quiz 3 (ch 19)

The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way?

Through a central venous line

A nurse is explaining to a client with asthma with a new prescription for prednisone what it is used for. What would be the most accurate explanation that the nurse could give?

To gain prompt control of inadequately controlled, persistent asthma

A client presents to the walk-in clinic reporting a dry, irritating cough and production of a small amount of mucus-like sputum. The client also reports soreness in the chest in the sternal area. The nurse should suspect that the primary care provider will assess the client for which health problem?

Tracheobronchitis

When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal?

Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises?

Use diaphragmatic breathing.

A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?

Venturi mask

The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving birth at home. Which principle should guide the nurse's administration of intravenous fluid?

Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency

While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often?

When adventitious breath sounds are auscultated

While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care?

Administer an analgesic before coughing and deep breathing.

A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction?

Administer an inhaled beta-adrenergic agonist.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor?

Arrhythmias

The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess?

Arterial blood gas (ABG) levels

When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following?

Asbestos

The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention?

Assessing and understanding shock and the significant changes in assessment data to guide the plan of care

A client's plan of care specifies postural drainage. Which action should the nurse perform when providing this noninvasive therapy?

Assist the client into a position that will allow gravity to move secretions.

An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of this care should be prioritized by the home health nurse?

Assisting the client and family to identify and mobilize community resources

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication?

Atelectasis

A nurse is preparing to perform an admission assessment on a client with chronic obstructive pulmonary disease (COPD). It is most important for the nurse to review which of the following?

Available diagnostic tests

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?

Bilateral wheezes

The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

Bradycardia

The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology?

Brain natriuretic peptide (BNP) level

A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF?

Bronchial mucus plugging, inflammation, and eventual bronchiectasis

An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care?

Cautious hydration

A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem?

Cells lack an adequate blood supply and are deprived of oxygen and nutrients.

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize?

Chronic inhalation of indoor toxins can cause lung damage.

A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care?

Communicate clearly and frequently with the client's family.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

Cool, clammy skin

The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client?

Correct and safe use of oxygen therapy equipment

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock?

Decreased urinary output

The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of:

Decreased venous return

A nurse is preparing to care for a client with bronchiectasis. The nurse should recognize that this client is likely to experience respiratory difficulties related to what pathophysiologic process?

Dilation of bronchi and bronchioles.

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax?

Diminished or absent breath sounds on the affected side

The nurse in the intensive care unit is caring for a client with pulmonary hypertension. Which finding should the nurse expect to assess?

Dyspnea at rest

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?

Early ambulation

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?

Early provision of nutritional support.

An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients?

Educating clients about recognizing and avoiding asthma triggers

An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize?

Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?

Fluid volume circulating in the blood vessels decreases.

An asthma educator is teaching a client newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures highest airflow during which type of breath?

Forced expiration

The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize?

Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration

The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?

Heart and respiratory rates are elevated

A nurse is caring for a client who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the client for which clinical manifestation?

Hemoptysis

A pediatric nurse practitioner is caring for a 2-year-old client who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. Which potential causative agent that may trigger an attack should the nurse describe?

Household pets

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor?

Hypothermia

The nurse is providing care for a client who has recently been diagnosed with chronic obstructive pulmonary disease. When educating the client about exacerbations, the nurse should prioritize which topic?

Identifying specific causes of exacerbations.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?

Increase oral fluids unless contraindicated.

A nurse has been asked to give a workshop on chronic obstructive pulmonary disease for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has which pathophysiologic effect?

Increases the amount of mucus produced

An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?

Initiate chest physiotherapy.

The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?

It dilates the blood vessels.

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs?

It promotes GI function through direct exposure to nutrients.

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer?

Lactated ringer

The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation?

Loss of skeletal muscle

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this?

Maintaining a patent airway

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify?

Maintenance of adequate mean arterial pressure

The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate?

Monitor cuff pressure every 8 hours.

A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside?

Monitor pulse oximetry readings.

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs?

Nasal cannula

A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?

Neurogenic shock

A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. Which other supportive measure should be initiated in this client?

Nutritional support

A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching?

Oral candidiasis

A nurse is caring for a 21-year-old client whose medical history includes an alpha1-antitrypsin deficiency. This client has an increased risk of which health problem?

Panacinar emphysema

A nurse is caring for a 6-year-old client with cystic fibrosis. To enhance the child's nutritional status, which priority intervention should be included in the plan of care?

Pancreatic enzyme supplementation with meals.

The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge?

Perform shoulder exercises five times daily.

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated?

Performing frequent oral care

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition?

Pneumothorax

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath after a prolonged episode of coughing. On assessment, the nurse notes an oxygen saturation of 84%, asymmetrical chest movement, and decreased breath sounds on the right side. Which condition should the nurse suspect and which interventions should the nurse implement based on these signs and symptoms?

Pneumothorax; give supplemental oxygen and continue to monitor the client

The nurse is caring for a client with bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this client's care?

Postural chest drainage

.The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT:

Progressive dyspnea

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention?

Promoting communication with the client and family along with addressing end-of-life issues

An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock?

Remove invasive devices as soon as they are no longer needed.

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for?

Removing excess air and fluid

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock?

Respiratory distress

A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care?

Restoration of adequate gas exchange

The hospital case manager for a group of recently discharged clients with asthma is providing health education. Which aspect of client teaching would have the greatest impact on preventing readmissions?

Self-care and the therapeutic regimen

A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care?

Setting realistic short and long term goals

The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock?

Shallow, rapid respirations

A 67-year-old client with severe bilateral arthritis of the hands has been diagnosed with chronic obstructive pulmonary disease. Which inhalation delivery method is best for the bronchodilator ordered for this client?

Small Volume Nebulizer (SVN)

A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. Which fact about lung cancer treatment should inform the nurse's response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action?

Smoking damages the ciliary cleansing mechanism.

The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and arterial blood gases (ABGs)

The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what method?

Surgical resection

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state?

Tachycardia

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing?

Take prescribed medications as scheduled.

A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation?

Teach the client strategies for promoting diaphragmatic breathing.

The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment?

The client desires a portable oxygen delivery system that can deliver 2 L/min.

The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion?

The client is in the compensatory stage of shock.

The nurse is caring for a client who has been in a motor vehicle accident and is suspected of having developed pleurisy. Which assessment finding would best corroborate this diagnosis?

The client's pain intensifies when the client coughs or takes a deep breath.

A nurse is providing health education to the family of a client with bronchiectasis. Which technique should the nurse prioritize teaching the client's family members?

The correct technique for providing postural drainage

The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

The cough reflex is depressed.

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug?

The drug dose should be tapered down once vital signs improve.

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize?

The importance of adhering closely to the prescribed medication regimen

A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize?

The patient will successfully mobilize pulmonary secretions.

The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs?

The release of catecholamines that creates an increase in metabolic rate and caloric requirements

The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment?

"Lately, I have this cough that just never seems to go away."

A client has just been diagnosed with lung cancer. After the health care provider discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status."

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

"The younger you are when you start smoking, the higher your risk of lung cancer."

A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication?

"This drug is particularly good at preventing asthma attacks during exercise."

A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend?

"Wear protective attire and devices when working with a toxic substance."

A nurse is assessing a client who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply.

- Airway obstruction - Pulmonary infections - Genetic disorders

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply.

- Anaphylactic - Septic - Neurogenic

An interdisciplinary team is planning the care of a client with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply.

- Antimicrobial therapy - Chest physiotherapy - Smoking cessation

A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.

- Blood urea nitrogen (BUN) level - Urine specific gravity - Creatinine level

A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply.

- Chest tightness - Wheezing - Cough

A nurse is performing a focused assessment on a client with bronchiectasis. Which are the most prevalent signs and symptoms of this condition? Select all that apply.

- Copious, purulent sputum - Chronic cough

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply.

- Difficulty breathing - Cardiovascular overload - Pulmonary edema

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply.

- Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines - Serum lactate greater than 4 mmol /L - MAP of less than 65 mm Hg

A nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD) admitted to the hospital for the second time this year with pneumonia. Which nursing diagnoses would be appropriate for this client? Select all that apply.

- Impaired gas exchange related to ventilation-perfusion inequality - Deficient knowledge regarding self-care related to preventable complications

A client with chronic obstructive pulmonary disease has recently begun a new bronchodilator. Which therapeutic effect(s) should the nurse expect from this medication? Select all that apply.

- Increased expiratory flow rate - Relief of dyspnea

A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply.

- Level of consciousness - Arterial blood gases - Vital signs

The occupational health nurse is assessing an employee who has just had respiratory exposure to a toxin. What should the nurse assess? Select all that apply.

- Time frame of exposure - Type of respiratory protection used - Breath sounds - Intensity of exposure

A nurse's assessment reveals that a client with chronic obstructive pulmonary disease may be experiencing bronchospasm. Which assessment findings would suggest that the client is experiencing bronchospasm? Select all that apply.

- Wheezes or diminished breath sounds on auscultation - Labored and rapid breathing

The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

20 cm H2O

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client?

A barrel chest

A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?

A tracheostomy

The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client?

Abdominal compartment syndrome

A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem?

Acute respiratory failure

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?

The system has an air leak.