Nursing Process Exam 1 Practice Questions

A 12-year-old client is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis of Impaired Gas Exchange? 1. Oxygen saturation of 62% 2. Heart rate of 100 bpm 3. Respiratory rate of 60/min 4. Bicarbonate level of 38 mEq/L

1 Normal levels of oxygen saturation are 90%-100%. The client with an O2 level of 62% is not exchanging gases. Heart rate increase is a sign of many disorders and by itself does not signify impaired gas exchange. A respiratory rate of 60 signifies respiratory distress but does not imply impaired gas exchange. Bicarbonate levels are an indication of kidney function.

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which concept? 1. Due to complex damage of the alveoli, gas exchange cannot occur. 2. The individual has difficulty expelling air trapped in the alveoli. 3. There is excess surfactant production by the alveoli. 4. Thick secretions block the airways.

1 Inflammatory cellular responses and biochemical mediators damage the alveolar-capillary membrane. Fluid begins to enter the alveoli, inactivating the surfactant, leading to atelectasis. The lungs become less compliant, and gas exchange is impaired. Hypoxemia becomes refractory or resistant to improvement with supplemental oxygen, and the PaCO2 rises as diffusion is further impaired.

The nurse would anticipate administering respiratory medications to a child hospitalized with asthma by which most frequently used route? 1. Aerosol 2. Intravenous 3. Subcutaneous 4. Oral

1. Aerosol therapy such as a nebulizer is frequently used during hospitalization to administer asthma medications because this method delivers the drug directly into the airways. Intravenous, subcutaneous, and oral routes may be used if the child's condition worsens, but there is no evidence given to support that.

The nurse should counsel the parents of a child with asthma that, before performing postural drainage exercises, the parents should perform which action? 1. Administer the bronchodilator. 2. Change the child's clothing. 3. Administer an antibiotic. 4. Suction the child.

1. Bronchodilators open the airways and allow for easier removal of secretions. Changing clothing and giving the antibiotic are irrelevant to the procedure. Suctioning is done after postural drainage if the child is unable to cough up secretions.

Which finding would be expected in a client with chronic obstructive pulmonary disease (COPD)? 1. Anteroposterior (AP) chest diameter equal to or greater than lateral chest diameter 2. Mental confusion and lethargy 3. Pitting edema of ankles and lower legs 4. Oxygen saturation of 85% or less

1. Development of a barrel chest due to air trapping is an expected finding of COPD. Confusion, lethargy, and low oxygen saturation levels indicate respiratory failure. Pitting edema occurs with heart failure.

The admitting orders for a client with acute bacterial pneumonia include: intravenous antibiotic every 8 hours; oxygen per nasal cannula at 5 L/min; continuous pulse oximetry monitoring; bed rest with bathroom privileges and chair at bedside as desired; diet as tolerated; sputum specimen for culture and sensitivity (C&S); complete blood count (CBC); urinalysis; and chemistry panel. Which order should the nurse carry out first? 1. Start the oxygen per nasal cannula. 2. Insert an intravenous catheter and start the prescribed antibiotic. 3. Provide a dinner tray to the client. 4. Obtain the sputum specimen.

1. Oxygenation takes first priority. Next, the sputum specimen should be collected for culture because it will direct the proper antibiotic treatment. Only after the specimen is collected can antibiotics be initiated. Lowest priority is the dinner tray.

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which of the following concepts? 1. Blood is shunted past alveoli with no ventilation. 2. The individual has difficulty expelling air trapped in the alveoli. 3. There is excess surfactant production by the alveoli. 4. Thick secretions block the airways.

1. The client is experiencing metabolic acidosis. Sodium bicarbonate acts by directly raising the pH of body fluids; it is the drug of choice for restoring plasma pH to normal limits. Sodium chloride is used to treat hyponatremia; ammonium chloride is used to treat severe metabolic alkalosis; and potassium chloride treats hypokalemia.

The nurse planning care for a client with viral pneumonia would identify which nursing diagnosis as the priority? 1. Ineffective Airway Clearance 2. Ineffective Breathing Pattern 3. Impaired Gas Exchange 4. Activity Intolerance

1. The client with pneumonia will have fluid accumulation in the alveoli, making airway clearance the highest priority nursing diagnosis. Minor pulmonary involvement may not impact breathing pattern or gas exchange, so further information is needed to choose these particular diagnoses. Insufficient information is provided to determine the client's tolerance of activity and how significantly impaired the client may be by the condition.

The nurse establishes a nursing diagnosis of risk for excess fluid volume for a client diagnosed with heart failure. Which physiological change resulting from heart failure supports the diagnosis? 1. Increased glomerular filtration rate (GFR) 2. Increased antidiuretic hormone (ADH) production 3. Increased sodium secretion 4. Increased cardiac output

2. ADH is produced in response to changes in intravascular volume. The result is increased water absorption

A child is hospitalized after an acute asthmatic episode. The nurse determines that the parents need further instruction if which statement is made? 1. "Next time, we'll be sure to give cromolyn before soccer." 2. "We will continue to use the peak flow monitor once a week to track expiratory flow." 3. "We think this is an exercise-induced episode." 4. "We need to make sure the inhaler is with our child at all times."

2. Giving cromolyn, making sure the child has the inhaler at all times, and realizing that exercise can cause an asthma attack are all correct statements. The child should use peak flow monitors daily, not weekly, to note any changes in the expiratory flow

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the acute care unit. The client is experiencing dyspnea on exertion and states that it is becoming more difficult to breathe. In order to plan care, the nurse interprets the client's signs and symptoms as indicating which stage of COPD? 1. Gold I 2. Gold II 3. Gold III 4. Gold IV

2. Gold I (mild) shows mild airflow limitation. Gold II (moderate) adds worsening airflow limitation and dyspnea on exertion. Gold III (severe) adds increased shortness of breath and repeated exacerbations. Gold IV (very severe) exacerbations are potentially life threatening.

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks whether the client is out of danger and whether normal activities can be resumed. Which explanation will the nurse provide to the client and family? 1. "The client is out of danger and can resume normal activities." 2. "The client will be ready for normal routines in about a year." 3. "The client will need to tailor activities until maximal respiratory function returns." 4. "The client will never recover fully."

3 The client will need to tailor activity until maximal respiratory function returns and the time frame is related to the overall health of the client. The client is taught measures to prevent further lung trauma. The client is not out of danger at discharge.

The nurse is caring for a pregnant woman with asthma. The nurse is aware the most common time for an asthma exacerbation is which time frame? 1. 8th-12th week of pregnancy 2. 16th-20th week of pregnancy 3. 24th-36th week of pregnancy 4. 37th-40th week of pregnancy

3. Asthma is the most common respiratory disease in pregnancy and affects 8% of all women in their childbearing years. One third of patients with asthma experience improvement in their asthma during pregnancy, one third experience little or no change, and the remaining third of patients experience worsening of their asthma during pregnancy. The highest incidence of asthma exacerbation in patients who are pregnant occurs between 24 and 36 weeks of gestation.

The nurse determines that which goal is appropriate goal for a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD)? 1. Client will verbalize self-care measures to regain lost lung function. 2. Arterial blood gases will be within normal limits by discharge. 3. Client will maintain oxygen saturation of 90% or greater. 4. Client will identify strategies to reduce the number of cigarettes smoked per day.

3. During an acute exacerbation of COPD, maintaining oxygen saturation of 90% is an appropriate goal. Lost lung function cannot be regained and blood gases will never be within normal limits. Any amount of smoking is not an option for a client with COPD.

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks whether the client is out of danger and whether normal activities can be resumed. Which of the following will the nurse explain to the client and family? 1. "The client is out of danger and can resume normal activities." 2. "The client will be ready for normal routines in about a year." 3. "Maximal respiratory function should return in 6 months." 4. "The client will never recover fully."

3. Full recovery from ARDS takes about 6 months, so the client is taught measures to prevent further lung trauma. The client is not out of danger at discharge. One year is much longer than the typical recovery time. Some clients may never fully recover, but a 6-month time period is generally correct.

In order to facilitate the removal of secretions in a client diagnosed with pneumonia, the nurse realizes that it may be necessary to increase fluid intake to how much per day? 1. 1,250 mL 2. 2,000 mL 3. 2,750 mL 4. 5,500 mL

3. Normal intake is 1,500-2,000 mL and may need to be increased to 2,500-3,000 mL in order to liquefy secretions. Increasing intake to 5,500 mL may cause fluid overload.

A client diagnosed with bacterial pneumonia has a gray skin tone with a bluish tinge around the lips. What is the correct order of priority actions for the nurse to take? 1. Start oxygen, assess breath sounds, obtain oxygen saturation level, notify the physician, and raise the head of the bed. 2. Assess breath sounds, obtain oxygen saturation level, start oxygen, raise the head of the bed, and notify the physician. 3. Start oxygen, raise the head of the bed, obtain oxygen saturation level, assess breath sounds, and notify the physician. 4. Notify the physician, raise the head of the bed, start oxygen, obtain oxygen saturation level, and assess breath sounds. 5. Notify the physician, start oxygen, obtain oxygen saturation level, raise the head of the bed, and assess breath sounds.

3. Overall gray skin color and bluish tinge to lips indicate hypoxemia; supplemental oxygen is highest priority. Second, raise the head of the bed to promote chest expansion and alveolar ventilation. Assessment of oxygen saturation and breath sounds provide important information to be provided to the physician.

The nurse is introducing the concept of a written asthma action plan to the parent of a school-aged child. The nurse knows the teaching was ineffective when the parent states that which person requires a copy of the written asthma action plan? 1. The classroom teacher 2. The soccer coach 3. The local hospital 4. The babysitter

3. The local hospital would not keep a copy of the written asthma action plan on file. All of the other individuals would need this information to assist them if the child were to have any problems in their presence, if the parent was not on-site.

An 8-year-old child, previously diagnosed with viral pneumonia, returns a week later with a higher fever, listlessness, and a harsh, productive cough. The child's parent states, "I knew a prescription for antibiotics was needed." Which response by the nurse is most appropriate? 1. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." 2. "Sometimes we just do not know. I'm glad you came back in." 3. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the duration of the illness, making antibiotics necessary at that time." 4. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars."

3. The nurse responds with the most informative, accurate response. The decision not to use antibiotics for viral pneumonia was based on sound rationale about the etiology of the illness, not cost.

The nurse is teaching effective breathing techniques to a client with chronic obstructive pulmonary disease. Which statement would the nurse use to explain why dyspnea occurs? 1. "Decreased surfactant causes many of your alveoli to collapse." 2. "You have difficulty breathing in enough air." 3. "Your airways open wider on inspiration and trap air on expiration." 4. "Your lung compliance is decreased."

3. The primary physiological alteration occurring with COPD is alveolar air trapping and alveolar hyperinflation, which lead to alveolar rupture and loss of area available for gas exchange. Decreased surfactant production is associated with ARDS and is not a primary alteration of COPD. Lung compliance is decreased, but this is a result of alveolar trapping and hyperinflation.

The daughter of an 82 year-old client with Alzheimer's disease contacts the clinic because the client has been unwilling to drink any fluids for 24 hours. Which instruction by the nurse is most appropriate? 1. Instruct the daughter to bring the client to the emergency department for intravenous replacement. 2. Ask the daughter to bring the client to the clinic for lab work. 3. Ask about the presence of other symptoms. 4. Tell the daughter to offer popsicles and then call the clinic again the next day.

3. Treatment will dependent upon other symptoms. While the client is at risk for dehydration, admission or diagnostic tests may not be indicated. The nurse should provide education regarding signs and symptoms of dehydration.

A client has been hospitalized in the respiratory intensive care unit because of an acute exacerbation of chronic obstructive pulmonary disease (COPD). Arterial blood gas analyses of the client's three samples from earlier in the day show increasing hypoxemia and hypercapnia. The nurse will observe the client closely for what indications of impending respiratory failure? 1. Increased expectoration of sputum 2. Decreased heart rate 3. Increased respiratory rate 4. Decreased level of consciousness

4. Increasing hypoxemia and hypercapnia, a decreased level of consciousness, cyanosis, or worsening of airway obstruction indicates respiratory status is deteriorating. The nurse should prepare for intubation and mechanical ventilation. Respiratory failure is a possible complication for the client, and immediate intervention is required to preserve the client's life. The client would experience decreased expectoration, increased heart rate, and decreased respirations.

When teaching use of a metered-dose inhaler (MDI), what instruction does the nurse include? 1. Take quick, shallow breaths in rapid succession while holding the canister down. 2. Use the inhaler containing the anti-inflammatory drug first, then the bronchodilator. 3. Wait 5 minutes before repeating the process for a second puff. 4. Rinse the mouth after using the inhaler.

4. The nurse teaches the client how to use the inhaler. The inhaler is held upright and the client breathes in slowly and deeply. The client needs to wait 20-30 seconds before repeating for a second puff of the medication, if ordered. If using two different inhaler medications, use the bronchodilator first to dilate the airway before use of the anti-inflammatory medication. Rinsing the mouth after using an MDI reduces systematic absorption and adverse effects of the drug.

The nurse teaches the parent how to attach a spacer to the metered-dose inhaler for a young child, citing which purpose of the spacer? 1. Makes the device look less intimidating to the child 2. Makes it unnecessary to shake the inhaler prior to administration 3. Decreases the chances of undesired side effects 4. Enhance the amount of drug reaching the lungs

4. The spacer sends the medication deeply into the airways and deposits less of the steroid into the mouth where yeast infections can occur. The spacer does not cause less intimidation, the inhaler still must be shaken, and the spacer does not reduce side effects of the medication.

Following an unrestrained motor vehicle crash, a client presents to the e.d. with multiple injuries, including chest trauma. A physician notifies the care team that the client has progressed to ARDS and requests that the family be updated on the client's condition. The nurse should plan to discuss with the family that: 1.The condition generally stabilizes with positive prognosis. 2.The client can be discharged home with oxygen. 3.The condition is always fatal. 4.The condition is highly life-threatening and that end-of-life concerns should be addressed.

4. ARDS has a reported mortality rate of 50-70% and family should be prepared for the possibility that their loved one may not survive the injury or diagnosis. The nurse must be able to discuss the care to be given, the progression of the syndrome, and make appropriate referrals needed (such as pastoral care).