prep U Nurs225
A client with a diagnosis of thrombocytopenia has been admitted to your unit for IV corticosteroid treatment. As the nurse caring for this client, you would expect the physician's orders to include which of the following?
A tapering course of solumedrol at discharge Explanation: If instituting corticosteroid therapy in thrombocytopenia, the nurse observes the client for adverse drug effects. The dose and frequency of steroid medication is tapered before discontinuing it to avoid adrenal insufficiency or crisis. When a client is on high dose steroid treatment, a sleeping medication might be ordered; also a medication for steroid headaches, but not oxycodone. Clients on steroids are often hungry throughout the day. However, what you would expect to find in the orders is a tapering course of the steroids.
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent unit Explanation: When ventilation exceeds perfusion a dead space exists. An example of a dead space is a pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea Explanation: Bradypnea is a slower than normal rate (<10 breaths/minute), with normal depth and regular rhythm. It is associated with IICP, brain injury, central nervous system depressants, and drug overdose. Tachypnea is associated with metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation is shallow, irregular breathing. Hyperventilation is an increased rate and depth of breathing.
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma? a) Decreased calcium level b) Increased urinary protein c) Polycythaemia vera d) Decreased serum protein
Correct response: Increased urinary protein Explanation: A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcaemia, anaemia, and hyperuricemia. Polycythaemia vera is not found in multiple myeloma
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? a) Client reports no chest pain. b) Lungs are clear on auscultation. c) Respiratory rate is 12 to 18 breaths per minute. d) Client can perform incentive spirometry
Correct response: Lungs are clear on auscultation. Explanation: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways
You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing?
How these issues affect the client's quality of life Explanation: Assessment of the respiratory system includes obtaining information about physical and functional issues related to breathing. It also means clarifying how these issues may affect the client's quality of life. Therefore, options B, C, and D are incorrect
When assessing a client, which adaptation indicates the presence of respiratory distress?
Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.
Which nursing intervention is most appropriate for a client with multiple myeloma? a) Balancing rest and activity b) Monitoring respiratory status c) Preventing bone injury d) Restricting fluid intake
Preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict his fluid intake.
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
Regular breathing where the rate and depth increase, then decrease Explanation: Observing the rate and depth of respiration is an important aspect of the nursing assessment. Certain patterns of breathing are characteristic of specific disease states or conditions. Head trauma can cause damage to the respiratory center in the brain, thereby altering the rate and depth of respirations. Cheyne-Stokes breathing is characterized by a regular cycle in which the rate and depth of breathing increase, then decrease until apnea occurs
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi Explanation: Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem. Explanation: SaO2 is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2 and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles
Pink frothy sputum may be an indication of
pulmonary edema. Explanation: Profuse, frothy pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms
Choice Multiple question - Select all answer choices that apply. Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. a) Hypertension b) Bradypnea c) Bleeding gums d) Hematemesis e) Epistaxis
• Bleeding gums • Epistaxis • Hematemesis Explanation: Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.
The thalassaemia's are a group of hereditary anaemias characterised by which of the following? Select all that apply.
• Hypochromia • Extreme microcytosis • Haemolysis • Anaemia Explanation: The thalassaemia's are a group of hereditary anaemias characterised by hypochromia, extreme microcytosis, destruction of blood elements (haemolysis), and variable degrees of anaemia. Thrombocytopenia is not associated with thalassaemia's.
A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.
• Use of accessory muscles to breathe • Purulent sputum with frequent coughing Explanation: Chronic bronchitis increases airway resistance and can thicken bronchial mucosa during an exacerbation. The client will have dyspnea requiring the use of accessory muscles to breathe, along with tachypnea and sputum production. Bronchial irritation and the need to expectorate mucus will lead to coughing. Percussion in this client would lead to resonant or hyperresonant sounds.
Choice Multiple question - Select all answer choices that apply. A 13-year-old client at the pulmonary clinic where you practice nursing has an extensive history of asthma and is seeing the pulmonologist for her monthly appointment. What are the primary functions of the lungs? Choose all correct options. a) Oxygen production b) Gas exchange c) Destroying CO d) Ventilation
• Ventilation • Gas exchange Explanation: The primary functions of the lungs include ventilation and gas exchange.
The instructor in the anatomy and physiology class is talking about alveolar respiration. What would the instructor tell the class is the main purpose of alveolar respiration?
Determines amount of CO2 in the body Explanation: Alveolar respiration determines the amount of CO2 in the body. It does not determine the amount of O2, bicarbonate, or PaO2 in the body.
The instructor in the anatomy and physiology class is talking about alveolar respiration. What would the instructor tell the class is the main purpose of alveolar respiration? a) Determines amount of CO2 in the body b) Determines amount of bicarbonate in the body c) Determines amount of oxygen in the body d) Determines amount of PaO2 in the body
Determines amount of CO2 in the body Explanation: Alveolar respiration determines the amount of CO2 in the body. It does not determine the amount of O2, bicarbonate, or PaO2 in the body.
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client? a) Immunoglobulin G (IgG) b) Factor VIII c) Pneumococcal vaccine d) Aspirin
Pneumococcal vaccine Explanation: Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be admin ... (more) Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be administered due to the increased risk of bleeding. IgG is administered to client with increased chance of bacterial infections but is not routinely given to client undergoing splenectomy, as is the pneumococcal vaccine. Factor VII is given to treat bleeding disorders.
You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a) Osteopathic tumors destroy bone causing fractures. b) Osteolytic activating factor weakens bones producing fractures. c) Osteoclasts break down bone cells so pathologic fractures occur. d) Osteosarcomas form producing pathologic fractures.
Osteoclasts break down bone cells so pathologic fractures occur. Explanation: The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This in turn causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a 'punched-out' or 'honeycombed' appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. Options A, C, and D are distractors for this question
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? a) Hypernatremia b) Hypermagnesemia c) Hypercalcemia d) Hyperkalemia
Correct response: Hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a) Pallor, tachycardia, and a sore tongue b) Angina pectoris, double vision, and anorexia c) Sore tongue, dyspnea, and weight gain d) Pallor, bradycardia, and reduced pulse pressure
Correct response: Pallor, tachycardia, and a sore tongue Explanation: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia
A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? a) Crackles b) Cyanosis c) Son's statement d) Respiratory rate
Cyanosis Explanation: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.
A client is receiving platelets. In order to decreased the risk of circulatory overload in this client, the nurse should do which of the following? a) Infuse each unit over 30-60 minutes per client tolerance. b) Flush the intravenous line with a liter of saline between units. c) Monitor vital signs closely before transfusion and once per shift. d) Administer each unit slowly over 3-4 hours.
Infuse each unit over 30-60 minutes per client tolerance. Explanation: Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the ... (more) Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload
Mr. Sam Wallace, a 53-year-old male, is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?
Type II cells Explanation: Type II cells—produce surfactant, a phospholipid that alters the surface tension of alveoli, preventing their collapse during expiration and limiting their expansion during inspiration
Choice Multiple question - Select all answer choices that apply. Which of the following are immunosuppressants that prevent the patient's lymphocytes from destroying the stem cells in a patient diagnosed with aplastic anemia? Select all that apply. a) Cyclosporine b) ATG c) Filgrastim d) Corticosteroids e) Cyclophosphamide
• Cyclosporine • Corticosteroids • ATG • Cyclophosphamide Explanation: Immunosuppressants, including cyclosporine, corticosteroids, ATG, and cyclophosphamide, prevent the patient's lymphocytes from destroying the stem cells. Filgrastim is a growth-colony stimulating factor that may be used to decease the duration and severity of neutropenia associated with aplastic anemia
You are caring for three clients who have the following blood count values: Client A has 24,500 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client? a) Client A has a normal WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count. b) Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a higher platelet count than normal. c) Client A has a normal WBC count, client B has a higher hemoglobin count than normal, and client C has a normal platelet count. d) Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.
Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count. Explanation: The normal leukocyte count is between 5,000 and 10,000/mm3. Client A has an increased number of leukocytes greater than 10,000/mm3 and hence has leukocytosis. In ... (more) The normal leukocyte count is between 5,000 and 10,000/mm3. Client A has an increased number of leukocytes greater than 10,000/mm3 and hence has leukocytosis. In adults, the normal amount of hemoglobin is 12 to 17.4 g/dL; therefore, client B has a normal hemoglobin count. A normal circulating platelet count is 150,000 to 350,000/mm3 platelets; therefore, client C has a normal platelet count
A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? a) Son's statement b) Cyanosis c) Respiratory rate d) Crackles
Cyanosis Explanation: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips
Which ventilation-perfusion ratio is exhibited by a pulmonary emboli?
Dead space Correct Explanation: When ventilation exceeds perfusion a dead space exists. An example of a dead space is pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?
Diagnosis of peripheral vascular disease Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment? a) Lateral diameter greater than anteroposterior diameter b) Lateral diameter less than anteroposterior diameter c) Anteroposterior diameter that equals the lateral diameter d) Elevation of the scapula with the lateral diameter unaffected
Lateral diameter greater than anteroposterior diameter Explanation: Inspecting the thorax is part of assessment of the respiratory system. Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2. Chest deformities are associated with respiratory disease
Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders? a) Manage decreased energy levels b) Manage respiratory distress c) Aid the caregivers of the client d) Ensure adequate rest periods
Manage decreased energy levels Explanation: In addition to the nursing management of individual tests, patients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these patients, breathing may in some way be compromised. Energy levels may be decreased. For that reason, explanations should be brief yet complete and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress
Which diagnostic is more accurate in detecting malignancies than a CT scan?
PET scan Explanation: A PET scan is more accurate in detecting malignancies than a CT scan, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thorascopy. The gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. An MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs
A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.
• Educate the client about the need to cleanse the thoracic area. • Apply pressure to the puncture site after the procedure. • Complete a respiratory assessment after the procedure. Explanation: A thoracentesis is performed to aspirate fluid or air from the pleural space. The nurse assists the client to a sitting or side-lying position, which provides support and exposes the base of the thorax. Encouraging a position of comfort helps the client to relax for the procedure. The nurse prepares the client by explaining the steps of the procedure and begins by cleansing the thoracic area using aseptic technique. After the procedure, the nurse applies pressure to the site to help stop bleeding; then, he or she applies an air-tight, sterile dressing. A chest x-ray verifies that there is no pneumonthorax. The nurse will monitor at intervals the client's respiratory function
Willy Trout, a 7-year-old boy, has been brought to the ED where you practice nursing. Willy and some friends were having a contest to see who could throw a piece of candy the highest and catch it in their open mouth. As a result, Willy aspirated candy, which brings him to you via ambulance. Where would be the most likely place to find the aspirated piece of candy?
• Right mainstem bronchus • Right upper lung Explanation: Aspiration of foreign objects is more likely in the right upper lung