medsurge practice questions from book/ati

A nurse is planning to instruct a client on how to perform pursed lip breathing. Which of the following statements should the nurse include? A. "Take quick breaths upon inhalation." B "Place your hand over your stomach" C. "Take a deep breath in through your nose" D. "Puff your cheeks upon exhalation"

C

Laboratory tests for BE

-ABG (PaCO2 levels are low, respiratory acidosis then metabolic acidosis) -D dimer (release of fibrin degradation products) -CT scan -VQ scan (air and blood ratio) -pulmonary angiography (gold standard but invasive and expensive)

Laboratory tests for pneumothorax and hemothorax

-ABG (hypoxemia) -Chest xray -thoracentesis (perforation of chest wall and pleural space with needle)

What is the difference between ARF, ARDS, and SARDS?

-ARF is caused by failure to adequately ventulate and/or oxygenate -ARDS is a state of acute respiratory failure with a mortality rate as high as 58% -SARDS is the result of a viral infection from a mutated strain of the coronaviruses

Most important nursing interventions for TB

-administer heated and humidified oxygen therapy -prevent infection transmission (n95, airborne prec) -negative-airflow room -take meds 6-12 months -need sputum samples every 2-4 weeks -contaminated tissues should be disposed in plastic bags

Nursing interventions for PE

-administer oxygen -initiate and maintain IV access -Assess respiratory status every 30 minutes -assess cardiac status -monitor bleeding times -monitor adr for anticoagulants -assess for bleeding from or bruising around injection and surgical sites every 2 hr

Expected findings for pneumothorax and hemothorax

-anxiety -pleuritic pain -respiratory distress -tracheal deviation to the unaffected side -reduced or absent breath sounds on the affected side -asymmetrical chest wall movement -hyper resonance on percussion due to trapped air -dull percussion

Nursing actions for pneumothorax and hemothorax

-assist client with specimen transport -assist the client to the edge of the bed and to lean over bedside table (thoracentesis) -administer oxygen therapy -auscultate heart and lung, vitals every 4 hours

Expected findings for a PE

-dyspnea and air hunger -hemoptysis (coughing up blood) -pleurisy (inflammation of lining of lungs) -pleural friction rub -tachycardia -hypotension -tachypnea -crackles -heart murmur in S3 and S4 -distended neck veins -cyanosis -low-grade fever

Expected finding for flail chest

-unequal chest expansion -paradoxical chest wall movement -tachycardia -hypotension -dyspnea -cyanosis -anxiety -chest pain

A nurse is caring for a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture C. Obtain a complete history from the pt D. Provide a pneumococcal vaccine

A

A nurse is discharging a client who has COPD. The client is concerned about not being able to leave the house due to the need for staying on continuous oxygen. Which of the following responses should the nurse make? A. "There are portable oxygen delivery systems that you can take with you" B. "When you go out, you can remove the oxygen and then reapply it when you get home" C. "You will not be able to go out as much as you used to"

A

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus" B. "I need to avoid drinking fluids if I develop symptoms" C. "I need a flu shot every 2 years because of the different strains" D. "I should cover my mouth with my hand when I sneeze"

A

A nurse is planning to test a client for TB and check for rifampin resistance. Which laboratory test would be best? A. Nucleic acid amplification testing. B. Quantiferon TB Gold C. Acid-fast bacilli smear and culture D. Mantoux test

A (most rapid and accurate screening for TB. quantiferon tb gold is to tell if disease is active or latent, acid-fast tests for active infections and mantoux tests for positive TB)

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. hip arthroplasty 2 weeks ago. B. Elevated sedimentation rate. C. Incident of exercise-induced asthma 1 week ago. D. Elevated platelet count

A (A client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of risk of hemorrhage from the surgical site)

A 62 patient is being seen for an initial evaluation of symptoms of shortness of breath, cough, and sputum production. Spirometry reveals an FEV1 of 65% predicted. The FVC is 90%, and FEV1/FVC is 60%. The patient is diagnosed with COPD. The patient's history includes smoking for over 35 years. The patient smokes 10 cigarettes a day and has tried to quit several times; they were able to quit for 1 week a few years ago. Concerns include weight gain once they quit smoking. provider gave a prescription for bupropion and nicotine nasal spray. The nurse is asked to review an approach to smoking cessation. What should be included in the teaching plan? A. Bupropion and nicotine replacement can assist in the quitting process. B. Successful smoking cessation includes multiple approaches. C. Dealing with the habit of smoking is important to success. D. Quitting smoking once COPD is diagnosed has no effect on lung function.

A, B, C (Smoking cessation is a key factor for improving prognosis in COPD. Even patients with severe disease will benefit from smoking cessation. There is strong evidence that nicotine replacement and/or bupropion or nortriptyline increase long-term smoking abstinence. For patients concerned with weight gain during a quit attempt, bupropion may be helpful. Smoking cessation slows the accelerated decline in lung function and the progression of COPD.)

A patient had a respiratory arrest requiring emergency intubation with an endotracheal tube (ETT). Which nursing interventions are appropriate after the provider places the ETT? Select all that apply. A. Auscultate for bilateral breath sounds B. Ensure STAT chest x-ray confirms placement C. Ensure that the ETT is secured with either waterproof medical tape or ETT holder D. Ensure the exact size cuffed tracheostomy is at the bedside E. An obturator should be available in the room in case of accidental dislodgment

A, B, C (The nurse listens for bilateral breath sounds and observes for chest movement. Lack of breath sounds is associated with esophageal intubation, while breath sounds heard in only one lung suggests placement in mainstem bronchus. A chest x-ray is obtained to confirm placement. The nurse ensures that the ETT is secured with either waterproof medical tape or ETT holder while awaiting confirmation that ETT placement is appropriate. The nurse also notes placement by recording the level of insertion (marked in centimeters on the side of the tube) at the teeth or nares (if inserted nasally) and secures the tube with tape or a commercial tube holder to prevent movement and potential dislodgment. Ensuring a cuffed tube and obturator is at the bedside is for patients with a tracheostomy tube, not an ETT.)

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be availavle in the client's room. Select all that apply. A. Oxygen B. Sterile water C. enclosed hemostat clamps D. indwelling urinary catheter E. occlusive dressing

A, B, C, E (oxygen helps respiratory stress, water restores the seal if tube becomes disconnected, hemostat clamps can check for air leaks)

Early signs of respiratory failure include which of the following? Select all that apply. A. Restlessness B. Tachycardia C. Cyanosis D. Tachypnea E. Respiratory arrest

A, B, D (Early signs are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, mild tachycardia and tachypnea, and increased BP. As the hypoxia progresses, more obvious signs may be present, including confusion, lethargy, central cyanosis, diaphoresis, and finally respiratory arrest. The nurse recognizes that the clinical manifestations are usually related to hypoxemia, hypercapnia, and acidosis.)

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? A. A client who experienced a near-drowning incidient B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced acute drug toxicity.

A, B, D, E (A bc trauma to lungs and cerebral edema. B bc trauma to the chest. C no bc needs to be lower to be at risk. D because risk for aspiration and E bc damage to CNS)

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A, B, E

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? A. Encourage the client to cough and deep breathe. B. Check for continuous bubbling in the suciton chamber. C. Strip the drainage tubing every 4 hours. D. Clamp the tube once a day. E. Obtain a chest x-ray

A, B, E

The patient is admitted with hypoxemia and fever, expectorating green sputum, and chest film reveals right middle and lower lobe pneumonia. The oxygen saturation is 89% and the patient complains of shortness of breath (SOB). What physical examinations findings are associated with this condition? Select all that apply. A. Whispered pectoriloquy B. Bronchial breath sounds C. Eupnea D. Stridor E. Dull percussion on right middle and lower lobe.

A, B, E (Consolidation of the lung that occurs in pneumonia results in bronchial breath sounds, crackles, bronchophony, egophony, and whispered pectoriloquy. Percussion would reveal a dull sound. Eupnea is normal breathing, and stridor is a high-pitched sound pronounced during inspiration that is associated with a narrowed trachea or larynx and is frequently a medical emergency)

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? A. Client who has dysphagia. B. Clint with AIDS. C. Client who was vaccinated for pneumococcous and influenza 6 months ago. D. Client who is postoperative and has received local anesthesia. E. Client who has myasthenia gravis

A, B, E, F (pt with dysphagia is at higher risk for aspiration which can lead to pneumonia. pt with aids is immunocompromised=pneumonia. pt receiving mechanical ventilation is at risk for hap and pt with myasthenia gravis is weak and will have trouble coughing secretions=pneumonia)

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate to deliver with this medication? A. Fentanyl B. Furosemide C. Midazolam D. Phenytoin E. Dexamethasone

A, C (fentanyl is pain medication administered to clients when a neuromuscular blocking agent, like vecuronium is administered. Midazolam is a sedative medication administered to clients when a neuromuscular blocking agent is administered. )

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risk for complication? A. Dyspnea B. localized bloody drainage on the dressing C. Fever D. Hypotension E. report of pain at puncture site

A, C, D (dyspnea can indicate a pneumothorax or a reaccumulation of fluid. fever can indicate infection. hypotension can indicate intrathoracic bleeding. pain and bloody drainage are expected findings)

The nurse is caring for a client who is schedyled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? A. Oxygen equipment B. Incentive spirometer C. Pulse Ox D. Sterile dressing E. Suture removal kit

A, C, D (incentive spirometer would be used following a thoracic surgery)

In a client with pulmonary artery hypertension (PAH), which sign(s) should lead the nurse to suspect right-sided heart failure (cor pulmonale)? Select all that apply. A. Jugular vein distention B. Productive cough C. Leg edema D. Hepatosplenomegaly E. Bilateral crackles

A, C, D (Signs of right-sided heart failure include peripheral edema, ascites, distended neck veins, hepatomegaly, right ventricular third heart sound (S3), heart murmur, and splitting of second heart sound. Crackles and productive cough are associated with left-sided HF.)

During morning rounds on a medical floor, the nurse assesses a patient admitted the previous evening with an exacerbation of COPD. The patient is complaining of increased dyspnea and is sitting on the side of the bed with their arms braced against their knees. The respiratory rate was 20 on admission and is now 28. Breath sounds are diminished with coarse crackles heard throughout. The oxygen saturation is 93% on 2 L/min of supplemental oxygen. The nurse would perform which of the following? Select all that apply. A. Administer albuterol using a spacer that has been ordered "as needed." B. Switch the patient's oxygen to a Venturi mask at 32%. C. Instruct the patient to begin pursed-lip breathing. D. Instruct the patient in controlled cough. E. Observe for signs and symptoms of further deterioration.

A, C, D, E (Albuterol is a sympathomimetic bronchodilator (short-acting beta adrenergic or SABA) used to relieve bronchospasm and improve secretion clearance. Pursed-lip breathing and controlled cough may further help the patient's dyspnea and secretion clearance. The patient's oxygen saturation is adequate, and there is no need to increase the FiO2 at this time. The nurse should monitor the effect of treatment. Worsening or unrelieved symptoms and/or worsening oxygen saturation will need further evaluation and treatment. The nurse observes the patient for signs and symptoms of further deterioration.)

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include? A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

A, C, D, E (client would lose weight not gain weight)

You are working the emergency room and a patient is en route after sustaining a traumatic injury while driving. A cervical collar was applied and oxygen was administered. The patient is moving all limbs and asking that the C-collar be removed. Which of the following assessments are the priority tasks when the patient arrives? Select all that apply. A. Assess vital signs. B. Remove the C-collar. C. Insert intravenous catheters. D. Apply pulse ox monitoring E. Log roll the patient if needed.

A, C, D, and E (Once arriving in the ER, vital signs must be repeated to obtain the patient's current baseline readings, IV(s) need to be inserted so that treatment can be administered if required. Since a cervical injurt is assumed until diagnostic imaging confirms the C-spine is stable, the C-collar remains in place and continuous oxygen saturations are monitored since a fracture to the cervical spine above C5 threatens respiratory paralysis. The patient must be log rolled until diagnostic testing confirms no fracture of the cervical spine)

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? A. A client with a BMI of 30 B. A female client who is post menopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic a fib

A, C, E

A patient who was involved in a motor vehicle accident and was admitted with maxillofacial injuries is currently postop day 2 from undergoing nasal surgical fracture repair with posterior packing in place. Which symptoms would alert the nurse to the possibility of continued active bleeding? Select all that apply. A. Black, tarry stools B. Raccoon eyes C. Mean arterial pressure of 65 mm Hg D. Friction rub E. Tachycardia

A, C, E (Black tarry stools suggest that an upper GI bleed exists. With a posterior nasal bleed, the patient can be swallowing the blood, which will present as melena. The raccoon eyes, or periorbital (around the eyes) ecchymosis, are associated with anterior skull base fractures, so they are attributed to the admitting injury, not continued bleeding. A normal MAP is 70 to 110 mm Hg. Major organs require an MAP of >65 mm Hg for perfusion; a low MAP in this situation suggests hypovolemic shock, as does the tachycardia. A friction rub results from the movement of inflamed and roughened pleural surfaces against one another and is associated with pleural disease.)

A nurse is preparing to administer an initial dose of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stool

A, C, E (hypokalemia, fluid retention, and black tarry stool are all adr for prednisone (corticosteroid). tachycardia is an adr of bronchodilator and nausea is adr of bronchodilator)

The following day the patient's symptoms are improving. There is less dyspnea, and the patient is able to walk to the bathroom with minimal assistance. In preparing for discharge, a home oxygen assessment is ordered. The patient's room air oxygen saturation is 88% at rest and 86% with exertion. Oxygen administered by nasal cannula at 2 L/min raises the oxygen saturation to 94% at rest and 92% when walking. Home oxygen is ordered as 2 L/min 24 hours a day. Teaching about home oxygen would include which of the following? Select all that apply. A. Oxygen improves cardiac and cognitive function and improves prognosis. B. Oxygen needs to be worn only when the patient is short of breath. C. Oxygen improves cardiac and cognitive function but does not improve prognosis. D. Home oxygen must be kept away from open flames. E. "Oxygen in Use" signs should be posted on the doors of the home.

A, D, E (Key studies have shown that oxygen improves vital organ function and improves prognosis. Symptoms are an unreliable method of determining the need for oxygen. Many patients may be dyspneic and have normal/near-normal oxygen saturation. Conversely, other patients may deny symptoms but be profoundly hypoxemic. To determine the need for supplemental oxygen, oxygen levels need to be measured by arterial blood gas or oximetry. Oxygen supports combustion, but it can be used safely in the home. Patients need to be taught to keep their oxygen away from open flames to decrease the risk of uncontrolled fire. Signage should be posted on doors to the home that oxygen is in use.)

A patient with a suspected pulmonary embolus is brought to the emergency department complaining of shortness of breath and chest pain. Which of the following additional signs and symptoms would the nurse expect to assess in this patient? Select all that apply. A. Tachypnea B. Thick green sputum C. Bradycardia D. Hyperresonance E. Tachycardia F. Blood-tinged sputum

A, E, F (Symptoms depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus. Acute onset of dyspnea is the most frequent symptom, followed by pleuritic chest pain, cough, hemoptysis, and palpitations. The most common signs found on physical assessment are tachypnea, crackles, tachycardia, and presence of an S4 heart sound and split S2. Thick green sputum is associated with infection, allergy, or stasis of secretions and unrelated to PE. Hyperresonance is associated with the overinflation of the lung(s) as in emphysema or pneumothorax.)

A nurse is caring for a client who is scheduled for a thorecentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure C. Obtain ABG D. Administer benzocaine spray.

A. (provider explains procedure, no indication for needing abg, benzocaine spray is for bronchoscopy not thorecentesis)

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air. Vital signs are heart rate 117/minute, respirations 38/minute, temperature 38.4 C, BP 100/54. Which of the following is the nursing priority" A. Notify the provider B. Administer heparin IV C. Administer oxygen therapy D. Obtain a CT

C

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Sex B. Environmental allergies C. Alcohol use D. History of diabetes

B

A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam D. Prepare for chest tube insertion

B

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates understanding? A. "This medication can decrease my immune response" B. "I take this medication to prevent asthma attacks" C. "I need to take this medication with food" D. "Thus medication has a slow onset to treat my symptoms"

B

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include? A. "You will need to continue to take your medication regimen for 4 months" B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication" C. "You will need to remain hospitalized for treatment" D. "You will need to wear a mask at all times"

B

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the infection site C. Place tape around the insertion site. D. Assess respiratory status

B (ABC)

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis" B. "It allows present pressure delivered during spontaneous ventilation" C. "It guarantees minimal minute ventilator" D. "It delivers a present ventilatory rate and tidal volume to the client"

B (PSV allows present pressure delivered during spontaneous ventilation to decrease the work of breathing)

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to delivers precise amount of oxygen to the client? A. nonrebreather mask B. Venturi mask C. nasal cannula D. simple face mask

B (a nonrebreather mask delivers an approximation, a nasal cannula delivers an approximation, simple face mask delivers approximation. *8 A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered)

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse. A. I am allergic to morphine B. I take antacids several times a day for my ulcer C. I had a blood clot in my leg several years ago D. It hurts to take a deep breath

B (the greatest risk for a client is the possibility of bleeding from a peptic ulcer.)

A nurse is orienting a newly licensed nurse on the purpose of administering vercuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "This medication is given to treat infection" B. "This medication is given to facilitate ventilation" C. "This medication is given to decrease inflammation"

B (vercuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption)

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? A. continuous bubbling in the water seal chamber. B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration. D. Exposed sutures without dressing. E. Drainage system upright at chest level.

B, C

In the case above, which interventions are appropriate for this patient? Select all that apply. A. Maintain the head of bed less than 30 degrees. B. Administer oxygen via nasal cannula. C. Turn the patient on the left side to prevent hypoxemia. D. Prepare for intubation E. Turn the patient on the right side to prevent hypoxemia.

B, C (The HOB should be elevated to semi-high Fowler position to relieve dyspnea; pulse oximetry monitoring and O2 administration are appropriate since the patient has a decreased oxygen saturation hypoxemia (low O2 saturation). The nurse understands that the dependent lung is better perfused and thus turns the patient left side down to match the best ventilated lung with the best perfusion. There is no need to intubate the patient at this time. nut the nurse should have airway management equipment nearly if needed.)

A patient is admitted to the ER after hitting the steering wheel in a motor vehicle crash. The patient is alert, restless, complaining of chest and back pain, and the skin is cool and clammy. Breath sounds are diminished over the left side. An upright chest x-ray reveals fractures of the left 5th through 7th ribs and a 25% left hemothorax. Pertinent data are: B/P is 80/50; HR is 125; RR is 28 and slightly labored. O2 sat is 93% on room air. Which of the following measures is most likely to be included in this patient's initial care? A. Immediate endotrachel intubation B. Chest tube administration C. oxygen administration D. IV at a keep-vein-open rate E. pericardiocentesis

B, C (The nurse anticipates chest tube insertion for the hemothorax (blood in the pleural space), IV insertion, and IV fluid bolus. The patient's vital signs are concerning for hypovolemic shock with an increased HR, RR, and low blood pressure; thus, fluid administration is anticipated. A pericardiocentesis is performed for the removal of pericardial fluid as in cardiac tamponade. the symtpms of tamponade known as Beck triad are hypotension, jugular venous distention, and mufflied heart sounds; while this patient does have hypotension, there is no evidence that cardiac tamponade is present. Since the O2 is 93% there is no cause for intubation at this time.)

A nurse is caring for a client who has pneumonia. Assessment findings include temperature, tachypnea, blood pressure 130/76, heart rate of 100 bpm, and SaO2 of 91%, Prioritize the actions. A. Administer antibiotics B. Administer oxygen therapy C. Perform a sputum culture. D. Instruct the client to obtain a yearly influenza vaccine.

B, C, A, D

A patient is admitted to the ICU after hitting the steering wheel in a motor vehicle crash. The patient is alert, restless, complaining of chest and back pain, and skin is cold and slightly clammy. Breath sounds are diminished over the left side. An upright chest x-ray reveals fractures of the left fifth through seventh ribs and a 25% left hemothorax. Pertinent data are: BP is 80/50; HR is 125; RR is 28 and slightly labored. O2 sat is 93% on room air. Which of the following measures is most likely to be included in this patient's initial care? Select all that apply. A. Immediate endotracheal intubation B. Chest tube insertion C. Oxygen administration D. IV fluid bolus E. Pericardiocentesis

B, C, D (A chest tube will be inserted for the hemothorax, oxygen must be provided since the saturation is 93%. Although the patient is tachypnic with an RR of 28, there is no need to intubate the patient at this time. Recall that hypoxemia is defined as a PaO2 level of less than 60 mm Hg and/or a POX level of less than 90%. Hypotension and tachycardia with a MAP of 60 mm Hg are associated with hypovolemic shock, and an IV fluid bolus is needed to replace the blood or fluid loss urgently to minimize tissue ischemia.)

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? A. assist-control B. Synchronized intermittent mandatory ventilation C. continuous positive airway pressure D. pressure support ventilation E. independent lung ventilation

B, C, D (assist control takes over the work of breathing and independent lung ventilation is used for unilateral lung disease to ventilate individually. B, C, D all force client to take breaths)

A nurse in the ED is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following dindings should the nurse expect? A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxical chest movement

B, C, D, E

An asthma educator is teaching a new patient with asthma and their family about the use of a peak flow meter. What is included in the teaching? Select all that apply. A. Teach that the meter is measuring the highest airflow during a forced inspiration. B. Teach that the meter is measuring the highest airflow during a forced expiration. C. Teach the patient to stand or sit up straight and put the marker on the meter at zero. D. Teach the patient to place the meter in their mouth with their tongue and teeth out of the way, seal their lips around the meter, and inhale as hard and fast as possible. E. Teach the patient to place the meter in their mouth with their tongue and teeth out of the way, seal their lips around the meter, and exhale as hard and fast as possible.

B, C, E (A peak-flow meter is a small handheld device that measures the fastest expiratory flow the patient can generate after taking a deep breath in and blowing out as hard and fast as possible. Patients are instructed to stand or sit up straight; put the marker on the peak-flow meter to zero; take a full, deep breath in; place the meter in their mouth with the tongue and teeth out of the way; and seal their mouth around the meter. They are to exhale as hard and fast as possible, note the reading, and then repeat the procedure two more times. They should write down the highest reading.)

A nurse in the emergencu department is caring for a client who is experiencing an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Tachycardia

B, C, E (wheezing is narrowing of airways, retraction indicates increased work trying to breath. SaO2 is still WNL and D is normal)

A home health nurse is teaching a client who has active tuberculosis and is following a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicates an understanding? A. "I can substitute one medication for another if I run out because they all fight infection" B. "I will wash my hands each time I cough" C. "I am glad I don't have to have any more sputum specimens" D. "I will wear a mask when I go in a public area"

B, D

For a patient who comes in to the emergency room with an epistaxis, which interventions will you implement? Select all that apply. A. Apply ice to the back of the neck B. Pinch the nares against the midline septum for 5 or 10 minutes C. Encourage them to blow their nose vigorously D. Use high Fowler with the head tilted forward E. Encourage the patient to swallow the blood

B, D (Ice may be applied to the bridge of the nares to help constrict blood vessels. Direct the patient to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes. The patient is told to avoid blowing their nose or touching it, which can increase irritation. The patient sits upright (venous pressure is reduced) with the head tilted forward to help keep the blood from draining to the back of the throat and prevent swallowing and aspiration of blood. Swallowed blood may act as an irritant causing the patient to vomit. The nurse will also try to keep the patient calm, as reducing the anxiety may help with the bleeding. The nurse should continuously assess the patient's airway and breathing, and vital signs including pulse oximetry monitoring.)

A patient who has just had a total laryngectomy for cancer is being discharged. Which statement indicates the patient needs further teaching on care of the tracheostomy? Select all that apply. A. "I must avoid getting any objects in the stoma" B. "I can take a shower when I get home." C. "I know it's really important to keep my scheduled appointments with the surgeon and my speech therapist" D. "I need to clean around the stoma once a week" E. "I will wash my hands before and after caring for the tracheostomy"

B, D (The patient must be taught to avoid any objects, sprays, loose hair, powder, etc. near the stoma, because they can block or irritate the trachea and possibly cause infection. Water cannot get into the stoma, as this will cause direct access into the bronchial tree. Methods of covering the stoma to protect it from water will be taught. Keeping health screening activities as well as keeping scheduled appointments with the provider, speech therapist, and other health care providers is important. The nurse teaches the patient and family to wash their hands before and after caring for the tracheostomy, to use tissue to remove mucus, and to dispose of soiled dressings and equipment properly.)

A nurse is planning care for a client who has severe acute respiratory distress system (SARDS). Which of the following actions should the nurse take? A. Administer antibiotics B. Provide supplemental oxygen C. Administer antiviral medications D. Administer bronchodilators E. Mainrain ventilatory support

B, D, E

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

B, D, E (client will have tachypnea and hypotension)

The nurse assesses the patient with acute pharyngitis for what signs and symptoms that indicate a complication of group A streptococcus (GAS) pharyngitis? Select all that apply. A. Pain and spasm of the lower leg muscles B. Rapid onset of gross hematuria C. Reduced visual fields, blurred vision, and insomnia D. Heartburn and abdominal distention E. Edema and hypertension

B, E (Acute poststreptococcal glomerulonephritis (APSGN) is a complication that follows roughly 10 days after the onset of streptococcal infection and results in temporary or persistent kidney failure (<1% of children, up to 10% of adults). APSGN is characterized by the rapid onset of gross hematuria, edema (leading to respiratory distress and pulmonary edema), and hypertension.)

The nurse is caring for a client diagnosed with ARDS. In evaluating the use of PEEP, what outcome would the nurse expect to find? Select all that apply. A. Increased ventilation-perfusion mismatch B. Increased FRC C. Decreased intrathoracic pressure D. Hypertension E. Decrease in preload

B, E (Use of PEEP helps increase FRC and reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a reduction in the severity of the ventilation-perfusion imbalance. The use of positive-pressure ventilation increases intrathoracic pressure and causes a decrease in preload to the heart. This drop in preload can result in decreased cardiac output and hypotension.)

A nurse is caring for a client who is experiencing respiratory distress Which of the following early manifestations of hypoxemia should the nurse recognize? A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B, E (bradycardia and hypotension are late manifestations)

A nurse at a provider's office is reviewing information with a client scheduled for pulmonary function tests (PFT). Which of the following information should the nurse include? A. "Do not use inhaler medications 6 hours after medication" B. "Do not smoke tobacco for 6 to 8 hour prior to the test" C. "You will be asked to bear down and hold your breath during the test" D. "The arterial blood flow to your hand will be evaluated as part of the test"

B. (the valsalva maneuver is not required for PTF testing, allen's test to evaluate arterial blood gas is performed prior to sampling)

A nurse is preparing to administer a new prescription for isoniazid to a light-skinner client who has tuberculosis. The nurse should instruct the client to report which of the following adverse effects of the medication? A. "You might notice yellowing of the skin" B. "You might experience pain in your joints" C. "You might notice tingling of your hands" D. "You might experience a loss of appetite"

C (yellowing of skin is adr of rifampin and pyrazinamide. joint pain and loss of appetite are adr for rifampin)

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels" B. "This medication can decrease my immune response" C. "I can have an increase in my heart rate while taking this medication" D. "I can have mouth sores while taking this medication"

C (bronchodilators, such as albuterol can cause tachycardia)

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding? A. "I will decrease my fluid intake" B. "I will expect to have black, tarry stools" C. "I will take my medication with meals" D. "I will monitor for weight loss while on this medication"

C (this medication causes GI upset)

A patient is admitted to the ICU after falling from a. roof and sustaining fractures of the first three ribs on the right side. the patient is dyspneic, and crepitus (subcutaneous emphysema) can be palpated. The chest x-ray reveals a pneumothorax. What physical examination findings are associated with pneumothorax? Select all that apply. A. Dullness to percuss on the right B. Increased fremitus on the right C. Decreased or absent breath sounds on auscultation of the right D. Hyperresonance on the right E. Egophony on the right

C, D (Pneumothorax would present with decreased to absent fremitus, hyperresonance, and decreased to absent breath sounds over the pneumothorax. Increased fremitus, dullness to percussion, and egophony are associated with consolidation of the lung)

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take? A. Instruct the client to lie prone with arms by the sides. B. Complete a surgical checklist on the client. C. Remind the client that there is minimal discomfort during the removal process. D. Place an occlusive dressing over the site once the tube is removed.

D

A nurse is instructing a client on the use of incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level" B. "I will lie on my back with my knees bent" C. "I will rest my hand over my abdomen to create resistance." D. " I will take a deep breath and hold it before exhaling"

D

A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements would the nurse include? A. "Notfy your provider if you experience weakness" B. "You should be able to return to work in a week" C. "You need to wear a mask when in crowded areas" D. "Notify your provider if you experience a productive cough"

D

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of the posterior lobes of the lungs. B. Auscultation of the trachea. C. Inspection of the conjunctiva. D. Palpation of the orbital areas.

D (A is for pneumonia, B is for bronchitis, C is for anemia)

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D (bronchospasm can indicate the client is having difficulty maintaining a patent airway)

A nurse is caring for a client 2 hour after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotics B. Beta-Blocker C. Antiviral D. Beta 2 agonist

D (beta2 agonist will cause bronchodilation)

A hospital conducts an outpatient clinic for patients with asthma. The nurse working in the clinic is responsible for teaching patients about their medications. Which is true about inhaled medications? Select all that apply. A. All inhalers must be given with a spacer device. B. Inhaled corticosteroids are used on an as-needed basis for quick relief. C. Long-acting beta adrenergics (LABAs) can be used as monotherapy to control asthma. D. LABAs and inhaled corticosteroids are used as controllers in the management of asthma. E. Rinse and gargle after using inhaled steroid preparations to decrease the risk of oral thrush.

D, E (Spacers are generally recommended for patients unable to use their inhalers correctly. In addition, they are useful for those using inhaled corticosteroids by MDI to decrease the risk of oral thrush. Patients are instructed to rinse and gargle after using inhaled steroid preparations to decrease the risk of oral thrush. The Expert Panel Guidelines recommend that LABAs not be used as monotherapy in the long-term treatment of asthma but instead be used in combination with inhaled corticosteroids.)

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator setting every 8 hours. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 4 hours.

D. (setting should be checked hourly, and placement in centimeters should be measured from teeth or lips)