iggy 4.1

A nurse auscultates a clients lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.) a. Inflammation of the pleura b. Constriction of the bronchioles c. Upper airway obstruction d. Pulmonary vascular edema

ANS: A A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lung wall. The other pathophysiologic processes would not cause a pleural friction rub. Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may be heard as stridor, and pulmonary vascular edema may be heard as crackles.

A major serum protein that is below normal in patients who have inadequate nutrition is: a. Albumin b. Globulin c. Fibrinogen d. Transferrin

ANS: A A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.

A serious condition which is not locally observable and is typically manifested by decreased blood flow to a distal extremity is known as __________ thrombosis. a. arterial b. venous c. partial d. atrial

ANS: A Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For example, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood to the leg. This is an emergent condition and requires immediate intervention.

Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta or through breast milk is called: a. natural passive b. artifical passive c. natural active d. artifical active

ANS: A Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or immunization.

The process to control cellular growth, replication, and differentiation to maintain homeostasis is called: a. cellular regulation. b. cellular impairment. c. cellular reproduction. d. cellular tumor.

ANS: A Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 8 within the body.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

An increase in platelet stickiness can lead to: a. hypercoagulability b. thromobocytopenia c. embolus d. atrial fibrillation

ANS: A Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive plately stickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to form adequate clots, which often occurs when there is an inadequate number of circulating platelets or a reduction in platelet stickiness.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the clients neck for redness and swelling.

ANS: A Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the clients neck, but these options do not decrease the clients discomfort.

a client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 222 unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the clients nose. d. Turn the client every 2 hours or as needed.

ANS: A Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen

The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Hydrogen ions. b. Bicarbonate. c. Oxygen. d. Phosphate.

ANS: A Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen and phosphate are not characteristic of respiratory acidosis.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

ANS: A Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

ANS: A Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best? a. Breathing so quickly can be dehydrating. b. Everyone with pneumonia is dehydrated. c. This is really just to administer your antibiotics. d. Why do you think you are so dehydrated?

ANS: A Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

ANS: A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the clients risk for infection.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

ANS: A The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

ANS: A The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

ANS: A The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

ANS: A The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.) a. Avoid drinking fluids just before and during meals. b. Rest before meals if you have dyspnea. c. Have about six small meals a day. d. Eat high-fiber foods to promote gastric emptying. e. Increase carbohydrate intake for energy.

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the clients risk of for acidosis.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 223 d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

ANS: A, B, C Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowlers position to assist in avoiding aspiration. Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

ANS: A, B, C, D The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

ANS: A, B, D Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the clients ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

ANS: A, B, D, E The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

ANS: A, C, D, E Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 231 Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the clients safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

ANS: A, C, E Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 230 f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called battle sign and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

ANS: A, D The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

ANS: A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

Acid-base balance occurs when the pH level of the blood is between: a. 7.3 and 7.5 b. 7.35 and 7.45 c. 7.4 and 7.5 d. 7.25 and 7.35

ANS: B Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production and elimination.

Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

ANS: B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the clients pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

ANS: B Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the clients history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone Disrupts the production of pathways of inflammatory mediators

ANS: B Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 220 c. Place the client on NPO status. d. Request that the client have a swallow study.

ANS: B Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional state is known as: a. dementia b. delerium c. amnesia d. depression

ANS: B Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

ANS: B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. Chest x-rays are always ordered when we suspect pneumonia. b. Older people often have vague symptoms, so an x-ray is essential. c. The x-ray can be done and read before laboratory work is reported. d. We are testing for any possible source of infection in the client.

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The xray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

A defining characteristic of malignant (cancerous) cells is: a. they cannot spread to other tissues or organs. b. they can invade healthy cells, tissues, and organs. c. they are not usually a health risk. d. none of the above.

ANS: B Malignant (cancerous) cells have no comparison to the original cells from which they are derived, and they have the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On the other hand, Benign cells do not have the ability to spread to other tissues or organs.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. I will consult the speech therapist to ensure you are swallowing properly. b. This is normal after surgery. What types of food do you like to eat? c. I will ask the dietitian to change the consistency of the food in your diet. d. Replacement of protein, calories, and water is very important after surgery.

ANS: B Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the clients concerns.

13. The inability to pass stool is known as ____________. a. constipation b. obstipation c. diarrhea d. incontinence

ANS: B Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition where stool can be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum from constipation, and occurs when stool is watery and without solid form. Elimination is the general term to describe the excretion of waste from the body by the gastrointestinal tract and by the urinary system.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the clients oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

ANS: B Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

ANS: B Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the clients on Contact Precautions. b. Cohort the clients in the same area of the unit. c. Do not allow pregnant caregivers to care for these clients. d. Place the clients on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

ANS: B Room air is 21% oxygen.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

ANS: B Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching? a. Add peppermint oil to the humidifier to relax the airway. b. Make sure you clean the humidifier to prevent infection. c. Keep the humidifier filled with water at all times. d. Use the humidifier when you sleep, even during daytime naps.

ANS: B Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 229 Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used while awake and asleep.

10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

ANS: B The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 226 a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

ANS: B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

ANS: B To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching? a. I will stay away from smokers to minimize inhalation of secondhand smoke. b. When I speak, I will whisper rather than use a normal tone of voice. c. For the next several weeks, I will not lift more than 10 pounds. d. I will drink at least three quarts of water each day to stay hydrated.

ANS: B Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, to stay hydrated, and to use stool softeners.

Signs and symptoms of ________ thromobsis include localized redness, swelling, and warmth: a. arterial Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 9 b. venous c. partial d. atrial

ANS: B Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed locally.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.) a. What color is your sputum? b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? d. Do you walk upstairs every day? e. Have you lost any weight lately?

ANS: B, C, E Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the clients sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

ANS: B, E The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

The minimum hourly urinary output in a patient should be at least: a. 5 mL per hour b. 10 mL per hour c. 30 mL per hour d. 60 mL per hour

ANS: C 30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in urinary output is a sign of diminished kidney activity and fluid deficit.

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

ANS: C Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.

The best indicator of fluid volume changes in the body is: a. skin dryness b. weight changes c. blood pressure d. pulse rate

ANS: C Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary indicators.

The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond? a. I will ask the provider to change your medication to a drug that is less potent. b. Would you like me to use music therapy to distract you from your pain? c. It is unlikely you will become addicted when taking medicine for pain. d. Would you like me to give you acetaminophen (Tylenol) instead?

ANS: C Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication.

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching? a. Take an antibiotic each day. b. Contact your provider to obtain genetic screening. c. Eat a well-balanced, nutritious diet. d. Plan to exercise for 30 minutes every day.

ANS: C Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. Do you have a strong support system? b. What do you understand about your disease? c. Do you experience shortness of breath with basic activities? d. What medications are you prescribed to take each day?

ANS: C Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the clients support systems, current knowledge, and medications, these questions do not address the clients appearance.

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. I plan to wear my oxygen when I exercise and feel short of breath. b. I will use my portable oxygen when grilling burgers in the backyard. c. I plan to use cotton balls to cushion the oxygen tubing on my ears. d. I will only smoke while I am wearing my oxygen via nasal cannula.

ANS: C Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond? a. Since many of your family members are carriers, your children will also be carriers of the gene. b. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder. c. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested. d. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor- Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.

ANS: C For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all times in case I need it. b. I will take this medication when I start to experience an asthma attack. c. I will take this medication every morning to help prevent an acute attack. d. I will be weaned off this medication when I no longer need it.

ANS: C Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. There are a variety of support groups for people who have COPD. b. I will ask your provider to prescribe you with an antianxiety agent. c. Share any thoughts and feelings that cause you to limit social activities. d. Friends can be a good support system for clients with chronic disorders.

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond? a. This medication will treat your sleep apnea. b. This sedative will help you to sleep at night. c. This medication will promote daytime wakefulness. d. This analgesic will increase comfort while you sleep.

ANS: C Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

10.A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

The most common causes of decreased comfort for a patient are pain and ____________. a. light-headedness b. nausea c. emotional stress d. depression

ANS: C Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact the outcome of surgery.

A high-level thinking process that allows an individual to make decisions and judgments is known as: a. amnesia b. personality c. reasoning d. memory

ANS: C Reasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments. Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain and recall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems.

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it. b. It may take a while before I notice a change in my asthma. c. I will use the drug when I have an asthma attack. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 234 d. I will be careful not to let the drug escape out of my nose and mouth.

ANS: C Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the clients part allows the drug to escape through the nose and mouth.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

ANS: C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

ANS: C The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the clients airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this clients gait should not be impacted by a total laryngectomy and therefore is not a priority.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond? a. Your children will be at high risk for the development of chronic obstructive pulmonary disease. b. I will contact a genetic counselor to discuss your condition. c. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke. d. This is a recessive gene and should have no impact on your health.

ANS: C The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partners AAT levels. Contacting a genetic counselor may be helpful but does not address the clients current question.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. Ice packs may help with the facial pain. b. Limit fluids to dry out your sinuses. c. Try warm, moist heat packs on your face. d. We will schedule you for a computed tomography scan this week.

ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: C, E Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the clients anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. T

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

ANS: D A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

ANS: D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in: a. calcium b. magnesium c. sodium d. potassium

ANS: D Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. Are any family members also ill? b. Have you traveled recently? c. How long have you been ill? d. What is your occupation?

ANS: D Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

14. A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

ANS: D Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the clients risk for a pneumothorax.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond? a. You are using the inhaler incorrectly. This medication should be taken daily. b. If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks. c. Tell me more about your fears related to feelings of breathlessness. d. It is important to use this type of inhaler every day. Lets identify potential community services to help you.

ANS: D Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the clients financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the clients immediate concerns.

The best way for an individual to maintain acid-base balance is to a. avoid or quit smoking. b. exercise regularly. c. eat healthy and well-balanced meals. d. All of the above.

ANS: D Maintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most cases of COPD can be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet can decrease the incidence of type-2 diabetes.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

ANS: D Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the clients hypoxia, which is the priority.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the devices manufacturer, not the provider.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D Sneezing and coughing into ones sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the clients cheek.

ANS: D The string should be attached to the clients cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the clients airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

ANS: D This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

Specialized cells that circulate in the body to promote clotting are called: a. anticoagulants. b. proteins. c. emboli. d. platelets.

Clotting is a complex, multi-step process through which blood forms a protein-based clot to prevent excessive bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when an injury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary, localized, solid plug.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 228 a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowlers position. d. Ask the client to perform deep-breathing exercises.

NS: A Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.