Hesi respiratory EAQ
A registered nurse is evaluating the statements of a nursing student providing instructions to the partner of a client with Ebola. Which instruction given by the nursing student needs correction? 1 "You should avoid direct contact with your partner's saliva." 2 "You should be careful because the Ebola virus spreads through the air." 3 "You should avoid having sex with your partner for 3 months even after the recovery of your partner." 4 "You should immediately report symptoms of fever, headache, and vomiting."
"You should be careful because the Ebola virus spreads through the air." Ebola disease is caused by the Ebola virus, which does not spread through the air, water, or food. Ebola spreads through bodily fluids. A client with Ebola may have the Ebola virus in the semen for 3 months even after recovery. Early symptoms of Ebola disease are fever, headache, and vomiting.
An 85-year-old client has a three-day history of nausea, vomiting, and diarrhea. The client develops weakness and confusion and is admitted to the hospital. To best monitor the client's rehydration status, what should the nurse assess? 1 Skin turgor 2 Daily weight 3 Urinary output 4 Mucous membranes
Daily weight A continuous increase in serial weight determinations indicates a movement toward correction in the dehydration; 1 L of fluid weighs 2.2 pounds (1 kilogram). The skin in older adults has less fluid and subcutaneous fat than in younger adults, which results in a subjective and inaccurate assessment of rehydration. In older adults there can be a decrease in renal blood flow and tubular function; therefore, urinary output does not provide an accurate assessment of rehydration therapy. The mucous membranes in older adults are drier than in younger adults because of the decrease in salivary secretions and therefore do not provide an accurate assessment of rehydration therapy.
A client has had two weeks of bile drainage from a T-tube following the client's cholecystectomy. To monitor for a lack of fat-soluble vitamins, the nurse should observe for what symptom? 1 Easy bruising 2 Muscle twitching 3 Excessive jaundice 4 Tingling of the fingers
Easy bruising Phytonadione, a precursor for prothrombin, cannot be absorbed without bile. Muscle twitching is commonly related to electrolyte imbalances, not fat-soluble vitamin deficiency. Jaundice results from a backup of bile, not a deficiency of fat-soluble vitamins. Tingling of the fingers may be related to electrolyte imbalances or deficiency of B vitamins, which are water soluble.
A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change? 1 Decreased afterload 2 Decreased heart rate 3 Increased stroke volume 4 Increased intravascular volume
Increased intravascular volume As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload, increasing pulmonary artery wedge pressure. Increased, not decreased, afterload will cause an increase in the pulmonary artery wedge pressure. Afterload is the peripheral resistance against which the left ventricle must pump. A decreased heart rate will not increase pulmonary artery wedge pressure. After a pulmonary artery wedge pressure reaches 20 mm Hg, the stroke volume does not increase significantly.
A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take? 1 Inspect the dressing 2 Increase the oxygen flow rate 3 Notify the healthcare provider 4 Place the client in the supine position
Inspect the dressing The dressing should be inspected to determine the presence of hemorrhage; vital signs also should be obtained. Increasing the oxygen flow rate is contraindicated because it may precipitate CO2 narcosis in a client with emphysema. Notifying the healthcare provider should be done after the nurse performs an appropriate assessment. Placing the client in the supine position is contraindicated because it may compromise the client's respiratory status.
A nurse is auscultating a client's heart sounds and hears S1. Which valves is the nurse assessing? 1 Mitral and tricuspid 2 Aortic and tricuspid 3 Mitral and pulmonic 4 Aortic and pulmonic
Mitral and tricuspid Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). The aortic and pulmonic are the semilunar valves; closure of these valves produces the second heart sound (S2). The other options do not close simultaneously.
Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? 1 The client is a chain smoker. 2 The client works in a cement factory. 3 The client has a history of a minor hand fracture. 4 The client has a history of travel to central parts of North America
The client has a history of travel to central parts of North America. Travel and geographic area of residence reveal the potential for exposure to certain diseases. Histoplasmosis is a fungal disease caused by inhalation of contaminated dust in the central parts of America and Canada. Smoking will not lead to histoplasmosis. Working in a cement factory is not related to histoplasmosis. A minor hand fracture is not related to histoplasmosis.
A client with a history of type 1 diabetes is experiencing progressive problems with venous stasis. The client tells the nurse, "I bumped my leg a week ago, and now it has an open draining area just above the ankle." Which information is most important for the nurse to explore when collecting the client's health history? 1 The type of treatment and care the client is receiving 2 What dosage and type of insulin the client is taking and how often 3 The number of family members that are experiencing similar problems 4 How many times a day the client voids and the frequency of bowel movements
The type of treatment and care the client is receiving Asking what type of treatment the client is receiving and how the client is managing care will elicit a variety of data such as medications, diet, and other aspects of care and even includes the care of the new wound. Although it is important to know about the client's insulin use, the information is too limited and does not include how the client is caring for the new wound or for the diabetes itself. Although information about a client's bowel and bladder habits is important, it is not the priority. Although information about the client's children is important, determining the number of family members the client has and whether they are having similar problems is not the priority.
An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? 1 A complete blood count 2 A serum electrolyte level 3 An arterial blood gas panel 4 An x-ray film of long bones
A serum electrolyte level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and an x-ray film of long bones have no significance in diagnosing a potassium deficit.
A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? 1 Septic shock 2 Cardiogenic shock 3 Neurogenic shock 4 Anaphylactic shock
Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1 Arteriolar constriction occurs. 2 The cardiac workload decreases. 3 Contractility of the heart decreases. 4 The parasympathetic nervous system is triggered.
Arteriolar constriction occurs. The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.
Which type of hepatitis virus spreads through contaminated food and water? 1 Hepatitis A virus 2 Hepatitis B virus 3 Hepatitis C virus 4 Hepatitis D virus
Hepatitis A virus Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.
The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? 1 High concentrations of oxygen cause alveoli to rupture. 2 High concentrations of oxygen eliminate the respiratory drive. 3 The client does not need any more than 1 L/min. 4 The oxygen at 1 L/min should be enough to diminish the anxiety
High concentrations of oxygen eliminate the respiratory drive. Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. Too much oxygen will knock out the stimulus to breathe. High concentrations of oxygen will not cause a rupture. The client actually could need more oxygen; however, if a higher concentration is given, it will knock out the respiratory drive. The oxygen is being given because of the shortness of breath.
A nurse is auscultating a client's heart; closure of what structures produces the first heart sound (S1)? 1 Mitral and tricuspid valves 2 Aortic and tricuspid valves 3 Mitral and pulmonic valves 4 Aortic and pulmonic valves
Mitral and tricuspid valves Closure of the atrioventricular valves, the mitral and tricuspid, produces S1. Neither the aortic and tricuspid valves nor the mitral and pulmonic valves close simultaneously. The aortic and pulmonic valves are the semilunar valves; closure of these valves produces the second heart sound (S2).
A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect? 1 Pencil-shaped 2 Mucus-coated 3 Loose and liquid 4 Moist and formed
Moist and formed A colostomy on the left side involves the descending colon, leaving most of the colon intact to absorb fluid. Pencil-shaped stool is associated with conditions that narrow the intestinal lumen like cancer; this usually is not associated with a colostomy. Stools usually are not covered with mucus; they may be moist but not mucoid. Loose and liquid stools are associated with a colostomy that involves the ascending colon.
A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply. 1 Oliguria 2 Dyspnea 3 Hypotension 4 Pulmonary crackles 5 Tenting tissue turgor
Oliguria Hypotension Tenting tissue turgor With dehydration, the body tries to conserve fluid, resulting in lowered urinary output (oliguria). There is a decrease in all body fluids, including the fluids within the circulatory system. With less blood volume, less force is needed to pump the blood, and the blood pressure decreases, causing hypotension. When the skin is pinched it remains raised after the pinch is released, indicating dehydration. Difficulty breathing is a result of pulmonary problems, which are not expected with dehydration. Auscultation of crackles is a result of pulmonary edema, which does not occur with dehydration.
A nurse is performing a health history and physical assessment of a client with cholelithiasis and obstructive jaundice. Which clinical finding should the nurse expect this client to exhibit? 1 Hematuria 2 Bloody stools 3 Straw-colored urine 4 Pain in the right upper quadrant
Pain in the right upper quadrant The gallbladder is located in the right upper quadrant. Pain occurs after fatty meals and may radiate to the right back or shoulder. Hematuria occurs with nephrolithiasis, not cholelithiasis. The stool will be clay-colored, not dark brown, because of the lack of bile. When the level of bile in blood increases, bile will be present in urine, causing it to have a dark color.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale? 1 Peripheral edema 2 Productive coughing 3 Twitching of the extremities 4 Lethargy progressing to coma
Peripheral edema Cor pulmonale [1] [2] is right ventricular failure caused by pulmonary congestion; edema results from increasing venous pressure. A productive cough is symptomatic of the original condition, COPD. Although twitching of the extremities and lethargy progressing to coma may be caused by alterations in oxygen and hydrogen ion levels and their effects on the central nervous system, it is the sign of peripheral edema that directly indicates increasing venous pressure secondary to cor pulmonale.
A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? 1 Obtain a new sterile drainage system. 2 Use two clamps to close the drainage tube. 3 Place the client in the high-Fowler position. 4 Reconnect the client's tube to the drainage system.
Reconnect the client's tube to the drainage system. To prevent further possibility of pneumothorax, the nurse should reconnect the tube immediately. Obtaining a new sterile drainage system is unnecessary. Clamping the tube is appropriate when changing a broken drainage system or when checking for an air leak. The high-Fowler position is appropriate for a client in respiratory distress, but it does not remedy the problem.
After abdominal surgery a client should be encouraged to turn from side to side and to engage in deep breathing exercises. The nurse explains that these activities are essential to prevent which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an elevated carbon dioxide level leads to acidosis [1] [2]. Metabolic acidosis is caused by a loss of bicarbonate from the lower gastrointestinal tract, which is associated with diarrhea. Metabolic alkalosis is caused by excessive loss of hydrogen ions from gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" What response by the nurse is the best? 1 "It's a good idea to explore other acceptable treatments for your cancer. There is information available for you." 2 "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" 3 "Maybe you will be more confident with a second opinion. I think you need a referral to another healthcare provider." 4 "With your disease your prognosis will improve if you follow the suggestion to have the recommended surgery."
Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" The response "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" provides needed information and establishes an opportunity for further discussion of surgery. The response "It's a good idea to explore other acceptable treatments for your cancer. There is information available for you" implies the other approaches are as effective as surgery; this places doubt in the client's mind that surgery is the most effective option. The response "Maybe you will be more confident with a second opinion" is an inappropriate response; the competence of the healthcare provider was not questioned, but there exists a need for further discussion of the treatment. Making this type of referral is not the nurse's role. The response "With your disease your prognosis will improve" is false reassurance; it cuts off communication and does not address the need for further discussion.
A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction? 1 Alanine aminotransferase (ALT) 2 Serum aspartate aminotransferase (AST) 3 Total lactate dehydrogenase (LDH) 4 Troponin T (cTnT)
Troponin T (cTnT) Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver; it is found in lesser quantities in the kidneys, heart, and skeletal muscles and is primarily used to diagnose and monitor liver, not heart, disease. AST, also known as serum glutamic-oxaloacetic transaminase (SGOT), is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.
While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record? 1 Crackles 2 Wheezes 3 Rhonchus 4 Pleural friction rub
Wheezes Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.