Chapter 2 Test
A client with thoracic trauma is admitted to the ICU. The nurse notes that the clients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcue emphysema. If this condition becomes severe and threatens airway patency what intervention is indicated?
A tracheostomy
A client is described as having pectus carinatum. What would be the physical manifestations of this condition? A. The sternum protrudes and the ribs are sloped backward B. The thoracic and lumbar spine have a lateral S-shaped curse C. The sternum is depressed from the second intercostal space D. The chest is rounded, ribs horizontal, and sternum is pulled forward
A.
A patient is brought into the ED with carbon monoxide poisioning after escaping a house fire. What should the nurse monitor this patient for? A. Anemic hypoxia B. Stagnant hypoxia C. Histotoxic hypoxia D. Hypoxic hypoxia
A.
A patient with emphysema informs the the nurse "The surgeon will be removing about 30% of my lung so that I will not be so SOB and will have an improved quality of life". What surgery does the nurse understand will be preformed? A. A lung volume reduction B. A sleeve resection C. Lobectomy D. A wedge resection
A.
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care? A. Suction the clients airway secretions B. Immobilize the ribs with an abdominal binder C. Prepare the client for surgery D. Immediately sedate and intubate the client
A.
It is important that the nurse provides required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to A. Manage decreased energy levels B. Ensure adequate rest periods C. Aid the client's caregivers D. Manage respiratory distress
A.
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? A. Administer over the counter decongestants B. Place a warm cloth over the sinus area of the forehead C. Use an anti-allergy medication to decrease rhinitis D. Gently blow the nose to eliminate secretions
A.
While assessing an acutely ill clients respiratory rate the nurse asses four normal breathes followed by an episode of apnea lasting 20 sec. How should the nurse document this finding? A. Biot's respiration B. Eupnea C. Cheyne-strokes D. Apnea
A.
When the nurse is assessing the older adult patient what gerontologic changes should she be aware of? Select all that apply. A. Decreased presence of mucus B. Decreased gag reflex C. Increased presence collagen in the alveolar walls D. Decreased alveolar duct diameter E. Increased presence of mucus
A. B. C.
A client has a suspected liquid 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. A. Educate the client about the need to cleanse the thoracic area B. Place the client in the prone position C. Prepare the client for an MRI after the procedure to verify tube placement D. Complete a respiratory assessment after procedure E. Apply pressure to the puncture site after procedure
A. D. E.
The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which lab values would be assessed when determining the nutritional status of the client? Select all that apply. A. Glucose level B. White blood cell count C. Platelet count D. Albumin level E. Protein level
A. D. E.
A client arrives in the ED reporting SOB. She has a 3+ pitting edema below the knees, a respiratory rate of 36 breaths per min, and heaving respiration's. The nurse auscultates the client's lung to reveal coarse, moist, high-pitched and non-continuous sounds that do not clear with coughing. The nurse documents these sounds as? A. Pleural rub B. Crackles C. Rhonchi D. Wheezes
B.
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short term goal for this client is? A. Use a room vaporizer to loosen secretions B. Report decreased congestion C. Assume an upright position to facilitate drainage D. Increase fluid intake
B.
A mechanically ventilated patient is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication? A. Pneumothorax B. Venous thromboemboli C. Pulmonary hypertension D. Cor pulmonae
B.
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months . The client reports occasional dyspnea. Which imaging study ordered by the physician will view the thoracic cavity when in motion? A. Chest x-ray B. Fluoroscopy C. CT scan D. MRI
B.
A physician determines that a client has been exposed to someone with TB. The nurse expects the physician to order what treatment? A. Isolation until 24 hours after antitubercular therapy begins B. Daily doses of isoniazid, 300mg for 6 months to 1 year C. Daily oral doses of isoniazid and rifampin for 6 months to 2 years D. Nothing until signs of active disease arise
B.
For a client with advanced COPD which nursing action best promotes adequate gas exchange? A. Administering a sedative as ordered B. Using a venturi mask to deliver O2 as ordered C. Encouraging the client to drink 3 glasses of fluid daily D. Keeping the patient in semi-fowlers postion
B.
The nurse caring for a client with emphysema understands that airflow limitations are not reversible. The end result of deterioration is A. Diminished alveolar surface area B. Respiratory acidosis C. Hypercapnia resulting from decreased CO2 elimination D. Hypoxemia secondary to O2 diffusion
B.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment which adventitious breath sounds are anticipated? A. Rales B. Wheezes C. Crackles D. Rhonchi
B.
The nurse should monitor a client receiving mechanical ventilation for what complications? A. Increased cardiac output B. Gastrointestinal hemorrhage C. Immunosuppression D. Pulmonary emboli
B.
Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? A. The lungs increase respiratory volume B. The lungs eliminate carbonic acid by blowing off more CO2 C. The kidneys retain more HCO3 to raise pH D. The lungs retain more CO2 to lower pH
B.
Which measure may increase complications for a client with COPD? A. Administration of antibiotics B. Increased O2 supply C. Decreased O2 supply D. Administration of antitussive agents
B.
Why would a client with COPD report feeling fatigued? Select all that apply. A. Muscle function gradually decreases over time in clients with COPD B. Lung functions gradually decrease over time in clients with COPD C. The Client is using all expendable energy for ADL's D. The client is using all expendable energy just to breathe
B. D.
A client with a decreased LOC is in the recumbent position. How should the nurse best assess the lung fields for a client in this position? A. Obtain a pulse Ox reading, and if reading is low, reposition the client and auscultate breath sounds B. Avoid turning the client and assess the accessible breath sounds from the anterior chest wall C. Turn the Client to enable assessment of all the patients lung fields D. Inform the physician that the client is in the recumbent position and anticipate an order for a portable chest x-ray
C.
A thorocentesis is preformed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? A. Emphysema B. Trauma C. Cancer D. Infection
C.
An adult 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 his cancer. What about lung cancer treatment should inform the nurses response? A. Clients with small cell lung cancer are not normally stable enough to survive surgery B. The cells in small cell cancer of the lung are not large enough to visualize in surgery. C. Small cell cancer of the lung grows rapidly and metastasizes early and extensively D. Small cell lung cancer is self-limiting in many clients and surgery should be delayed
C.
which action by the nurse is Most appropriate when the client demonstrates subcue emphysema along the suture line or chest dressing 2 hours after chest surgery? A. Measure the patients pulse ox B. Report the finding to the physician C. Record the observation D. Apply a compression dressing to the area
C.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? A. Blood-tinged secretions B. Absent cough and gag reflex C. Respiratory rate of 13 breaths per min D. O2 sat of 90%
D.
A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache , fatigue, and feeling that "he just can't breathe enough". The nurse notes that the client is restless and tachycardic with an elevated BP. The client may be in the early stages of what respiratory problem? A. Pneumoconiosis B. Pleural effusion C. Pneumonia D. Acute Respiratory Failure
D.
The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure the client begins to vomit large amounts of dark blood at frequent intervals, is tachycardic and febrile. After notifying the surgeon the nurse A. Prepares for a needle aspiration B. Orally suctions the client as needed C. Stays with and closely monitors the client D. Obtains a light, mirror, gauze and curved hemostats
D.
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? A. PaO2 B. pH C. SaO2 D. PaCO2
D.
The nurse practitioner treats a patient diagnosed with the common cold by recommending the most common treatment. Which is A. Decongestants B. Expectorants C. Antitussives D. Antihistamines
D.
The mother of a client with cancer comes to the nurse with concerns for her daughters safety. She states that the dose of morphine that her daughter requires for her pain is getting higher and higher. She is afraid her daughter will overdose. The nurse should educate the mother about what aspect of pain management?
There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.