Practice questions exam 4 CHA

A 78 year old male patient with left sided congestive heart failure is undergoing a thoracentesis. Which statement from the client reflects understanding of the procedure?

" I will use a pillow and table to curve my back like an angry cat." The ideal position for thoracentesis is for the patient to sit up at the edge of the bed leaning forward to rest arms and face on a table such that the back is accessible for the procedure However, this may not be possible in many patients in the ICU due to mechanical ventilation or other reasons. Access from the infra-axillary area is another approach, with the patient in a semireclined position with the arm to the side.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

"I get a sharp, stabbing pain when I take a deep breath."

After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

"I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response " During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up large amounts of thicker mucus for the past several days" may indicate a pulmonary infection.

The school nurse recommends suitable physical activity for a child with exercise-induced asthma. Which statement by a parent indicates the need for additional teaching?

"I'll encourage him to join a youth running club."

A client scheduled for a permanent tracheostomy is receiving education on tracheostomy care by the nurse. Which statement by the client requires further education?

"If a fenestrated tube is placed, I will not be able to speak." Fenestrated tubes, if capped, can allow patient to cough and speak as air moves through fenestration and up through the natural airway. Providing inner cannula care will help prevent secretion buildup and tube obstruction. Cuffs are inflated to create a seal between the trachea and cuff, but does not protect against aspiration during feeding or mouth care. Suctioning is a sterile technique to help prevent infection.

A client with tuberculosis asks the nurse about the communicability of the disease. Which response woulf the nurse use?

"Untreated active tuberculosis is communicable." The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false assurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts would be screened via a skin test.

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse?

"Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics." Generally, upper respiratory infections are viral; therefore, antibiotics should not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response?

"You seem concerned about your diagnosis."

A client is receiving oxygen therapy with a non-rebreather mask. What is an appropriately flow rate for this oxygen device.

10-15L/min A flow rate for a non-rebreather mask should be from 10-15L/min. A flow rate less than this will not adequately inflate the bag.

The nurse is assigned a group of pediatric clients. After receiving shift report, which client should the nurse assess first?

A 6-month-old with a croupy cough and inspiratory stridor with exertion

A client's arterial blood gas report indicates that pH is 7.25, PaCO2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results?

A 65-year-old with pulmonary fibrosis The low pH and elevated PaCO2 = respiratory acidosis - this can be caused by pulmonary fibrosis (impedes the exchange of oxygen and carbon dioxide in the lung). A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bircarbonate.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates?

A previous exposure to the organism

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

A. "I'll start to have symptoms when I drink less fluid." Dehydration precipitates sickling of RBCs - it's a major cause for painful episodes associated with sickle cell anemia. Low platelets is associated with thrombocytopenia. Iron is unrelated to sickling. Low WBCs is not associated with sickle cell anemia.

A 3-month-old infant who has a 3-day history of diarrhea is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. Which acid- base imbalance does the nurse suspect?

A. Metabolic acidosis The pH indicates acidosis, not alkalosis. The HCO3 level is further from the expected range than is the PaCO2 level - indicating a metabolic, not respiratory origin (losses from diarrhea).

A client's serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.

Abdominal cramping C. Irregular heart rate D. Muscular weakness E. Decreased bowel sounds Hypokalemia may cause nerve and muscle weakness, which may precipitate irregular heartbeats and dysrhythmias. Decreased bowel sounds, abdominal cramping, and paralytic ileus can be from decreased bowel motility associated with hypokalemia.

Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs?

Adventitious Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and heard over the main stem bronchi on either side of the sternum and posteriorly between the scapulae.

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer?

Amiodarone Amiodarone decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. It is used in the treatment of ventricular dysrhythmias such as ventricular tachycardia. Digoxin slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats. Furosemide, a diuretic, does not affect ectopic foci.

A post-surgical client presents to the medical-surgical unit after a cholecystectomy. What interventions should be included in the care plan to prevent an pulmonary embolism in the post-surgical patient? Select all that apply.

Application of SCDs as ordered Cough and deep breathing exercises Early and frequent ambulation Deep vein thrombosis and pulmonary embolism prevention include: SCDs, TED hose, early and frequent ambulation, ROM exercises, IS, cough and deep breathing exercises, anticoagulation medication, IVC filters, embolectomy. Bedrest is not recommended for post surgical patients. Rapid dorsiflexion of the foot (Homans sign) is an older practice to diagnosis NOT prevent blood clots. The practice is no longer recommended as it may cause a blood clot to break and cause a PE.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority?

Apply a petroleum gauze dressing over the site.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?

Arterial blood gas RBC count, sputum culture, and Hgb tests assist in the evaluation of a client with respiratory difficulties; however, ABG analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?

Aspirin Early administration of aspirin in the setting of acute myocardial infarction (MI) has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstructing blood flow. Gabapentin is an anticonvulsant and is not the drug of choice to relieve the pain associated with an MI. Midazolam HCl is a sedative-hypnotic that is used for its calming effect, but it will not relieve the pain of an MI. Alprazolam is an anxiolytic that is used for its calming effect, but it will not relieve the pain of an MI.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

The nurse is preparing to suction a client with a tracheostomy in place. Which action by the nurse should be completed first?

Assess the patient's respiratory status.

Which pulmonary risk may be increased in a postoperative client due to anesthesia?

Atelectasis Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. this condition is caused by the effects of anesthesia. Rhonchi are continuous or snoring sounds caused by the obstruction of the larger airways. fremitus is the vibration of the chest wall during vocalization. Dyspnea is a shortness of breath; this condition is an after effect of atelectasis.

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity?

Blowing the nose Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. Instruct the client to avoid blowing the nose - this can increase the risk of bleeding. Ambulation, visiting with children, and semi-Fowler's position are not contraindicated with thrombocytopenia.

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition?

Bordetella pertussis This disease is caused by Bordetella pertussis. Pertussis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.

A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order?

C. "If something happens to me, I do not want CPR." If cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, CPR will not be started. For Power of Attorney, the client gives power to another person to make healthcare decisions on their behalf. For an Advance Directive, or Living Will, the client determines treatment

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.

Chemotherapy D. Blood transfusion E. Radiation therapy Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation, blood transfusions - help alleviate symptoms and promote well being. Other cares include oral care and repositioning.

A client with chronic obstructive pulmonary disease(COPD) reports a 5-pound (2.3kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?

Cor pulmonale

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages Fine crackles (Sometimes called rales) are the sounds of fluid bubbling within smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis?

D. PCO 2: 28, HCO 3: 18, pH: 7.28 Decreased pH and bicarb values = metabolic acidosis; a decreased PaCO2 = compensatory hyperventilation. Increased pH and bicarb = metabolic alkalosis; an increased PaCO2 = compensatory hypoventilation. Increased pH and decreased PaCO2 = hyperventilation and respiratory alkalosis. Decreased pH and increased PaCO2 = hypoventilation and respiratory acidosis.

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?

Decreased lung sounds

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators?

Demonstrates use of a metered-dose inhaler

A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response?

Depression in the respiratory center

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding requires action by the nurse?

Diminished breath sounds

The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching?

Do not change to a standing position suddenly. Enalapril is classified as an ACE inhibitor. It is used to treat hypertension and congestive heart failure by relaxing the blood vessels so they can open up. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow. Clients should be advised to change positions slowly to minimize orthostatic hypotension. A healthcare provider should be notified immediately if the client is experiencing lightheadedness or feeling like he or she is about to faint, as this is a serious side effect. This medication does not cause a sore throat the first few days of treatment. Presently, there are no guidelines that suggest blood tests are required weekly for the first 2 months.

A nurse is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply.

Dyspnea Hemoptysis Feeling of impending doom

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment?

Elevated serum troponin Elevations of troponin levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.

When preparing a child with asthma for discharge, what instructions must the nurse emphasize to the family? Select all that apply.

Eliminate allergens in the home. Continue the medications even if the child is asymptomatic.

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing.

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take?

Encourage the client to take deep, cleansing breaths. The client is in respiratory acidosis - likely from the depressant effects of an anesthetic or a compromised airway. Deep breaths blow off CO2 and encourage coughing. Obtaining a prescription for a diuretic will not correct respiratory acidosis and may aggravate hypokalemia if present. Having the client breathe into a rebreather bag is the treatment for respiratory alkalosis; the client is in respiratory acidosis. Obtaining a prescription for sodium bicarb is not necessary if clearing of the airway corrects the problem.

Which nursing intervention should the nurse consider to be a priority for clients with fluid overload?

Ensuring client safety Priority interventions include ensuring client safety and restoring normal fluid balance - this will help prevent complications like pulmonary edema and heart failure. Serum sodium levels are low during fluid overload - resulting in potential neuro changes. Providing drug therapy and nutritional therapy are secondary nursing interventions. Prevention of future overload should be done after restoring the fluids to normal levels.

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?

Excessive mechanical ventilation The high pH and low CO2 levels = respiratory alkalosis. This can be caused by mechanical ventilation that is too aggresive. Airway obstruction causes CO2 buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which leads to metabolic acidosis. Prolonged gastric suctioning causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?

Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium. Lack of mineralcorticoids (aldosterone) leads to loss of sodium ions in the urine, leading to hyponatremia. Potassium intake is not encouraged. Hyperkalemia is a problem because of insufficient mineralcorticoids. Increasing protein is needed to heal the adrenal tissue - tissue repair of the gland is not possible. Vitamins are not directly energy-producing, nor will they help the client gain weight.

The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest impact on the child's health status and is of priority in the care plan?

Extremely thick mucus causes obstructed airways.

What clinical findings does a nurse expect when assessing a child with acute laryngotracheobronchitis? Select all that apply.

Fever Hoarseness Barking cough Inspiratory stridor

A nursing student is preparing to start their clinical experience. What action by the nursing student can best help prevent the spread of Influenza to patients.

Frequent hand hygeine Frequent and effective hand hygiene is the best practice to decrease the spread for the influenza virus. An antibiotic is unnecessary, influenza is a viral infection. A N95 is not necessary for influenza, a simple mask will assist in the decrease transmission. Avoidance is not necessary for the duration of influenza season.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

Give prescription drugs to promote bronchiolar dilation.

A client who is suspected of having Cushing syndrome is admitted to the hospital. When checking the laboratory reports, which condition should the nurse expect?

Hypokalemia With glucocorticoid excess, aldosterone hypersecretion occurs and sodium is retained; therefore potassium is excreted, leading to hypokalemia. Hypervolemia occurs because of sodium and water retention precipitated by aldosterone. Hypocalcemia is not associated with aldosteronism. Aldosterone hypersecretion causes sodium retention and hypernatremia, no hyponatremia.

The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client?

Hypokalemia In case of hypokalemia, the nurse should assess the respiratory status of the client q2hrs. In case of hyperkalemia, the nurse should notify the healthcare team if the heart rate falls below 60bpm or T waves become spiked. In case of hyponatremia, the nurse should be aware of muscle weakness and immediately check respiratory effectiveness.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?

I have trouble breathing when I walk rapidly." Dyspnea on exertion often occurs with left ventricular heart failure - the heart is unable to pump oxygenated blood to meet the energy requirements for muscle contractions related to the activity. Swollen ankles are more likely with right ventricular heart failure. Being tired at the end of the day is not specific to left ventricular heart failure.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: less than body requirements, relater to fatigue

A 13-year-old child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. At what time does the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur?

In the afternoon NPH insulin is an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration. It was administered at 7:00 AM, so between 1:00 and 3:00 PM is when the nurse should anticipate that a hypoglycemic reaction will occur. Noon is when a reaction from a short-acting insulin is expected. Short-acting insulin peaks in 2 to 4 hours after administration. Within 30 minutes of administration is when a reaction from a rapid-acting insulin is expected. Rapid-acting insulin peaks 30 to 60 minutes after administration. During the evening or night is when a reaction from a long-acting insulin is expected. Long-acting insulin has a small peak 10 to 16 hours after administration.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

Inadequate antidiuretic hormone (ADH) secretion Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production.

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit?

Increased pulse rate Tachycardia occurs as the body tries to compensate for hypoxia due to mild iron deficiency anemia. Severe anemia - pale, cool, clammy skin Increased BP is not a response associated with anemia. Cyanosis of the nail best is a sign of CO2 poisoning.

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicated a need for correction?

Inhaling air fully before inserting mouthpiece

What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply

Instituting fall risk precautions D. Monitoring for and reporting neurologic changes The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. This then leads to decreased urinary output, increased intravascular fluid volume, low serum osmolarity, and dilutional hyponatremia. Fall risk precautions are in place to protect the client from injury that might occur as a result of neurologic changes associated with declining serum sodium. Look for and report changes from cerebral edema and hyponatremia. We need to immediately restore fluid balance - but fluids are restricted to no more than 1000mL. Also, laying supine helps promote venous return to the heart, which increases ventricular filling pressure, which tells the pituitary that ADH release should decrease.

Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?

Lower extremity color Checking color and temperature (neuro assessment) provides data about current perfusion of the extremity and the possibility of graft occlusion/blockage. Although pain assessment is essential, incisional pain does not provide data about the neuro status of the extremity - a dramatic increase in pain or severe continuous, aching pain is indicative of a graft occlusion. Although the presense and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the popliteal rate. Clients with PAD experience loss of extreme hair, which will not suddenly change because of surgery.

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?

Muscle spasms Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia, hypoactive reflexes are signs of hypercalcemia. Increased urine specific gravity is a sign of fluid volume deficit.

The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.

Nose blowing B. Teeth brushing C. Bending forward After a hypophysectomy a drip pad is placed under the nose of the client for 2-3 days. Therefore, the client should not blow their nose, brush their teeth, or bend forward because these activities can increase intracranial pressure and delay healing. Because of the nasal packing, the client is advised to breathe through their mouth. Lying in a semi-Fowler's position will not interfere with the nasal packing; therefore it will not cause any complication.

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first?

Notify the primary healthcare provider. Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the primary healthcare provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.

The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?

Obtain the other vital signs. The radial pulse of a client with chronic a-fib may range from 50-180bpm. Other vital signs should be assessed before notifying the primary healthcare provider. Although rechecking the pulse to verify the rate may be done, it's not necessary because a pulse of 136bpm is not unusual for a client with chronic a-fib. Staying with the client until the ambulance arrives or alerting the primary healthcare provider are not the initial actions.

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply.

Pain history, including location, intensity, and quality of pain C. Pain pattern, including precipitating and alleviating factors Initial assessment: location, quality, intensity, onset, duration, frequency, what relieves/exacerbates pain Vitals are a secondary assessment. Pain is subjective so ask client instead of accepting statements from family members.

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem?

Pathology of mucus-secreting glands

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?

Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques Patients with leukemia are at very high risk of infection, due to their low neutrophil count. Placing the child in a private room, restricting visitors who are ill, and using strict hand washing techniques are the best ways to minimize complications. The diet and avoiding overexertion are relevant to anemia. Avoiding rectal temps, limiting injections, and applying pressure after venipuncture are relevant to preventing bleeding.

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow Vasodilation helps reduce pain from cellular clumping. The warmth can help the pain until the pump can be activated. Television is a good distractor for mild pain, not moderate or severe. Nursing measures should be attempted first before calling the provider. Telling the adolescent to wait provides no comfort.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP)

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning.

What are the uses of pulmonary function tests (PFT)? Select all that apply

Pulmonary function tests (PFT) can measure lung volume. Pulmonary function tests (PFT) can assess responses to bronchodilators. Pulmonary function tests (PFT) can diagnose pulmonary disease.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?

Raise the head of the bed to a high-fowlers position and administer 2L/min oxygen per nasal cannula

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.

Rapid, thready pulse D. Elevated specific gravity The pulse is rapid and thready because of the decreased blood volume associated with dehydration. The urine specific gravity is elevated because the urine is concentrated. Skin turgor would be decreased with evidence of tenting. Hct would be increased because of hemoconcentration. Adventitious breath sounds (crackles) would occur with FVE

A nurse is caring for a client that was recently exposed to a caustic chemical while at work. The nurse is needing to frequently titrate the oxygen level to maintain SpO2 above 92%. What physiological process does the nurse suspect is occur?

Refractory hypoxia from poor gas exchange at the alveoli The client is experiencing acute respiratory distress syndrome (ARDS) ARDS is caused by an injury to the lung tissue, which can be obstruction, chemical, infection, or aspiration. The alveoli fill up with fluid and prevent appropriate O2/CO2 gas exchange. This results in refractory hypoxia, or the persistent hypoxia despite increased oxygen delivery.

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning. Secretions in the airway will increase pressure by blocking air flow and must be removed. The nurse must identify/correct the problem so that the set tidal volume can be delivered. Connections that are not intact would cause a low-pressure alarm. ABG's are used to assess client status, but they are not taken each time a pressure alarm is heard.

A pediatric nurse is preparing to discharge a 11-month old client home after receiving treatment for croup. What information should not be included in the discharge planning?

Ribavirin can be given to infants to decrease severity of croup. Ribavirin is an antiviral that is given in the treatment of Bronchiolitis caused by respiratory syncytial virus, not croup. Interventions/education for croup include: Humidified O2, steamy showers to soothe inflamed mucous membranes, cold air to decrease swelling, frequent respiratory assessments, creating a calm, quiet environment, knowing when to seek additional medical treatment.

A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply.

Sedation C. Bradycardia E. Slow respirations Morphine depresses the CNS, leading to sedation - bradycardia, bradypnea. Morphine does not increase urine output. Morphine causes constriction of pupils.

The nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax?

Severe shortness of breath Severe shortness of breath may indicate a recurrence of the pneumothorax because one ling is unable to meet the oxygen demands of the body. A pneumothorax causes sharp pain on the involved side, not substernally. Usually palpitations reflect a cardiac, not a respiratory, problem. Dizziness when standing up is not specific to a pneumothorax; this is orthostatic hypotension, which may be related to a variety of medical problems.

The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis?

Shunting of blood from right to left Right to left shunting results in inadequate perfusion of blood; not enough blood flows to the lungs for oxygenation. Left to right shunting results in too much blood flowing to the lungs; blood is adequately perfused. Left sided obstruction to the flow of blood results in decreased peripheral pulses, not cyanosis. Obstruction of blood flow between the left and right sides of the heart usually occurs with patent ductus arteriosus. There should be no shunting of blood between the right and left sides of the heart after the ductus arteriosus has closed.

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?

Stop the blood transfusion immediately. An incompatible blood transfusion can result in an acute hemolytic reaction in the client. The nurse should stop the blood transfusion, report it to the healthcare provider, recheck the client's ID tags and numbers, maintain a patent IV line with saline solution, and continue to monitor the client.

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

The parents of a 4-year-old child call and report that their child has a fever of 102.6F (39.2C), is complaining of a sore throat, and will not lie down. preferring to sit up and lean forward. The child is drooling and looks ill and agitated, Which guidance would the nurse provide this family?

The child needs immediate medical attention; call 911. The child is presenting with signs and symptoms of epiglottitis, which is a medical emergency because of the airway obstruction. Cool mist is effective in reducing the inflammation of croup, but it is not effective in epiglottitis; the child will not be able to drink any fluids because of the enlarged epiglottis. A nonsteroidal anti-inflammatory medication such as ibuprofen may help reduce fever, but the child will have difficulty swallowing, which may cause the epiglottis to spasm and close off the airway. Waiting to call is unsafe.

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion?

The client smokes four cigarettes per day

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse?

The client's gag reflex has returned The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protest his or her airway. Confusion due to anesthesia may be manifested as disorientation. the ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not be obstruct the airway,

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

The signs and symptoms of heart failure The teaching plan for this client should focus on the possibility of heart failure. Clients with a failed valve are prone to heart failure; report any signs of dyspnea, syncope, dizziness, edema, and palpitations. Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart. There is no evidence of pathology of other valves. There is no schedule that valves will be replaced every 6 months.

In order to start employment, a nursing student is required to have a PPD test. During the test reading an induration of 14mm is identified. What is the interpretation of this result?

The student nurse has had an exposure to TB. A positive PPD test has an induration of >10mm. This indicated the patient has had exposure to TB and a chest x-ray is needed to detect TB. If the x-ray detects TB, a sputum culture is needed to confirm the diagnosis.

A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age?

These children digest little food because pancreatic enzymes are blocked.

A elderly client presents to their PCP office with complaints of fever, cough, and green-sputum production. Which assessment findings are consistent with the diagnosis of pneumonia? Select all that apply.

WBC 13,500 Increase density on a CXR Pleuritic pain with breathing Signs and symptoms of pneumonia include: increased respiratory rate, pleuritic CP with breathing, fever, crackles, cough with green/yellow sputum production, increased WBC.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings?

Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercoastal spaces anteriorly and posteriorly between scapulae.

The nurse caring for a patient with cystic fibrosis recognizes that the manifestations of the disease are caused by the pathophysiologic processes of:

altered function of exocrine glands, with abnormally thick, viscous secretions.

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?

barrel chest

A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the physician immediately upon finding:

decreased breath sounds and wheezing.

A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. The nurse asks the patient if he has been taking his medication as prescribed, with the knowledge that:

directly observed therapy will be necessary if the patient has been noncompliant.

A 60-year-old homeless man has a cough, late-afternoon fever, and night sweats. The patient's response to a purified protein derivative (PPD) skin test is 15 mm induration. The nurse recognizes that this response indicates that the patient:

has been exposed to the tuberculosis organism.

A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. The patient says his doctor said his heart was failing and asks whether he is having a heart attack. The nurse explains to the patient that:

he is not having a heart attack, but his heart has been damaged by having to work harder to pump blood into his lungs.

A 52-year-old patient has been diagnosed with lung cancer. He tells the nurse that he didn't know that anything was wrong until he had a routine chest x-ray. The nurse explains that symptoms of lung cancer occur late in the disease but usually the first thing people notice is:

persistent cough.

To protect susceptible patients in the hospital from aspiration pnuemonia, the nurse:

places patients with dysphagia in High Fowler's position while eating.

The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by:

preventing bronchial collapse and air trapping in the lungs during expiration.

Advair diskus (fluticasone and salmetrol combination drug) dry powder inhaler is prescribed for a patient diagnosed with mild persistent asthma. The patient asks the nurse why she must use two different drugs. The best response by the nurse is:

the salmeterol is used to decrease the bronchospasm in the long term, and the fluticasone helps reduce the inflammatory response.

A 70-year-old patient is recovering from an acute episode of COPD. In planning with the patient to increase his activity tolerance at home, the nurse knows that an appropriate initial exercise goal for the patient is to:

walk for 20 minutes per day with his pulse rate less than 120 bpm.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply

wheezing tachycardia