an instruction the nurse can give to help people prevent lung cancer? Recommend that people have their houses and apartments checked for asbestos leakage. Encourage people to install central air filters in their homes. Instruct people about techniques for smoking cessation. Encourage cigarette smokers to have yearly chest radiographs.
Instruct people about techniques for smoking cessation.
Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? Irritability. Coma. Depression. Apathy.
Irritability Patients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the patient may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
An elderly patient has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? The patient is becoming dehydrated and needs to increase her fluid intake to decrease secretions. The patient has not been taking her decongestants and bronchodilators as prescribed. The assessment findings are consistent with influenza and are to be expected. It is likely that the patient is developing a secondary bacterial pneumonia.
It is likely that the patient is developing a secondary bacterial pneumonia. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.
An adult patient has been diagnosed as having pulmonary tuberculosis. Which test(s) would the nurse expect to be ordered before the patient is started on Isoniazid (INH) therapy? Skin test for allergy Chest X-ray Kidney function tests- BUN, serum creatinine Liver function tests- LDH, SGOT (AST)
Liver function tests- LDH, SGOT (AST) Liver function tests, SGOT (AST) and LDH would be performed to serve as baseline. Liver toxicity can occur with INH. Renal function tests, BUN and serum creatinine are essential in persons who are receiving streptomycin therapy. There is not a skin test for allergy to INH. A chest X-ray will have been done as part of the diagnostic process but is not necessary again before starting INH therapy.
A 65 year-old male patient is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the patient? Education about infection prevention. Maintenance of adequate oxygenation. Prevention of fluid volume excess. Pain reduction.
Maintenance of adequate oxygenation.
The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which signs and symptoms should be included in the teaching plan? Increased appetite. Peripheral edema. Clubbing of nail beds. Hypertension
Peripheral edema. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure included: peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Patients with heart failure have decreased appetite.
A nurse is caring for a patient who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse has determined that the patient is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? Sodium level of 145 mEq/L. Magnesium level of 2.0 mg/L. Potassium level of 3.0 mEq/L. Phosphorus level of 4.0 mg/dL.
Potassium level of 3.0 mEq/L. Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options 1, 3, and 4 identify normal laboratory values. Option 2 identifies the presence of hypokalemia.
A 63 year-old male patient is receiving furosemide and digoxin, which laboratory data would be the most important to assess in planning the care for the patient? Magnesium level. Sodium level. Potassium level. Calcium level.
Potassium level. Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the patient is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the patient at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.
Patients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why? Reducing fluid volume improves respiratory function. Reducing fluid volume reduces oxygen demand. Reducing fluid volume improves patients' mobility. Restricting fluid volume reduces sputum production.
Reducing fluid volume reduces oxygen demand. Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the respiratory rate. It may also reduce edema and improve mobility a little, but exercise tolerance will still be harder to clear airways. Reducing fluid volume won't improve respiratory function, but may improve oxygenation.
Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to: Suppress the cough. Relax smooth muscles of the bronchial airway. Prevent infection. Promote expectoration.
Relax smooth muscles of the bronchial airway. Aminophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway.
The nurse is reviewing the lab report for her patient in hospice care with breast cancer and brain metastasis. According to the following lab values, what should the nurse do next: Potassium 4.0 mEq/L Sodium 142 mEq/L Chloride 100 mEq/L Calcium 12.4 mg/dL Report the elevated potassium level immediately. Document these results on the medical record. Refrain from reporting the results because the patient is in hospice care. Report the elevated calcium level immediately.
Report the elevated calcium level immediately. The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide, or administration of calcitonin, Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the patient is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.
It's highly recommended that patients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons? All patients are recommended to have these vaccines. Respiratory infections can cause severe hypoxia and possibly death in these patients. These vaccines produce bronchodilation and improve oxygenation. These vaccines help reduce the tachypnea these clients experience.
Respiratory infections can cause severe hypoxia and possibly death in these patients. It's highly recommended that patients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these patients to need intubation and mechanical ventilation, and it may be difficult to wean these patients from the ventilator. The vaccines have no effect on bronchodilation or respiratory care.
Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? Chloride. Potassium. Phosphate. Sodium.
Sodium.
The patient with pneumonia develops mild constipation, and the nurse administers docusate sodium prescribed. This drug works by: Stimulating peristalsis. Increasing stool bulk. Lubricating the stool. Softening the stool.
Softening the stool. Docusate sodium is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.
A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? Blood cultures. Sputum culture and sensitivity. ABG analysis. Chest x-ray.
Sputum culture and sensitivity.
The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? Apply a drip pad and reassure the patient this is normal. Document the findings and continue monitoring. Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance.
Test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.
A patient diagnosed with active TB would be hospitalized primarily for which of the following reasons? To evaluate his condition. To determine the need for antibiotic therapy. To prevent spread of the disease. To determine his compliance.
To prevent spread of the disease. The patient with active TB is highly contagious until three consecutive sputum cultures are negative, so he's put in respiratory isolation in the hospital.
Which of the following is the primary reason to teach pursed-lip breathing to patients with emphysema? To promote carbon dioxide elimination. To promote oxygen intake. To strengthen the diaphragm. To strengthen the intercostal muscles.
To promote carbon dioxide elimination. Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the patient relax, pursed-lip breathing helps the patient learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.
The best method of oxygen administration for patient with COPD uses: Venturi mask. Non rebreather mask. Simple Face mask. Nasal cannula.
Venturi mask.
An elderly patient with pneumonia may appear with which of the following symptoms first? altered mental status and dehydration. fever and chills. hemoptysis and dyspnea. pleuritic chest pain and cough.
altered mental status and dehydration. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly patients may first appear with only an altered mental status and dehydration due to a blunted immune response.
A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first? take a full medication history. apply a cardiac monitor to the patient. provide emotional support to the patient. give a bronchodilator by nebulizer.
apply a cardiac monitor to the patient. The patient is having an acute asthma attack and needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First, resolve the acute phase of the attack ad how to prevent attacks in the future. It may not be necessary to place the patient on a cardiac monitor because he's only 19-years-old, unless he has a past medical history of cardiac problems.
Insensible fluid losses include perspiration. bleeding. gastric drainage. urine.
perspiration.
Patients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk? rest and inactivity. physical and emotional stress. active exercise and exertion. cool and damp weather.
physical and emotional stress. Tuberculosis can be controlled but never completely eradicated from the body, Periods of intense physical or emotional stress increase the likelihood of recurrence. Patients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis.
A young adult is admitted for elective nasal surgery for a deviated septum. Which sign would be an important indicator of bleeding even if the nasal drip pad remained dry and intact? rapid respiratory rate. feelings of anxiety. presence of nausea. repeated swallowing.
repeated swallowing.
A 55 year-old female patient is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse expect to assess in the patient? bulging neck veins. bounding pulse. tachycardia. rales.
tachycardia. Tachycardia, poor tissue turgor, and hypotension are symptoms of fluid volume deficit (FVD). Other choices are symptoms of fluid volume excess (FVE).
Which patient with burns will most likely require an endotracheal or tracheostomy tube? A patient who has: secondhand smoke inhalation. thermal burns to the head, face, and airway resulting in hypoxia. electrical burns of the hands and arms causing arrhythmias. chemical burns on the chest and abdomen.
thermal burns to the head, face, and airway resulting in hypoxia.
