N320 Exam 3

pneumonia

infectious process that causes inflammation and excess fluid in lungs

ischemia

insufficient blood flow, lack of oxygen will cause cell injury and death

crackles

intermittent popping sounds caused by fluid, inflammation, infection, or secretions

hypoxemia

low oxygen level in the blood

hypoxia

low oxygen levels in the tissues

pleural friction rub

low pitched, creaking sound heard when pleural surfaces rub together

A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? a. Hyperthyroidism b. Phenylketonuria (PKU) c. Hypothyroidism d. Thyroid storm

b. Phenylketonuria (PKU)

dyspnea

difficulty breathing

hyperparathyroidism

effects: pulls calcium out of bone and cause osteoporosis. risk factors: kidney stone

hypercapnia

elevated CO2 levels in the blood

the movement of oxygen and carbon dioxide

gas moves from an area of high pressure to an area of low pressure across alveolar membrane

inhalation

lungs deliver oxygen to pulmonary capillaries and the oxygen is carried by hemoglobin to cells, CO2 is then carried in hemoglobin to the lungs

the normal sound percussed throughout the lungs

resonance (low pitched, clear sound that is heard over normal lung tissue)

respiratory distress syndrome

respiratory failure caused by injury to the alveolar capillary membrane and inflammation to the lungs

Which client complaint would alert the nurse to a possible hypoglycemic reaction?

*1. Tremors* 2. Anorexia 3. Hot, dry skin 4. Muscle cramps *rationale* Decreased blood glucose levels produce automatic nervous system symptoms, which are classically manifested as nervousness, irritability, and tremors. Option 3 is more likely to occur with hyperglycemia. Options 2 and 4 are unrelated to the signs of hypoglycemia.

A nurse is reviewing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?

*1. "I can eat foods that contain potassium."* 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet." *rationale* A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.

Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?

*1. "I had a radionuclide test done 3 days ago."* 2. "When I exercise I sweat more than normal." 3. "I drank some water before the blood was drawn." 4. "That hamburger I ate before the test sure tasted good." *rationale* Option 1 indicates that a recent radionuclide scan had been performed. Recent radionuclide scans performed before the test can affect thyroid laboratory results. No food, fluid, or activity restrictions are required for this test, so options 2, 3, and 4 are incorrect.

A nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for further teaching?

*1. "I need to stop my insulin."* 2. "I need to increase my fluid intake." 3. "I need to call my health care provider." 4. "I need to monitor my blood glucose every 4 to 6 hours." *rationale* When a client with diabetes is unable to eat normally because of illness, the client should still take the prescribed insulin or oral medication. Additional fluids should be consumed and a call placed to the health care provider. The client should monitor the blood glucose levels every 4 to 6 hours.

A nurse has reinforced home care measures to a client diagnosed with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction?

*1. "I should perform my exercise at peak insulin time."* 2. "I should always carry a quick-acting carbohydrate when I exercise." 3. "I should always wear a Medic-Alert bracelet especially when I exercise." 4. "I should avoid exercising at times when a hypoglycemic reaction is likely to occur." *rationale* The client should be instructed to avoid exercise at peak insulin time because this is when a hypoglycemic reaction is likely to occur. If exercise is performed at this time, the client should be instructed to eat an hour before the exercise and drink a carbohydrate liquid. Options 2, 3, and 4 are correct statements regarding exercise, insulin, and diabetic control.

A nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to plan to prepare to:

*1. Administer intravenous (IV) regular insulin.* 2. Administer IV 5% dextrose. 3. Correct the acidosis. 4. Apply an electrocardiogram (ECG) monitor. *rationale* Lack (absolute or relative) of insulin is the primary cause leading to DKA. Treatment consists of IV fluids (normal saline initially), regular insulin administration, and potassium replacement, followed by correcting the acidosis. An ECG monitor may be applied but is not the priority in this situation.

A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first?

*1. Administering oxygen* 2. Administering thyroid hormone 3. Warming the client 4. Giving fluid replacement *rationale* As part of maintaining a patent airway, oxygen would be administered first. This would be quickly followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones.

A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse focuses on which potential problem for this client?

*1. Dehydration* 2. The need for knowledge about the causes of hyperglycemia 3. Lack of knowledge about nutrition 4. Inability of family to cope with the client's diagnosis *rationale* Increased blood glucose will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis that leads to dehydration. This fluid loss must be replaced when it becomes severe. Options 2, 3, and 4 may be concerns at some point but are not the priority with hyperglycemia.

A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, would the nurse determine as being likely related to the manifestations of this disorder?

*1. Depression* 2. Nervousness 3. Irritability 4. Anxiety *rationale* Hypothyroid clients experience a slow metabolic rate, and its manifestation includes apathy, fatigue, sleepiness, and depression. Options 2, 3, and 4 identify the clinical manifestations of hyperthyroidism.

A nurse is reinforcing dietary instructions to a client newly diagnosed with diabetes mellitus. The nurse instructs the client that it is best to:

*1. Eat meals at approximately the same time each day.* 2. Adjust mealtimes depending on blood glucose levels. 3. Vary mealtimes if insulin is not administered at the same time every day. 4. Avoid being concerned about the time of meals as long as snacks are taken on time. *rationale* Mealtimes must be approximately the same time each day to maintain a stable blood glucose level. The client should not be instructed that mealtimes are varied, depending on blood glucose levels or insulin administration. Mealtimes should not be adjusted based on blood glucose levels or snacks.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis?

*1. Elevated blood glucose and low plasma bicarbonate* 2. Decreased urine output 3. Increased respirations and an increase in pH 4. Coma *rationale* In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria and Kussmaul's respirations. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis.

A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? *Select all that apply.*

*1. Encouraging fluid intake of at least 3000 mL/day* 2. Encouraging an intake of low-protein foods *3. Monitoring for changes in mental status* *4. Monitoring intake and output* 5. Maintaining a low-sodium diet *rationale* The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required.

A client with Addison's disease asks the nurse how a newly prescribed medication, fludrocortisone acetate (Florinef), will improve the condition. When formulating a response, the nurse should incorporate that a key action of this medication is to:

*1. Help restore electrolyte balance.* 2. Make the body produce more cortisol. 3. Replace insufficient circulating estrogens. 4. Alter the body's immune system functioning. *rationale* Fludrocortisone acetate is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addison's disease. Mineralocorticoids cause renal reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body. The other options are incorrect.

In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate?

*1. High in calcium and low phosphorous* 2. Low in vitamins A, D, E, and K 3. High in sodium with no fluid restriction 4. Low in water and insoluble fiber *rationale* Hypocalcemia is the end result of hypoparathyroidism resulting from either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus because these two electrolytes must exist in inverse proportions in the body. The other options are not dietary interventions with hypoparathyroidism.

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a health care provider's prescription?

*1. IV infusion containing 5% dextrose* 2. NPH insulin and a syringe for subcutaneous injection 3. An ampule of 50% dextrose 4. Phenytoin (Dilantin) for prevention of seizures *rationale* During management of DKA, when the blood glucose level falls to 300 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA; 50% dextrose is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA.

A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which of the following liquids?

*1. Milk* 2. Water 3. Iced tea 4. Fruit juice *rationale* Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? *Select all that apply.*

*1. Monitoring daily weight* *2. Monitoring intake and output* 3. Maintaining a low-potassium diet *4. Monitoring extremities for edema* *5. Maintaining a low-sodium diet* *rationale* The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

When a nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs, what information should the nurse obtain from the client?

*1. Plan of injection rotation* 2. Consistency of aspiration 3. Preparation of the injection site 4. Angle at which the medication is administered *rationale* Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus, clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage.

A nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited by the client, would indicate hyperglycemia and thus warrant health care provider notification?

*1. Polyuria* 2. Bradycardia 3. Diaphoresis 4. Hypertension *rationale* The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results drawn on the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client?

*1. Positive Trousseau's sign* 2. Negative Chvostek's sign 3. Unresponsive pupils 4. Hyperactive bowel sounds *rationale* Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia.

A nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which of the following values needs to be reported?

*1. Potassium 3.1 mEq/L* 2. Calcium 9.2 mg/dL 3. Sodium 137 mEq/L 4. Serum osmolality 288 mOsm/kg H2O *rationale* The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Thus the nurse carefully monitors the results of serum potassium levels and reports hypokalemia (option 1) promptly. The other laboratory values are within the normal ranges.

A client with diabetes mellitus visits the health care clinic. The client previously had been well controlled with glyburide (Diabeta), but recently, the fasting blood glucose has been running 180 to 200 mg/dL. Which of the following medications, if added to the client's regimen, may be contributing to the hyperglycemia?

*1. Prednisone* 2. Atenolol (Tenormin) 3. Phenelzine (Nardil) 4. Allopurinol (Zyloprim) *rationale* Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Options 2, a β-blocker, and 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral medications, which can lead to hypoglycemia.

A health care provider has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. A priority nursing measure to be included in the plan regarding this medication is to monitor the client for:

*1. Signs and symptoms of hypothyroidism* 2. Signs and symptoms of hyperglycemia 3. Relief of pain 4. Signs of renal toxicity *rationale* Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity.

A nurse is preparing to discharge a client who has had a parathyroidectomy. When teaching the client about the prescribed oral calcium supplement, what information should the nurse include?

*1. Take the calcium 30 to 60 minutes following a meal.* 2. Avoid sunlight because it can cause skin color change. 3. Store the calcium in the refrigerator to maintain potency. 4. Check the pulse daily and hold the dosage if it is below 60 beats per minute. *rationale* Oral calcium supplements can be taken 30 to 60 minutes after meals to enhance their absorption and decrease gastrointestinal irritation. All the other options are unrelated to oral calcium therapy.

A nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client's learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn?

*1. The client complains of fatigue whenever the nurse plans a teaching session.* 2. The client asks if the spouse can attend the classes also. 3. The client asks for written materials about diabetes before class. 4. The client asks appropriate questions about what will be taught. *rationale* Physical symptoms can interfere with an individual's ability to learn and can indicate to the teacher that the learner lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. Options 2, 3, and 4 identify the client as actively seeking information.

A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care, understanding that which of the following accurately reflects this client's level of knowledge?

*1. The client needs immediate education before discharge.* 2. The client's statement is accurate, but knowledge should be evaluated further. 3. The client's statement is inaccurate, and the client should be scheduled for outpatient diabetic counseling. 4. The client requires follow-up teaching regarding the administration of insulin. *rationale* If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the health care provider should be notified. The client's statement in this question indicates a need for immediate education to prevent HHNS, a life-threatening emergency situation.

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans first to address which problem?

*1. The possibility of injury* 2. Constipation 3. Urinary retention 4. Need for teaching about the disorder *rationale* The client with severe osteoporosis as a result of hyperparathyroidism is at risk for injury as a result of pathological fractures that can occur from bone demineralization. The client may also have a risk for constipation from the disease process but this is a lesser priority than client safety. The client may or may not have urinary elimination problems, depending on other factors in the client's history. There is no information in the question to support whether the client needs teaching.

A nurse is monitoring a client following a thyroidectomy for signs of hypocalcemia. Which of the following signs, if noted in the client, likely indicates the presence of hypocalcemia?

*1. Tingling around the mouth* 2. Negative Chvostek's sign 3. Flaccid paralysis 4. Bradycardia *rationale* Following a thyroidectomy, the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and fingertips, muscle twitching or spasms, palpitations or dysrhythmias, and positive Chvostek's and Trousseau's signs. Options 2, 3, and 4 are not signs of hypocalcemia.

During routine postoperative assessment of a client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complications of this surgery, the nurse would next check the:

*1. Urine specific gravity* 2. Serum glucose 3. Respiratory rate 4. Blood pressure *rationale* Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess specific gravity and notify the registered nurse if the results are less than 1.005. Although options 2, 3, and 4 may be components of the assessment, the nurse would next check urine specific gravity.

A nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which of the following items in the diet?

*1. Vegetables* 2. Meat 3. Fish 4. Cereals *rationale* The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables are allowed in the diet.

A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor the:

*1. Vital signs* 2. Intake and output 3. Blood urea nitrogen (BUN) level 4. Urine for glucose and acetone *rationale* Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a brain attack (stroke) or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.

A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which of the following would be acceptable to take before the test?

*1. Water* 2. Coffee without any milk 3. Tea without any sugar 4. Clear liquids such as apple juice *rationale* When a client is scheduled for a fasting blood glucose level, the client should not eat or drink anything except water after midnight. This is needed to ensure accurate test results, which form the basis for adjustments or continuance of treatment. Options 2, 3, and 4 are inaccurate, and the client should not consume these items before the test.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which physician order should the nurse implement first? 1. Administer levofloxacin (Levaquin) 500 mg IV. 2. Draw aerobic and anaerobic blood cultures. 3. Give lorazepam (Ativan) as needed for agitation. 4. Refer to social worker for alcohol counseling.

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The RN is caring for a client with severe acute respiratory syndrome (SARS) who is receiving mechanical ventilation. Which nursing action should the nurse delegate to a nursing assistant? 1. Keeping the head of the bed elevated 30 to 45 degrees 2. Monitoring the impact of the ventilator on the client's oxygenation 3. Performing oral care with disinfecting rinses every 12 hours 4. Suctioning the client's endotracheal tube as needed

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A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate?

1. "Don't be concerned, this problem can be covered with clothing." 2. "This is permanent, but looks are deceiving and not that important." *3. "Usually, these physical changes slowly improve following treatment."* 4. "Try not to worry about it. There are other things to be concerned about." *rationale* The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 4 are not therapeutic responses.

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which of the following?

1. "Are you placing an air bubble in the syringe before injection?" 2. "Are you using a 1-inch needle to give the injection?" 3. "Are you aspirating before you inject the insulin?" *4. "Are you rotating the injection site?"* *rationale* The client should be instructed that insulin injection sites should be rotated within one anatomical area before moving to another. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. Options 1, 2, and 3 are not associated with the condition (skin leakage of insulin) presented in the question.

A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder?

1. "Cushing's disease is characterized by an oversecretion of insulin." *2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."* 3. "Cushing's disease is characterized by an undersecretion of corticotropic hormones." 4. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones." *rationale* Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones. Options 1 and 4 are inaccurate regarding Cushing's syndrome.

A nurse is collecting data on a client with hyperparathyroidism. Which of the following questions would elicit the accurate information about this condition from the client?

1. "Do you have tremors in your hands?" *2. "Are you experiencing pain in your joints?"* 3. "Have you had problems with diarrhea lately?" 4. "Do you notice swelling in your legs at night?" *rationale* Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures.

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? *Select all that apply.*

1. "I enjoy exercising but I need to be careful." 2. "I need to pace my activities throughout the day." *3. "I need to limit playing football to only the weekends."* 4. "I should gauge my activity level by my energy level." *5. "I should exercise in the evening to encourage a good sleep pattern."* *rationale* The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

A nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement?

1. "I should check my blood glucose level before eating a big meal." *2. "I should check my blood glucose level before eating each meal, regardless of how much I eat."* 3. "I should check my blood glucose level 2 hours after each meal." 4. "I should check my blood glucose level once a day." *rationale* The most effective and accurate measure for testing blood glucose is to test the level before each meal regardless of the amount of food to be eaten. The client should also check the blood glucose level at bedtime. Checking the level after the meal will provide an inaccurate assessment of diabetic control. Checking the level once daily will not provide enough data related to controlling the diabetes mellitus.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of NPH insulin and exercise?

1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." *4. "I should not exercise in the late afternoon."* *rationale* A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 12 to 14 hours; therefore, late afternoon exercise would occur during the peak of the medication.

A nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen?

1. "I should take my metformin (Glucophage) only if my blood glucose is elevated." 2. "By taking these medications, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." *4. "The medication that I am taking helps release the insulin I already make."* *rationale* Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose use and need to be taken on a regular schedule as prescribed. To maintain normal blood glucose levels throughout the day, oral hypoglycemic agents such as metformin are not taken on an as-needed basis depending on the blood glucose levels. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available or effective because of the breakdown of the insulin by digestion.

A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." What response by the nurse is appropriate?

1. "I think you are making the right decision to have the surgery." 2. "You are very ill. Your health care provider has made the correct decision." 3. "There is no reason to worry. Your health care provider is a wonderful surgeon." *4. "You have concerns about the surgical treatment for your condition."* *rationale* Paraphrasing is restating the client's message in the nurse's own words. Option 4 addresses the therapeutic communication technique of paraphrasing. The client is reaching out for understanding. In option 3, the nurse is offering a false reassurance, and this type of response will block communication. Option 2 also represents a communication block because it reflects a lack of the client's right to an opinion. In option 1, the nurse is expressing approval, which can be harmful to a nurse-client relationship.

A health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further instruction?

1. "I will start the collection in 2 days. I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed." 2. "When I start the collection, I will urinate and discard that specimen." 3. "I will pour the urine into the collection bottle each time I urinate and refrigerate the urine." *4. "I can take any medications if I need to before the collection."* *rationale* Because a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore the client is instructed to void and discard the first urine and note the time and start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. In a VMA collection, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins. Also clients are reminded not to take certain medications for 2 to 3 days before the test.

When the nurse is teaching a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective?

1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." *4. "I will notify my health care provider if my blood glucose level is greater than 250 mg/dL."* *rationale* During illness, the client should monitor the blood glucose level, and he or she should notify the health care provider (HCP) if the level is greater than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice.

A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates the need for further teaching?

1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." *3. "I need to buy special dietetic foods."* 4. "I will snack on fruit instead of cake." *rationale* It is important to emphasize to the client and family that they are not eating a diabetic diet but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

A nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy?

1. "If my blood sugars are elevated, I can bolus myself with additional insulin as prescribed." 2. "I'll need to check my blood sugars before meals in case I need a pre-meal insulin bolus." *3. "Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again."* 4. "I still need to follow an appropriate diet and exercise plan even though I don't have to inject myself daily anymore." *rationale* All of the statements are correct in regard to insulin pump therapy, except the one that mentions insulin reactions and ketoacidosis. Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump.

A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client would indicate an understanding of this occurrence?

1. "My blood glucose levels are running low because I'm tired." *2. "I forgot to take my usual afternoon snack yesterday."* 3. "I took less insulin this morning so I won't feel funny today." 4. "I don't know why I have to check my blood glucose four times a day. That seems too much." *rationale* Hypoglycemia is a blood glucose level of 60 mg/dL or less. The causes are multiple, but, in this case, omitting the afternoon snack is the cause. Fatigue and self-adjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day.

Which of the following statements made by the nursing student demonstrates an understanding of the hormone oxytocin?

1. "Production of oxytocin occurs in the ovaries." 2. "It is produced by the anterior pituitary gland." *3. "It causes contractions of the uterus during birth."* 4. "Release of oxytocin stimulates the pancreas to produce insulin." *rationale* Oxytocin is produced by the posterior pituitary, not the anterior pituitary gland, and stimulates the uterus to produce contractions during birth. The ovaries are the endocrine glands that produce estrogen and progesterone. The pancreas produces insulin and other enzymes that aid digestion. Oxytocin does not stimulate the pancreas to produce insulin.

A nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's syndrome. Which statement reflects a need for further client education?

1. "Taking my medications exactly as prescribed is essential." *2. "I need to read the labels on any over-the-counter medications I purchase."* 3. "My family needs to be familiar with the signs and symptoms of hypoadrenalism." 4. "I could experience the signs and symptoms of hyperadrenalism because of Cushing's." *rationale* The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the health care provider before purchasing any over-the-counter medications, and maintaining regular follow-up care. The nurse should also instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.

A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband?

1. "Would you like me to ask the health care provider for a prescription for a stimulant?" 2. "Give it time. I've seen dozens of clients with this problem that fully recover." 3. "I don't blame you for being frustrated, because the symptoms will only get worse." *4. "It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."* *rationale* Using therapeutic communication techniques, the nurse acknowledges the husband's concerns and conveys that the client's symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal. Option 1 is not helpful, and it blocks further communication. Option 3 is pessimistic and untrue. Option 2 is not appropriate and offers false reassurance.

A nurse is caring for a client newly diagnosed with diabetes mellitus. The client asks the nurse whether eating at a restaurant will affect the diabetic control and whether this is allowed. Which nursing response is appropriate?

1. "You really should not eat in restaurants." 2. "If you plan to eat in a restaurant, you need to avoid carbohydrates." *3. "You should order a half-portion meal and have fresh fruit for dessert."* 4. "You should increase your daily dose of insulin by half on the day you plan to eat out." *rationale* Clients with diabetes mellitus are instructed to make adjustments in their total daily intake to plan for meals at restaurants or parties. Some useful strategies include ordering half portions, salads with dressing on the side, fresh fruit for dessert, and baked or steamed entrées. Clients are not instructed to avoid any food group or to increase their prescribed insulin dosage.

A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about:

1. 14 days *2. 28 days* 3. 30 days 4. 45 days *rationale* The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. The first day of the menstrual period is counted as day 1 of the woman's cycle. Options 1, 3, and 4 are incorrect.

A nurse has just supervised a newly diagnosed diabetes mellitus client self-inject NPH insulin at 7:30 ᴀᴍ. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between:

1. 7:30 ᴀᴍ and 9:30 ᴀᴍ *2. 1:30 ᴘᴍ and 7:30 ᴘᴍ* 3. 8:30 ᴘᴍ and 12:00 ᴀᴍ 4. 2:30 ᴀᴍ and 4:30 ᴀᴍ *rationale* NPH is an intermediate-acting insulin. It begins to work in 1 to 2 hours (onset), peaks in 6 to 12 hours, and lasts for 18 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak time, which in this case is option 2.

A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and a positive for serum ketones. The diagnosis is supported by which noted data?

1. Hypertension *2. Fruity breath odor* 3. Slow regular breathing 4. Moist mucous membranes *rationale* Diabetic ketoacidotic coma is usually identified with a fruity breath odor, dry cracked mucous membranes, hypotension, and rapid deep breathing.

Which of the following clients is at risk for developing thyrotoxicosis?

1. A client with hypothyroidism *2. A client with Graves' disease who is having surgery* 3. A client with diabetes mellitus scheduled for debridement of a foot ulcer 4. A client with diabetes insipidus scheduled for an invasive diagnostic test *rationale* Thyrotoxicosis is usually seen in clients with Graves' disease with the symptoms precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, the birth process, or major surgery. It also must be recognized as a potential complication following a thyroidectomy.

A nurse is caring for a client with Addison's disease. The nurse checks the vital signs and determines that the client has orthostatic hypotension. The nurse determines that this finding relates to which of the following?

1. A decrease in cortisol release *2. A decreased secretion of aldosterone* 3. An increase in epinephrine secretion 4. Increased levels of androgens *rationale* A decreased secretion of aldosterone results in a limited reabsorption of sodium and water; therefore the client experiences fluid volume deficit. A decrease in cortisol, an increase in epinephrine, and an increase in androgen secretion do not result in orthostatic hypotension.

A nurse is monitoring a client receiving glipizide (Glucotrol). Which outcome indicates an ineffective response from the medication?

1. A decrease in polyuria 2. A decrease in polyphagia 3. A fasting plasma glucose of 100 mg/dL *4. A glycosylated hemoglobin level of 12%* *rationale* Glipizide (Glucotrol) is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control.

A nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. Which health care provider's prescription supports the treatment of this condition?

1. A decreased amount of NPH daily insulin *2. An increased amount of NPH daily insulin* 3. An increased-calorie diet 4. A decreased-calorie diet *rationale* Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection exists, the client will require an increase in the dose of insulin to facilitate the transport of excess glucose into the cells. The client does not necessarily need an adjustment in the daily diet.

A nurse is caring for a client with pheochromocytoma. Which data would indicate a potential complication associated with this disorder?

1. A urinary output of 50 mL/hr 2. A coagulation time of 5 minutes *3. Congestion heard on auscultation of the lungs* 4. A blood urea nitrogen (BUN) level of 20 mg/dL *rationale* The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of CHF. A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. The appropriate intervention to decrease the client's anxiety would be to:

1. Administer a sedative. *2. Convey empathy, trust, and respect toward the client.* 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure the client knows all the correct medical terms so that he or she can understand what is happening. *rationale* The appropriate intervention is to address the client's feelings related to the anxiety and to convey empathy, trust, and respect toward the client. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem?

1. Administering methimazole (Tapazole) every 8 hours 2. Lubricating the eyes with tap water every 2 to 4 hours 3. Instructing the client to avoid straining or heavy lifting *4. Obtaining dark glasses for the client* *rationale* Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Medical therapy for Graves' disease does not help alleviate the clinical manifestation of exophthalmos. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. There is no need to prevent straining with exophthalmos.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? 1. Adventitious breath sounds 2. Fremitus 3. Oxygenation status 4. Respiratory excursion

1. Adventitious sounds are additional breath sounds superimposed on normal sounds. they indicate pathologic changes in the lung. Fremitus is vibration and not detected by auscultation, not can oxygenation status. resp excursion is detected by both observation of the movement of the chest and palpation as the client inhales and exhales.

A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which of the following substances?

1. Amylase 2. Lipase 3. Trypsin *4. Insulin* *rationale* The pancreas produces both endocrine and exocrine secretions as part of its normal function. The organ secretes insulin as a key endocrine hormone to regulate the blood glucose level. Other pancreatic endocrine hormones are glucagon and somatostatin. The exocrine pancreas produces digestive enzymes such as amylase, lipase, and trypsin.

A nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique will provide data necessary to support the admitting diagnosis?

1. Auscultation of lung sounds *2. Inspection of facial features* 3. Percussion of the thyroid gland 4. Palpation of the adrenal glands *rationale* Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and a blank expression that are characteristic of myxedema. The techniques in the remaining options will not reveal any data that would support the diagnosis of myxedema.

A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and Regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease?

1. Avoid all strenuous exercise. 2. Maintain health at an optimum level. 3. Lose 40 pounds to achieve ideal body weight. *4. Adjust insulin according to capillary blood glucose levels.* *rationale* There are many learning goals for the client who is newly diagnosed with diabetes mellitus. The client must learn dietary control, medication management, and proper exercise in order to control the disease. As a first step, the client learns to adjust medication (insulin) according to blood glucose results as prescribed by the health care provider. The client should then focus on long-term dietary control and weight loss, which will often lead to a decreased need for insulin. At the same time that diet is being controlled, the client should begin a regular exercise program to aid in weight loss.

A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which of the following foods in the diet?

1. Bananas 2. Oatmeal *3. Ice cream* 4. Chicken breast *rationale* The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods.

A nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? *Select all that apply.*

1. Bradycardia *2. Fever* *3. Sweating* *4. Agitation* 5. Pallor *rationale* Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder?

1. Bradycardia *2. Hypotension* 3. Constipation 4. Hypothermia *rationale* Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse.

A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse includes which priority item in the preoperative teaching plan for the client?

1. Brushing the teeth vigorously and frequently is important to minimize bacteria in the mouth. *2. Blowing the nose following surgery is prohibited.* 3. A small area will be shaved at the base of the neck. 4. It will be necessary to cough and deep breathe following the surgery. *rationale* The approach used for this surgery is the oronasal route, specifically where the upper lip meets the gum. The surgeon then uses a route through the sphenoid sinus to get to the pituitary gland. The client is not allowed to blow the nose, sneeze, or cough vigorously because these activities could raise intracranial pressure. The client also is not allowed to brush the teeth, to avoid disrupting the surgical site. Alternate methods for performing mouth care are used.

The wife of a client with diabetes mellitus who takes insulin calls the nurse in a health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which of the following should the nurse tell the woman to do first?

1. Call an ambulance. 2. Take his temperature. *3. Check his blood glucose level.* 4. Drive him to the health care provider's office. *rationale* The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the health care provider. Option 1 or 4 may be done at a later time if required. Option 2 is unrelated to the client's immediate problem.

A nurse is caring for a client with a diagnosis of myasthenia gravis. The health care provider plans to perform an Enlon test on the client to determine the presence of cholinergic crisis. In addition to planning care for the client during this testing, which of the following will the nurse ensure is at the bedside?

1. Cardiac monitor *2. Oxygen equipment* 3. Vial of protamine sulfate and a syringe 4. Potassium injection and a liter of normal saline solution *rationale* An Enlon test is performed to distinguish between myasthenic and cholinergic crisis. Following administration of Enlon, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of Enlon, atropine sulfate and oxygen should be immediately available whenever Enlon is used.

A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate?

1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. *4. Reassure the client that this is usually a temporary condition.* *rationale* Weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.

A nurse working on an endocrine nursing unit understands that which correct concept is used in planning care?

1. Clients with Cushing's syndrome are likely to experience episodic hypotension. 2. Clients with hyperthyroidism must be monitored for weight gain. 3. Clients who have diabetes insipidus should be assessed for fluid excess. *4. Clients who have hyperparathyroidism should be protected against falls.* *rationale* Hyperparathyroidism is a disease that involves excess secretion of parathyroid hormone (PTH). Elevation of PTH causes excess calcium to be removed from the bones. There is a decline in bone mass, which may cause a fracture if a fall occurs. Cushing's syndrome is likely to cause hypertension. Clients with hypothyroidism must be monitored for weight gain and clients with hyperthyroidism must be monitored for weight loss. Clients who have diabetes insipidus should be assessed for fluid deficit.

A nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which of the following does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally?

1. Cola 2. Ginger ale 3. Apple juice *4. Mineral water* *rationale* Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates.

A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action first?

1. Continue to observe for further drainage. *2. Test the drainage for glucose.* 3. Put the head of the bed flat. 4. Test the drainage for occult blood. *rationale* Following hypophysectomy the client should be monitored for rhinorrhea (clear nasal drainage), which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for the presence of CSF by testing it for glucose. CSF tests positive for glucose, whereas true nasal secretions would not. It is not necessary to test drainage that is clear for occult blood. The head of the bed should not be lowered, to prevent a rise in intracranial pressure. Continuing to observe the drainage without taking action could put the client at risk for developing a serious complication.

A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following?

1. Crackers with cheese and tea *2. Graham crackers and warm milk* 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar *rationale* The client with pheochromocytoma needs to be provided with a diet that is high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited.

A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication should be included on the list?

1. Decreased urine output 2. Profuse sweating *3. Increased thirst* 4. Shakiness *rationale* The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition.

The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period?

1. Dehydration 2. Infection 3. Urinary retention *4. Bleeding* *rationale* Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must frequently check the neck dressing for bleeding and monitor vital signs to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Infection is a concern for any postoperative client but is not the priority in the immediate postoperative period. Urinary retention can occur in postoperative clients as a result of medication and anesthesia but is not the priority from the options provided.

A client with type 2 diabetes mellitus has a blood glucose of more than 600 mg/dL and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and would expect to note which of the following diagnoses?

1. Diabetic ketoacidosis (DKA) 2. Hypoglycemia *3. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)* 4. Pheochromocytoma *rationale* HHNS is seen primarily in individuals with type 2 diabetes who experience a relative deficiency of insulin. The onset of symptoms may be gradual. The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. DKA normally occurs in type 1 diabetes mellitus. The clinical manifestations noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical manifestations.

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder?

1. Diarrhea *2. Polydipsia* 3. Weight gain 4. Blurred vision *rationale* Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea, weight loss, and blurred vision are not manifestations of the disorder.

A client is being admitted for pneumonia. The sputum culture is positive for Streptococcus. The client asks about the length of the treatment. On what does the nurse base the answer? 1. The client may be switched from IV to oral antibiotics in 2 to 3 days. 2. Usually anti-infectives are used for 7 to 10 days. 3. When the client has completed 6 days of therapy 4. When the client is afebrile for 24 hours

1. IV abx will be switched to ral abx in 2-3 days.

A nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder?

1. Diarrhea *2. Polyuria* 3. Polyphagia 4. Weight gain *rationale* Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration and the client would lose weight. Options 1, 3, and 4 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation).

Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. The initial nursing action is to:

1. Document the complaints. 2. Increase fluid intake. *3. Check the urine specific gravity.* 4. Check for urinary glucose. *rationale* Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine for specific gravity and report the results if they are less than 1.005. Urinary glucose and diabetes mellitus is not a concern here. In this situation, increasing fluid intake would require a health care provider's prescription. The client's complaint would be documented but not as an initial action.

A nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which of the following, if noted in the client, indicates signs and symptoms related to adrenal insufficiency? *Select all that apply.*

1. Double vision *2. Hypotension* *3. Mental status changes* *4. Weakness* *5. Fever* *rationale* The nurse should be alert to signs and symptoms of adrenal insufficiency in a client following adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. Double vision is generally not associated with this condition.

A nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?

1. Eat six small meals daily. 2. Test the urine ketone levels. *3. Monitor blood glucose levels frequently.* 4. Receive appropriate follow-up health care. *rationale* Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the health care provider when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease?

1. Edema 2. Obesity 3. Hirsutism *4. Hypotension* *rationale* Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea, vomiting, abdominal cramps, weight loss, depression, and irritability. The manifestations in options 1, 2, and 3 are not associated with Addison's disease.

A nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. The need for additional education regarding this problem is identified when the nursing student suggests which nursing intervention?

1. Encouraging the client's expression of feelings 2. Evaluating the client's understanding of the disease process 3. Encouraging family members to share their feelings about the disease process *4. Evaluating the client's understanding that the body changes need to be dealt with* *rationale* Evaluating the client's understanding that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. Options 1, 2, and 3 are appropriate because they address the client and family feelings regarding the disorder.

A client is taking INH, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? 1. Ethambutol 2. INH 3. Pyrazinamide 4. Rifampin

1. Ethambutol can cause optic neuritis leading to blindness at high doeses. Rifampin will cause the urine and all other secretions to have a yellowish orange color. this is harmless. contact lenses will also be stained. oral contraceptives will be less effective.

A nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists to develop a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan?

1. Hair will need to be shaved. 2. Deep breathing and coughing will be needed after surgery. *3. Toothbrushing will not be permitted for at least 2 weeks following surgery.* 4. Spinal anesthesia is used. *rationale* Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although coughing and deep breathing are important, specific to this procedure is avoiding toothbrushing to prevent disruption of the surgical site. Also, coughing may disrupt the surgical site.

A client has been diagnosed with hypoparathyroidism. The nurse teaches the client to include foods in the diet that are:

1. High in phosphorus and low in calcium 2. Low in phosphorus and low in calcium *3. Low in phosphorus and high in calcium* 4. High in phosphorus and high in calcium *rationale* Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder is one that is high in calcium but low in phosphorus because these two electrolytes have inverse proportions in the body. All of the other options are unrelated to this disorder and are incorrect.

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which of the following findings would the nurse note as being consistent with this diagnosis?

1. High serum glucose level and an increase in pH 2. Low serum potassium and high serum bicarbonate level *3. High serum glucose level and low serum bicarbonate level* 4. Decreased urine output and Kussmaul's respirations *rationale* In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The arterial pH is low, less than 7.35. The plasma bicarbonate is also low. The client would exhibit polyuria and Kussmaul's respirations. The potassium level usually is elevated as a result of dehydration.

A nurse is caring for a client experiencing thyroid storm. Which of the following would be a priority concern for this client?

1. Inability to cope with the treatment plan 2. Lack of sexual drive 3. Self-consciousness about body appearance *4. Potential for cardiac disturbances* *rationale* Clients in thyroid storm are experiencing a life-threatening event, which is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. The signs and symptoms of the disorder develop quickly, and therefore emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of airway as well as providing adequate ventilation. Options 1, 2, and 3 are not a priority in the care of the client in thyroid storm.

A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem?

1. Inadequate knowledge about the surgical procedure *2. Fear about impending surgery* 3. Embarrassment about the changes in personal appearance 4. Lack of support related to the surgical procedure *rationale* The client is having a difficult time coping with the scheduled surgery. The client is able to express fears but is scared. No data in the question support options 1, 3, and 4.

A nurse is caring for a postoperative parathyroidectomy client. Which of the following would require the nurse's immediate attention?

1. Incisional pain *2. Laryngeal stridor* 3. Difficulty voiding 4. Abdominal cramps *rationale* During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which cause swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

A nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the client. Which of the following is an appropriate instruction?

1. Increase dietary intake of calcium. *2. Drink at least 2 to 3 L of fluid daily.* 3. Eat sparely when experiencing nausea. 4. Decrease dietary intake of potassium. *rationale* The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption. This is aided by the sufficient intake of fluids. Dietary restriction of calcium may be used as a component of therapy. The parathyroid is responsible for calcium production, and the term, "hyperparathyroidism" can be indicative of an increase in calcium. The client should eat foods high in potassium, especially if the client is taking furosemide. Limiting nutrients is not advisable.

A nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. The nurse appropriately tells the client that the hoarseness:

1. Indicates nerve damage 2. Is harmless but permanent 3. Will worsen before it subsides *4. Is normal and will gradually subside* *rationale* Hoarseness that develops in the postoperative period is usually the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. Options 1, 2, and 3 are incorrect.

A nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that the first step is to:

1. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin. *2. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.* 3. Draw up the correct dosage of regular insulin into the syringe. 4. Draw up the correct dosage of NPH insulin into the syringe. *rationale* The initial step in preparing an injection of insulin that is a mixture of NPH and regular is to inject air into the NPH bottle equal to the amount of insulin prescribed. The client is instructed to next inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin should then be withdrawn followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form.

A nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription, if noted on the record, indicates the need for clarification?

1. Instruct the client about the need for a Medic-Alert bracelet. *2. Apply a loose dressing if any clear drainage is noted.* 3. Monitor vital signs and neurological status. 4. Instruct the client to avoid blowing the nose. *rationale* The nurse should observe for clear nasal drainage, constant swallowing, and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted following this procedure, the health care provider needs to be notified immediately. Options 1, 3, and 4 indicate appropriate postoperative interventions.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which of the following items in the preoperative period?

1. Intake and output 2. Blood urea nitrogen (BUN) *3. Vital signs* 4. Urine glucose and ketones *rationale* Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

A client who is managing diabetes mellitus with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which of the following diets would be appropriate for the client?

1. Low-fiber, high-fat diet 2. Limit carbohydrate intake to three meals per day 3. Large amounts of carbohydrates between low protein meals *4. Small frequent meals with protein, fat, and carbohydrates at each meal* *rationale* The definition of hyperinsulinism is an excessive insulin secretion in response to carbohydrate-rich foods leading to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed and delivered in frequent but portion-controlled meals. Diets high in soluble fiber may be beneficial.

A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client?

1. Low-protein diet 2. Low-sodium diet *3. High-sodium diet* 4. Low-carbohydrate diet *rationale* A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea.

When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is appropriate?

1. Lower the head of the bed. *2. Test the drainage for glucose.* 3. Obtain a culture of the drainage. 4. Continue to observe the drainage. *rationale* After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

A nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which of the following nursing interventions will the nurse suggest to include in the plan of care?

1. Maintain a supine position. 2. Encourage coughing and deep breathing exercises. *3. Monitor neck circumference frequently.* 4. Maintain a pressure dressing on the operative site. *rationale* Following a thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site because it could affect breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored at least every 4 hours to assess for postoperative edema.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse who is assisting to care for the client obtains which of the following immediately in preparation for the treatment of this syndrome?

1. NPH insulin 2. A nasal cannula 3. Intravenous (IV) infusion of sodium bicarbonate *4. IV infusion of normal saline* *rationale* The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. A nasal cannula for oxygen administration is not necessarily required to treat HHNS.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission?

1. NPH insulin 2. Regular insulin 3. Acarbose (Precose) *4. Chlorpropamide* *rationale* Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 ᴀᴍ. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which of the following signs in the late afternoon?

1. Nausea and vomiting, and abdominal pain *2. Hunger; shakiness; and cool, clammy skin* 3. Drowsiness; red, dry skin; and fruity breath odor 4. Increased urination; thirst; and rapid, deep breathing *rationale* The client taking NPH insulin obtains peak medication effects approximately 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse should teach the client to watch for signs and symptoms of hypoglycemia including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. The other options list various signs and symptoms of hyperglycemia.

A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care and places highest priority on which potential problem?

1. Nervousness *2. Infection* 3. Concern about appearance 4. Inability to care for self *rationale* The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection because of excess cortisol secretion and subsequent impaired antibody function and decreased proliferation of lymphocytes. The client may also have a potential for the problems listed in the other options but these are not the highest priority at this time.

A client has a blood glucose level drawn for suspected hyperglycemia. After interviewing the client, the nurse determines that the client ate lunch approximately 2 hours before the blood specimen was drawn. The laboratory reports that the blood glucose to be 180 mg/dL, and the nurse analyzes this result to be:

1. Normal 2. Lower than the normal value *3. Elevated from the normal value* 4. A dangerously high value requiring immediate health care provider notification *rationale* Normal fasting blood glucose values range from 70 to 120 mg/dL. A 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 180 mg/dL 2 hours after the client ate, which is an elevated value as compared to normal. Although the result may be reported to the health care provider, it is not a dangerously high one.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions to the client regarding the program. Which of the following should the nurse include in the teaching plan?

1. Try to exercise before mealtime. 2. Administer insulin after exercising. *3. Take a blood glucose test before exercising.* 4. Exercise should be performed during peak times of insulin. *rationale* A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be:

1. Normal 2. Lower than the normal value *3. Slightly higher than the normal value* 4. A value that indicates immediate health care provider notification *rationale* Normal fasting blood glucose values range from 70 to 120 mg/dL. The 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 150 mg/dL 2 hours after the client ate, which is slightly elevated above normal. This value does not require health care provider notification.

A male client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. The nurse tells the client to:

1. Obtain referrals to health care providers in the destination cities. 2. Check the blood glucose every 2 hours during the flight. *3. Keep snacks in carry-on luggage to prevent hypoglycemia during the flight.* 4. Pad the insulin and syringes against breakage and place in a suitcase to be stowed. *rationale* A frequent concern of diabetics during air travel is the availability of food at times that correspond with the timing and peak action of the client's insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand. Insulin equipment and supplies should always be placed in carry-on luggage (not stowed). This provides ready access to treat hyperglycemia, if needed, and prevents loss of equipment if luggage is lost. Options 1 and 2 are unnecessary.

A maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which of the following, if identified by the student, indicates an understanding of the hormones produced by this endocrine gland?

1. Oxytocin 2. Luteinizing hormone (LH) *3. Estrogen and progesterone* 4. Follicle-stimulating hormone (FSH) *rationale* The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions. LH and FSH are produced by the anterior pituitary gland.

A nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care, knowing that which problem has the highest priority for this client?

1. Pain as a result of intermittent claudication 2. Lack of self-confidence as a result of impaired ability to walk 3. Lack of self-esteem as a result of perceived loss of abilities *4. The possibility of injury as a result of decreased sensation in the legs and feet* *rationale* The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Thus the highest priority problem is option 4, which can be determined using Maslow's Hierarchy of Needs theory. Options 2 and 3 represent problems that are more psychosocial in nature, and as such are secondary needs using Maslow's theory. Option 1 is incorrect because intermittent claudication is not directly associated with diabetic neuropathy.

A nurse is caring for a client with hypothyroidism who is overweight. Which food items would the nurse suggest to include in the plan?

1. Peanut butter, avocado, and red meat *2. Skim milk, apples, whole-grain bread, and cereal* 3. Organ meat, carrots, and skim milk 4. Seafood, spinach, and cream cheese *rationale* Clients with hypothyroidism may have a problem with being over-weight because of their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories. Option 2 is the only option that identifies food items that are low in calories.

A nurse is caring for a postoperative adrenalectomy client. Which of the following does the nurse specifically monitor for in this client?

1. Peripheral edema 2. Bilateral exophthalmos 3. Signs and symptoms of hypocalcemia *4. Signs and symptoms of hypovolemia* *rationale* Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. A deficiency of adrenocortical hormones does not cause the clinical manifestations noted in options 1, 2, and 3.

A nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

1. Polyuria *2. Shakiness* 3. Blurred vision 4. Fruity breath odor *rationale* Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which of the following medications as a primary treatment for this problem?

1. Potassium *2. Regular insulin* 3. Sodium bicarbonate 4. Calcium gluconate *rationale* The primary treatment for any acid-base imbalance is treatment of the underlying disorder that caused the problem. In this case, the underlying cause of the metabolic acidosis is anaerobic metabolism as a result of the lack of ability to use circulating glucose. Administration of regular insulin corrects this problem.

A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. The nurse would immediately:

1. Prepare for the administration of an insulin drip. 2. Give the client a glass of orange juice. 3. Prepare for the administration of a bolus dose of 50% dextrose. *4. Check the client's capillary blood glucose.* *rationale* The nurse must first obtain a blood glucose reading to determine the client's problem. Options 2 and 3 would be implemented as needed in the treatment of hypoglycemia. Insulin therapy is guided by blood glucose measurement.

When caring for a client diagnosed with pheochromocytoma, what information should the nurse know when assisting with planning care?

1. Profound hypotension may occur. *2. Excessive catecholamines are released.* 3. The condition is not curable and is treated symptomatically. 4. Hypoglycemia is the primary presenting symptom. *rationale* Pheochromocytoma is a catecholamine-producing tumor of the adrenal gland and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of a high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral.

A nurse would expect to note which interventions in the plan of care for a client with hypothyroidism? *Select all that apply.*

1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. *3. Instruct the client about thyroid replacement therapy.* *4. Encourage the client to consume fluids and high-fiber foods in the diet.* *5. Instruct the client to contact the health care provider if episodes of chest pain occur.* 6. Inform the client that iodine preparations will be prescribed to treat the disorder. *rationale* The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the health care provider if chest pain occurs since it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone.

What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease?

1. Provide a high-fiber diet. *2. Provide a restful environment.* 3. Provide three small meals per day. 4. Provide the client with extra blankets. *rationale* Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required, because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment.

A nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse?

1. Pulse and respirations 2. Blood pressure 3. Blood glucose *4. Temperature* *rationale* Elevated temperature may be indicative of infection, which is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) or diabetic ketoacidosis (DKA). Options 1, 2, and 3 are findings that are within a normal range.

A nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication?

1. Relief of pain 2. Absence of side effects *3. Reaching normal serum calcium levels* 4. Verbalization of appropriate medication knowledge *rationale* Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium level. The highest priority outcome in this client situation would be a reduction in serum calcium level. Option 1 is unrelated to this medication. Although options 2 and 4 are expected outcomes, they are not the highest priority for administering this medication.

Which nursing measure would be effective in preventing complications in a client with Addison's disease?

1. Restricting fluid intake 2. Offering foods high in potassium 3. Checking family support systems *4. Monitoring the blood glucose* *rationale* The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Therefore monitoring the blood glucose would detect the presence of hypoglycemia so that it can be treated early to prevent complications. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia. Option 3 is not a priority for this client.

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do which of the following as a next step?

1. Seek treatment for diabetes mellitus. 2. Ask the pharmacist about starting insulin therapy. 3. Begin blood glucose monitoring three times a day. *4. Call the health care provider to have the value rechecked as soon as possible.* *rationale* Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, polyphagia) or by laboratory values. Diabetes is also diagnosed by an abnormal glucose tolerance test, when random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater than 140 mg/dL on two separate occasions. Further confirmation of this result is needed to ensure appropriate diagnosis and therapy.

A client is admitted with a diagnosis of pheochromocytoma. The nurse would monitor which of the following to detect the most common sign of pheochromocytoma?

1. Skin temperature *2. Blood pressure* 3. Urine ketones 4. Weight *rationale* Hypertension is the major symptom associated with pheochromocytoma and is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the most common sign.

A nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the symptoms of hypoglycemia. Which symptoms will the nurse review?

1. Slow pulse; lethargy; and warm, dry skin 2. Elevated pulse; lethargy; and warm, dry skin *3. Elevated pulse; shakiness; and cool, clammy skin* 4. Slow pulse, confusion, and increased urine output *rationale* Symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin. Options 1, 2, and 4 are not symptoms of hypoglycemia.

A nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?

1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. *3. Apply a moisturizing lotion to dry feet, but not between the toes.* 4. Always have a podiatrist cut your toenails; never cut them yourself. *rationale* The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed to not soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

The anticipated intended effect of fludrocortisone acetate (Florinef) for the treatment of Addison's disease is to:

1. Stimulate the immune response. *2. Promote electrolyte balance.* 3. Stimulate thyroid production. 4. Stimulate thyrotropin production. *rationale* Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. The client rapidly can develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. Options 1, 3, and 4 are not associated with the effects of this medication.

A nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. Which problem would the nurse consider first, when planning care for this client?

1. The need for knowledge about the diagnosis 2. Insomnia 3. Lack of appetite *4. Signs of dehydration* *rationale* Hyperglycemia can develop into ketoacidosis in the client with type 1 diabetes mellitus. Polyuria develops as the body attempts to get rid of the excess glucose, and the client will lose large amounts of fluid. Because glucose is hyperosmotic, fluid is pulled from the tissue. Nausea and vomiting can occur as a result of hyperglycemia and can lead to a loss of sodium and water. Water also is lost from the lungs in an attempt to get rid of excess carbon dioxide. The severe dehydration that occurs can lead to hypovolemic shock. Of the problems listed, dehydration is considered first.

A nurse is providing discharge instructions to a client who had a unilateral adrenalectomy. Which of the following will be a component of the instructions?

1. The reason for maintaining a diabetic diet *2. Instructions about early signs of a wound infection* 3. Teaching regarding proper application of an ostomy pouch 4. The need for lifelong replacement of all adrenal hormones *rationale* A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Because of the anti-inflammatory properties of corticosteroids, clients who undergo an adrenalectomy are at increased risk for developing wound infections. Because of this increased risk for infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection is present. Options 1, 3, and 4 are incorrect instructions.

A nurse is discussing foot care with a diabetic client and spouse. The nurse includes which of the following during this informational session?

1. There is decreased risk of infection when feet are soaked in hot water. 2. Lanolin should be applied to dry feet, especially the heels and between the toes. *3. The toenails should be cut straight across.* 4. Strong soap should be used to decrease skin bacteria. *rationale* The client should be instructed to cut the toenails straight across. The client should not soak the feet in hot water, to prevent burns. The client should be instructed to wash the feet daily using a mild soap. Moisturizing lotion can be applied to the feet but should not be placed between the toes.

A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that:

1. This is a permanent feature. 2. It can be minimized by wearing tight clothing. *3. It may slowly improve with treatment of the disorder.* 4. It will quickly disappear once medication therapy is started. *rationale* The client with Cushing's syndrome should be reassured that most physical changes resolve over time with treatment. The other options are incorrect.

Glucagon hydrochloride injection would most likely be prescribed for which disorder?

1. Thyroid crisis *2. Type 1 diabetes mellitus* 3. Hypoadrenalism 4. Excess growth hormone secretion *rationale* Glucagon hydrochloride is a medication that can be administered subcutaneously or intramuscularly. It is prescribed to stimulate the liver to release glucose when a client is experiencing hypoglycemia and unable to take oral glucose replacement. It is important to teach a person other than the client how to administer the medication because the client's symptoms may prevent self-injection. Therefore options 1, 3, and 4 are incorrect.

A nurse is preparing to administer an injection of regular insulin. The vial of the regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. The nurse should:

1. Wait for the insulin to thaw at room temperature. 2. Check the temperature settings of the refrigerator. *3. Discard the insulin and obtain another vial.* 4. Rotate the vial between the hands until the medication becomes liquid. *rationale* Insulin preparations are stable at room temperature for up to 1 month without significant loss of activity. Insulin should not be frozen. If the insulin is frozen, it should be discarded and the nurse should obtain another vial. Options 1, 2, and 4 are incorrect.

A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which of the following to perform the procedure properly?

1. Wash the hands first using cold water. 2. Puncture the center of the finger pad. 3. Puncture the finger as deeply as possible. *4. Let the arm hang dependently and milk the digit.* *rationale* Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures may lead to pain and bruising. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining a good-size blood drop.

Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma?

1. Weigh the client. 2. Test the client's urine for glucose. *3. Monitor the client's blood pressure.* 4. Palpate the client's skin to determine warmth. *rationale* Hypertension is the major symptom that is associated with pheochromocytoma. The blood pressure status is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are also clinical manifestations of pheochromocytoma, but hypertension is the major symptom.

While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as:

1. Within normal limits *2. A finding that needs to be reported immediately* 3. An expected finding caused by the operative stress response 4. Slightly abnormal but an insignificant finding *rationale* An adrenalectomy is performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, which puts the client at risk for infection. Because of this, the client needs to be protected from infection, and minor variations in normal vital sign values must be reported so that infections are detected early, before they become overwhelming. In addition, the surgeon may elect to postpone surgery in the event of a fever because it can be indicative of infection. Options 1, 3, and 4 are not correct interpretations.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? 1. Face tent 2. Venturi mask 3. Nasal cannula 4.Non-rebreather mask

1. a client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. a Venturi and a non-rebreather mask requires snug fitting on the face, and a NC is not a high-flow device.

The RN has received report about all of these clients. Which client needs the most immediate assessment? 1.Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry 2. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes 3. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago 4. Client with pleural effusion who has decreased breath sounds at the right base

1. an O2 sat level <81% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation. the other tasks do not require immediate actions

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? 1. Client with acute allergic reaction 2. Client with dyspnea on exertion 3. Client with lung cancer with cough 4. Client with sinus infection with fever

1. an acute allergic reaction can lead to immediate resp distress, this is an emergent situation, while none of the others are. the client with dyspnea on exertion will need further evaluation eventually, however.

Which client has the most urgent need for frequent nursing assessment? 1. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask 2. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percents in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties 3. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy 4. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

1. an older client with a long hx of smoking and chronic lung disease who is receiving high flow oxygen delivery is at elevated risk for resp depression owing to the hypoxic drive of respirations countered by high levels of oxygen. this client must be assessed frequently while receiving high-flow oxygen. a young client with no s/s of resp compromise, not a client who meets d/c criteria do not require frequent assessment. although a middle aged client with PNA who is receiving oxygen at 2L per NC will require more frequent assessment than a client who is not receiving oxygen therapy, a client with chronic lung disease who requires higher-flow oxygen is at greater risk for resp demise and therefore needs frequent assessment more urgently.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin addicted. Which action will be most effective in ensuring that the client completes treatment? 1. Arrange for a health care worker to watch the client take the medication. 2.Give the client written instructions about how to take prescribed medications. 3. Have the client repeat medication names and side effects. 4. Instruct the client about the possible consequences of nonadherence.

1. because this client is unlikely to adhere to long-term treatment unless directly supervised while taking meds, the best option is to arrange for directly observed therapy.

An older adult resident in a long-term care facility becomes confused and agitated, telling the nurse "Get out of here! You're going to kill me!" Which action will the nurse take first? 1. Check the resident's oxygen saturation. 2. Do a complete neurologic assessment. 3. Give the prescribed PRN lorazepam (Ativan). 4. Notify the resident's primary care provider.

1. check the resident's oxygen saturation, as a common reason for sudden confusion in older clients is hypoxemia. the cause must first be determined before (ativan) is given.

A 70-year-old client has a complicated medical history including chronic obstructive pulmonary disease (COPD). Which client statement indicates the need for further teaching about the disease? 1. "I am here to receive the yearly pneumonia shot again." 2. "I am here to get my yearly flu shot again." 3. "I should avoid large gatherings during cold and flu season." 4. "I should cough into my upper sleeve instead of my hand."

1. clients 65 yo and older, as well as those who have chronic health problems, should be encouraged to receive PNA vaccine, which is not given annually but only once.

Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma? 1. Brother is allergic to peanuts. 2. Father is obese. 3. Mother is diabetic. 4. Sister is pregnant.

1. clients with asthma often have a family hx of allergies. it may be important to assess whether this client has any allergies that may serve as triggers for an asthma attack.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? 1. Crackles 2. Rhonchi 3. Pleural friction rub 4. Wheeze

1. crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. the airways have been deflated d/t to the presence of fluids in the lungs, and crackles should be considered a sign of fluid overload. rhonci are low pitched, coarse snoring sounds caused by fluid or secretions in larger airways. a pleural rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. wheezes are frequently referred to as musical or squeaky. they may occur on inspiration or on expiration and may be heard without a steth as air rushes through narrowed airways.

In the older adult client, which respiratory change does not require further assessment by the nurse? 1. Increased anteroposterior (AP) diameter 2. Increased respiratory rate 3. Shortness of breath 4. Sputum production

1. increased AP diameter is normal with aging. increased RR may indicate pain or infection and requires evaluation. SOB may be r/t infection, tumor, or cardiac issues, and sputum production may be chronic, but it is not r/t the aging process and requires attention to note the character and quantity as well as the duration of sputum production.

A "Do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? 1. Ensures that the tubing is patent and that oxygen flow is high 2. Notifies the chaplain and the family member of record 3. Calls the Rapid Response Team and prepares to intubate 4. Comforts the client and confirms that signed DNR orders are in the chart.

1. labored breathing and ultimately suffocation can occur if the reservoir bag kinks, or if the oxygen source disconnects or is not set to high flow levels.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? 1. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula 2. The client with chronic lung disease who is being evaluated for possible home oxygen use 3. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar 4. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

1. orthopedic RNs are familiar with pulm emboli and with administration of oxygen through nasal cannulas. orthopedic RNs do not specialize in chronic lung conditions or in airway surgery.

The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? 1. "I can only take baths, no showers." 2. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." 3. "I should put cotton or foam over the tracheostomy hole." 4. "I will have to learn to suction myself."

1. the client CAN shower with the use of a shower shield over the trach tube to prevent water from entering the airway. NS should be instilled into the artificial airway 10-15x/d, the stoma should be covered with cotton or foam to protect it during the day: this filters the air entering the stoma, keeps humidity in the airway and enhances appearance. the client should be taught clean suctioning technique

The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first? 1. Assess the client's respiratory status. 2. Decrease the sensitivity of the alarm. 3. Ensure that the connecting tubing is not kinked. 4. Suction the client.

1. the client must always be assessed before attention is turned to equipment. suctioning may not even be needed.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? 1. Hyperoxygenate before and after suctioning. 2. Repeat suctioning until the tube is clear. 3. Apply suction during insertion of the tube. 4.Suction for 30 seconds.

1. the client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. after suctioning, the client should be hyperoxygenated for 1-5 minutes, or until the client's baseline HR and AL suction passes. additional suctioning will cause or worsen hypoxemia, just as suctioning >10-15 seconds. applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. suction is applied on;y when the suction tube is removed.

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? 1. Adjust the position of the oxygen tubing. 2. Assess for signs and symptoms of hypoventilation. 3. Change the O2 flow rate to keep SpO2 as prescribed. 4. Choose which O2 delivery device should be used for the client.

1. the scope of an assistant includes positioning of oxygen tubing for the client's comfort.

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule? 1. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% 2. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test 3. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment 4. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

1. this client has an appropriate SPO2 for home O2 use. a positive Mantoux test, in addition to the other symptoms is highly suspicious for TB. a newly diagnosed pleural effusion needs a complete and thorough assessment to ensure that he has adequate resp fxn to meet his basic oxygenation needs. hemo or pneumothorax is a possible life-threatening complication of a percutaneous lung bx, and requires assessment in a timely manner.

Your client has been homeless and has spent the past 6 months living in shelters. The client has been diagnosed with confirmed tuberculosis (TB). You are completing your medication teaching with this client. About which medications will the nurse teach the client? 1. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Tebrazid), ethambutol (Myambutol) 2. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) 3. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Trabrazide) 4. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

1. this combo is used to treat TB.

The client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply. 1. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. 2. The medications may cause nausea. The client should take them at bedtime. 3. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. 4. These medications must be taken for 2 years. 5. These medications may cause renal failure.

1., 2

The client is homeless and has been living in shelters for the past 6 months. The client asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Select all that apply. 1. Combination drug therapy is effective in preventing transmission. 2. Combination drug therapy is the most effective method of treating tuberculosis (TB). 3. Combination drug therapy will decrease the length of required treatment to 2 months. 4. Multiple drug regimens destroy organisms as quickly as possible. 5. The use of multiple drugs reduces the emergence of drug-resistant organisms.

1., 2., 4., 5: combined therapy will decrease the required length of time for tx, the length of treatment is decreased to 6 months, from 6-12 months

The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? 1. Increasing carbon dioxide levels 2. Decreasing respiratory rate 3. Increasing adventitious breath sounds 4. Increased coughing

2. RR and depth should be closely monitored while the client receives oxygen, because hypoventiliation is seen during the 1st 30 min of oxygen therapy in clients with hypoxic drive for respiration. the client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or resp arrest occurs from loss of the hypoxic drive. the ability to cough and breathe deeply is a positive sign, and monitoring for adventitious breath sounds is important, but would not be a result of the oxygen that the client is receiving. the COPD client is not sensitive to PaCO2 but rather low PaO2 levels (hypoxic drive). oxygen administration can cause high PaO2 levels in the COPD client; this revives the stimulus for breathing, and the client can experience resp depression.

An older client presents to the emergency department (ED) with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? 1. A bronchodilator would not be beneficial for this client. 2. A bronchodilator would help decrease the bronchospasm. 3. It would clear up the density in the bases of the client's lungs. 4. It would decrease the client's pain on inspiration.

2. a bonchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? 1. Auscultate the client's breath sounds while applying a nasal cannula. 2. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. 3. Apply a 100% non-rebreather mask while administering high-flow oxygen. 4. Replace the obturator while reinserting the tracheostomy tube.

2. because a fresh trach stoma will collapse, the client will lose his airway patency, which will require the RN to ventilate the client through the mouth and nose while waiting for assistance to recannulate the client. Effective use of a 100% NRB mask requires a patent airway.

Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? 1. Barrel-shaped chest 2. Bronchial breath sounds heard at the bases 3. Hyperresonance to percussion of the chest 4. Ribs lying horizontal

2. bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or infective process, such as PNA. a barrel-shaped chest is expected as are ribs lying horizontal (d/t air trapping in the chest). hyperresonance is heard with air filled cavities with percussion and is expected

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? Class I, can perform perform manual labor Class II, can perform desk job Class III, minimally employable Class IV, must remain at home

2. class II, can perform desk job. the client is dyspneic when climbing stairs or walking on an incline but not on level walking, therefore employable only for a sedentary job.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? 1. Complete the referral form for a home health agency. 2. Suction the tracheostomy using sterile technique. 3. Teach the client and spouse about tracheostomy care. 4. Consult with the physician about using a fenestrated tube.

2. complex sterile procedures are within the education, scope, and practice of the experienced LPN.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? 1. Crackles on auscultation 2. Fever 3. Headache 4. Wheezing

2. older adults may not have fever and may have a lower than normal temp with PNA. crackles may be present in all age groups, as well as HA, and wheezing

The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? 1. "But you know you need this to breathe, right?" 2. "Do you have a pretty scarf or a large loose collar that you could place over it?" 3. "Your family and friends probably won't even care." 4. "It won't take you long to learn to manage."

2. suggesting strategies to cover the trach recognizes client concerns and explores options for dealing with the effects of the procedure.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? 1. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor 2. Client with pulmonary tuberculosis who is receiving multiple medications 3. Client with sinusitis who has just arrived after having endoscopic sinus surgery 4.Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

2. the LPN scope of practice includes med administration, so a client receiving multiple meds can be managed appropriately by an LPN. stridor is an indication of resp distress; this client need to be managed by the RN. a client who just arrived after surgery requires frequent assessments by the RN. and the client with difficulty swallowing is at risk for deterioration.

The client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? 1. "You are not contagious unless you stop taking your medication." 2. "You will not be contagious to the people you have been living with." 3. "You will have to take these medications for at least 1 year." 4. "Your sputum may turn a rust color as your condition gets better."

2. the ppl the client has been living with have already been exposed and need to be tested. they cannot be re-exposed simply because the diagnosis has now been confirmed. sputum turns a rust colored when the TB is getting worse. the length of tx time is 6 months.

Which method is the best way to prevent outbreaks of pandemic influenza? 1. Avoiding public gatherings at all times 2. Early recognition and quarantine 3. Vaccinating everyone with pneumonia vaccine 4. Widespread distribution of antiviral drugs

2. the recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus.

In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO3 of 22. What action does the nurse need to take first? 1. Call the physician. 2. Encourage the client to slow his breathing rate. 3. Nothing. These results are within the normal range. 4. Provide oxygen support.

2. the situation is not emergent, and does not require the physician at this time. the ABGs indicate resp alkalosis, which is commonly caused by hyperventilation. the RN should encourage the client to slow his breathing rate, may help to return to normal breathing and correct the abnormality. the PAO2 is within normal limits, so the pt does NOT need oxygen.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? 1. Assess the puncture site for drainage. 2. Implement NPO (nothing by mouth) status. 3. Monitor for signs of anaphylaxis. 4. Perform aggressive chest physiotherapy.

2. until the client has a gag reflex and is fully alert, he should be maintained on NPO status to prevent aspiration. anaphylaxis would occur immediately with any med administration, and aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy, and may cause bleeding if biopsies have been obtained.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. Administering antibiotic prophylaxis Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client Placing a nasogastric tube Placing the client in a negative airflow room

2., 3., 4.: abx must be given on the basis of the culture.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? 1. Bronchoscopy 2. Chest x-ray 3. Computed tomography (CT) scan 4. Thoracoscopy

3. CT scans, esp spiral or helical CT scans with injected contrast can detect pulm emboli. a chest Xray will rule out other causes of symptoms, but is not specific to a pulm emboli.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalational anthrax. Which of the following medications will the RN anticipate as a physician request? 1. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours 2. Ceftriaxone (Rocephin) 2 g IV every 8 hours 3. Ciprofloxacin (Cipro) 400 mg IV every 12 hours 4. Pyrazinamide (PZA) 1000 to 2000 mg orally every day

3. Cipro is the first line drug for tx of inhaled anthrax

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? 1.Hemoglobin of 22 g/dL 2. PaCO2 of 30 mm Hg 3. PaO2 of 65 mm Hg 4. Oxygen saturation of 88%

3. PaO2 of 65 mmHg indicates low levels of oxygen in the arterial blood, termed hypoxemia. oxygen saturation measures tissue perfusion.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? 1. Contacts the health care provider for tuberculosis (TB) medications 2. Performs a TB skin test 3. Places a respiratory mask on the client 4. Tests all family members for TB

3. Place a resp mask on the client, as the concern is that the pt may have TB.

The client has a fever of 40° C. In which direction, if any, will this shift the oxyhemoglobin dissociation curve? 1. Down 2. To the left 3. To the right 4. Will not shift

3. a client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation. moving to the left would cause Hgb to dissociated oxygen less easily, and the curve does not move up or down on the vertical axis.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? 1. Blood in the sputum 2. Mucoid sputum 3. Pink frothy sputum 4. Yellow sputum

3. pink frothy sputum is common with pulm edema and requires immediate attention and intervention to prevent the client's condition from getting worse. blood in the sputum may occur with chronic bronchitis or lung CA (these chronic conditions do not require immediate attention). mucoid sputum may be r/t smoking, and yellow sputum may indicate an infection, neither which is emergent.

The medical-surgical unit has one negative airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? 1. Client with bacterial pneumonia and a cough productive of green sputum 2. Client with neutropenia and pneumonia caused by Candida albicans 3. Client with possible pulmonary tuberculosis who currently has hemoptysis 4. Client with right empyema who has a chest tube and a fever of 103.2° F

3. a client with poss TB should be admitted to the negative airflow room to prevent airborne transmission of TB. a client with neutropenia should be in a room with positive airflow. the other two options do not require a negative airlow room.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? 1. Computer keyboard 2. Magic Slate 3. Picture board 4.Pen and paper

3. a picture board does not require much dexterity, while the other options do.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? 1. Abscess 2. Pneumonia 3. Pneumothorax 4. Pulmonary embolism

3. a pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. thoracentesis is not a cause of pulm emboli, an abscess is possible but would not cause such SOB, and PNA would not develop so rapidly causing this level of s/s

You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? 1. Call the Rapid Response Team. 2. Give methylene blue 1% 1 to 2 mg/kg by IV injection 3. Administer oxygen. 4. Notify the physician immediately.

3. administering oxygen and reassessing VS to observe for improvement is the 1st action. the Rapid Response Team should be called if the client as any s/s of methemoglobinemia, which then would be treated with methylene blue (however the RN does not have enough info to determine whether the client has this condition)

The oxygen saturation monitor of the client recovering from an empyema indicates periodic decreased perfusion, yet the client is talking and laughing with a visitor. The client's respirations are even and unlabored, and the nail beds are pink. What does the nurse do first? 1. Auscultates breath sounds 2. Calls Respiratory Therapy 3. Ensures that the pulse oximetry probe is in place 4. Instructs the client to breathe deeply

3. because the client does not appear to be in distress, check to make sure that the pulse ox probe is in place, and that the equipment is functioning properly. it is always important to remember to treat the client, not the monitor.

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? 1. Client with pain on deep inspiration 2. Client with pain on palpation 3. Client with pain radiating to the shoulder 4. Client with pain that is rubbing in nature

3. chest pain radiating to the shoulder shoulder assumed to be in cardiac origin until proven otherwise, requiring immediate attention. pain on palpation is not usually pulm in nature, may be d/t trauma or referred from another source such as the GI tract

The nurse plans discharge teaching for the client who is recovering from pneumonia. When is the best time to accomplish this? 1. After the client has had his bath 2. In the evening 3. Midmorning or midafternoon 4. When visitors are present

3. client teaching is most effective during a quiet period in the midmorning or midafternoon, when the client is less fatigued.

Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)? 1.Administer bronchodilator medication on call. 2. Encourage clear fluid intake 12 hours before the procedure. 3. Ensure no smoking 6 hours before the test. 4. Provide supplemental oxygen as testing begins.

3. ensure no smoking 6 hours before the test as this will alter parts of the PFT (diffusing capacity [DICO]), yielding inaccurate results. administering bronchodilators is not indicated for PFT, but may be withheld for 4-6 hours before the test. fluid intake does not have an effect on PFT testing. unless the client develops distress during testing, supplemental oxygen is not required and will alter the results of PFT

The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? 1. The low PaO2 level may result in oxygen toxicity. 2. The 100% oxygen delivery requirement indicates immediate extubation. 3. Lung sounds may indicate absorption atelectasis. 4. The level of oxygen delivery may indicate absorption atelectasis.

3. high levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. high PaO2 levels may result in oxygen toxicity, the need for 100% oxygen suggest the client continues to require intubation.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? 1. Ensure that ED staff members receive oseltamivir (Tamiflu). 2. Obtain specimens for the H5 polymerase chain reaction test. 3. Place the client in a negative air pressure room. 4. Start an IV line and administer rehydration therapy.

3. if a client is exhibiting symptoms of avian flu or any other pandemic influenza, he is assumed to be contaigous until proven otherwise. protecting the spread of the disease to the community is the top priority, so placing the client in a negative air pressure room is the RN's first action. obtaining specimens will be important to determine whether the client has avian flu. this test takes approx 40 min to complete. it is important that those exposed receive oseltamivin or zanamivir (Relenza), and a client with avian flu will become dehydrated owing to diarrhea.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? 1. Suction as needed. 2. Clean the tracheostomy inner cannula and stoma. 3. Listen to lung sounds. 4.Change the tracheostomy dressing as needed.

3. suction may not be needed. cleanliness is a priority, but assessment is the 1st phase of the nursing process. all other actions are driven by assessment findings. the 1st nursing action for a client following an airway procedure is to assess the client's resp status and this requires auscultation of the lungs.

A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords? 1. Arytenoid cartilage 2. Epiglottis 3. Glottis 4. Palatine tonsils

3. the glottis is the opening of the vocal cords, into which the ET tube is passed through during intubation. the arytenoid cartilages work with the thyroid cartilage to control the movement of the vocal cords, the epiglottis is a structure that prevents aspiration during swallowing, and the palatine tonsils are part of the immune system, located in the oropharynx.

The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? 1. Client who is short of breath after walking up two flights of stairs 2. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test 3. Client with sore throat and fever of 39° C oral 4. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry

4. 90% indicates hypoxemia, and the client should be able to speak more than 3 word sentences. the other options require evaluation but not emergently

Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? 1. Client with allergic rhinitis scheduled for skin testing 2. Client with emphysema who needs teaching about pulmonary function testing 3. Client with pancreatitis who needs a preoperative chest x-ray 4. Client with pleural effusion who has had 1200 mL removed by thoracentesis

4. a RN working in the PACU would be familiar with assessing VS and resp status after procedures such as thoracentesis. skin testing is performed in the outpatient setting.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU? 1. Assess breath sounds. 2. Check gag reflex. 3. Determine level of consciousness. 4. Monitor blood pressure and pulse.

4. a nursing assistant working in the PACU would have experience in taking client VS after the client had conscious sedation or anesthesia. all the other actions require a more advanced knowledge.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? 1. The client is not being treated for asthma. 2. The client has a mental disorder. 3. The client received a dose of Valium. 4. The client is receiving oxygen at 4 L/min.

4. a simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client.

The client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? 1. Chest x-ray 2. Complete blood count 3. Tuberculosis (TB) skin test 4.Throat culture

4. a throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection.

An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN? 1. Administer the purified protein derivative (PPD) for tuberculosis testing. 2. Assess vital signs and the puncture site after thoracentesis. 3. Monitor oxygen saturation using pulse oximetry every 4 hours. 4. Plan client and family teaching regarding upcoming pulmonary function testing.

4. developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. all the other actions can be performed by an LPN.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? 1. Homeless people 2. Hospital staff 3. Politicians 4. Prison staff and inmates

4. high risk groups for resp infection include those who live in crowded areas such as LTC facilities, prisons, etc

Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? 1. Humidifying the oxygen source 2. Increasing oxygenation 3. Removing the inner cannula of the tracheostomy 4. Suctioning the client

4. suctioning the client will liekly result in clear sounds and lower peak pressure, and the appearance of the sputum will indicate wheter bleeding is a concern. humidifying the ocygen source will help mobilize secretions, but an active cough response is also required to clear the airway.a sedated client has a weak cough. increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. and removing the inner cannula of a ventilated client is contraindicated.

The nurse has taught the client about influenza infection control. Which client statement indicates the need for further teaching? 1. "Handwashing is the best way to prevent transmission." 2. "I should avoid kissing and shaking hands." 3. "It is best to cough and sneeze into my upper sleeve." 4. "The intranasal vaccine can be given to everybody in the family."

4. the intranasal flu vaccine is approved for healthy clients ages 2-49 who are not pregnant.

Why are the turbinates important? 1. They decrease the weight of the skull on the neck. 2. They increase the surface area of the nose for heating and filtering. 3. They move inspired particles from nose to throat for removal. 4. They separate two nasal passages down the middle.

4. the turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx. the paranasal sinuses are air-filled cavities that decrease the wt of the skull, the cilia are responsible for moving inspired particles to the throat, and the septum divides the nasal cavity into two passages.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? 1. Ensures that the client is wearing a mask 2. Tells the visitor that the client cannot receive visitors at this time 3. Provides a particulate air respirator to the visitor 4. Provides a mask to the visitor

4. the visitor must wear a mask.

The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? 1. Cut sterile 4 × 4 gauze to fit around the tracheostomy tube. 2. Reinforce the dressing with sterile 4 × 4 gauze. 3. Replace the dressing with clean, folded 4 × 4 gauze. 4. Replace the dressing with sterile, folded 4 × 4 gauze.

4.replace with STERILE folded 4x4

The 75-year-old client tells the nurse he is not planning to receive a "flu shot" this year because he had one just a year ago. What is the nurse's best response? A. "Because you are older and your immune system is more fragile, you should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The 'flu shot' you had last year should still protect you for seasonal influenza, but you still need a vaccination for H1N1." D. "The fact that you have been vaccinated by injection just last year makes you a candidate to use the nasal vaccination this year."

: B Rationale: The influenza vaccine is changed every year because the strains of virus that hit a geographic area are usually different each year, which means that last year's vaccination is not likely to be effective against this year's influenza. The yearly vaccine is changed based on which specific viral strains are most likely to pose a problem during the influenza season. Usually, the vaccines contain three antigens for the three expected viral strains (trivalent influenza vaccine [TIV]). The nasal vaccination is an attenuated live virus and is not approved for anyone older than 49 years of age.

Which action is most important for the nurse to teach the family of a client who is receiving oxygen therapy at home by continuous nasal cannula? A. Providing mouth care every 8 hours B. Lubricating the lips with water-soluble jelly C. Draining the condensation in the tubing every 2 hours D. Changing the position of the elastic band every 4 hours

: D Rationale: Clients receiving oxygen by nasal cannula are prone to skin breakdown on the ears, back of the neck, and face. Changing the position of the elastic band relieves pressure and prevents skin breakdown.

a pt has two chest tubes from the left thorax, connected with a Y-tube to water seal drainage, where there is a continuous bubbling in the suction control chamber of the collection device. the appropriate action by the RN is to: A. document the suction level and amount of drainage B. strip and milk the tubing close to the pt to promote drainage C. auscultate the chest to detect a tension pneumothorax D. progressively clamp the chest tubes from the pt toward the drainage, while watching for a change in bubbling.

???

The client is 1 day postoperative after an open thoracotomy and has two chest tubes in place on the right side. The nurse notes that the client's trachea is pointing toward the left upper chest. What is the nurse's best first action? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Check the suction setting for chamber three and compare it with the prescribed setting. C. Assess the client's oxygen saturation, and attempt to reposition the trachea within the midline. D. No action is needed because the trachea is deviated toward the unaffected side rather than the affected side.

A Rationale: A tracheal deviation away from the midline after a thoracotomy is not normal. In this case, a tension pneumothorax is most likely because the deviation is away from the operative side. This is a life-threatening emergency. The deviated trachea cannot be manually corrected because the problem is in the chest. The suction setting is not responsible for the tension pneumothorax.

The client's oxygen saturation by pulse oximetry on the finger is 84%. What is the nurse's best first action? A. Recheck the value on the forehead. B. Assess the client's cognitive function. C. Notify the Rapid Response Team immediately. D. Apply supplemental oxygen by mask or nasal cannula.

A Rationale: Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

A client who has a pulmonary embolism and a venous thromboembolism is to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is the nurse's best action? A. Administer the medications as prescribed. B. Remind the prescriber that two anticoagulants should not be administered concurrently. C. Hold the dose of warfarin until the client's partial thromboplastin time is the same as the control value. D. Monitor the client for clinical manifestations of internal or external bleeding at least every 2 hours.

A Rationale: Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin in order to maintain a safe level of anticoagulation.

Why can oxygen therapy cause hypoventilation in clients who have hypercarbia? A. Low arterial oxygen levels are the neurologic trigger for these clients to breathe. B. Excessive carbon dioxide levels reduce the ability of hemoglobin molecules to carry oxygen. C. High concentrations of oxygen cause sedation, which reduces the strength of respiratory muscle contractions. D. Unlike people who do not have hypercarbia, these clients are no longer sensitive to changing levels of arterial oxygen.

A Rationale: In a healthy person, a rising PaCO2 level is the drive to breathe and stimulates an increased rate and depth of respiration. When the PaCO2 rises gradually, resulting in hypercarbia, the central chemoreceptors lose their sensitivity and are no longer the drive to breathe—a condition called CO2 narcosis. Therefore the only trigger to stimulate breathing in clients with CO2 narcosis is hypoxemia, a declining PaCO2 level. When arterial oxygen levels increase with oxygen therapy, the higher oxygen level is perceived as the client no longer needing to breathe as often or as deeply.

A client reaches for the salmeterol (Serevent) inhaler with the onset of an asthma attack. What is the nurse's best action? A. Instruct the client to use the albuterol (Proventil) inhaler instead. B. Assist the client to use oxygen for three breaths between the two puffs of the inhaled drug. C. Instruct the client to attach the spacer to the inhaler before using it and inhale as rapidly as possible. D. Remind the client to take a deep breath, hold it for 15 seconds, and then exhale before using the inhaler.

A Rationale: Salmeterol is a long-acting beta2 agonist. This type of drug needs time to build up an effect and is useful in preventing asthma attacks. The effects of this drug are longer lasting but are not of value during an acute asthma attack. The client should use albuterol in this case.

respiratory acidosis

A falling blood pH and a rising partial pressure of carbon dioxide due to pneumonia or emphysema

respiratory alkalosis

A rise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: (select all that apply) a. Atherosclerosis. b. Retinopathy. c. IUFD. d. Nephropathy. e. Neuropathy. f. Autonomcs neuropathy.

A, B, D, E

Nursing interventions for a patient with COPD might include (select all that apply): A. Specific breathing techniques B. Positioning to relieve dyspnea C. Energy conservation D. Managed fluid intake

A,B,C

The patient has an order for each of the following inhalers. Which of the following should the nurse offer to the patient at the onset of an asthma attack? A. Albuterol (Proventil) B. Salmeterol (Serevent) C. Beclomethasone (Beclovent) D. Ipratropium bromide (Atrovent)

A. Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which of the following patient vital signs? A. Pulse rate of 76 B. Respiratory rate of 18 C. Temperature of 98.4° F D. Oxygen saturation 96%

A. Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 76 indicates that the patient did not experience tachycardia as an adverse effect.

A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which of the following clinical manifestations might be present as an early symptom during an exacerbation of asthma? A. anxiety B. cyanosis C. bradycardia D. hypercapnia

A. An early symptom during an asthma attack is anxiety because he is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions

A. Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/min. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for signs and symptoms of: A. Pneumothorax. B. Bronchospasm. C. Pulmonary edema. D. Respiratory acidosis.

A. Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing pulmonary edema, respiratory acidosis, or bronchospasm.

A patient with recurrent shortness of breath has just had a bronchoscopy. Which of the following is a priority nursing action immediately following the procedure? A. Monitoring the patient for laryngeal edema B. Assessing the patient's level of consciousness C. Monitoring and controlling the patient's pain D. Assessing the patient's heart rate and blood pressure

A. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions? A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." B. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." C. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." D. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

A. The patient should be instructed to breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

Which of the following physical assessment findings in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Respiratory rate of 28 C. Oxygen saturation of 85% D. Presence of greenish sputum

A. The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions.

The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicates to the nurse that the patient's respiratory status is improving? A. Wheezing becomes louder B. Vesicular breath sounds decrease C. The cough remains nonproductive D. Aerosol bronchodilators stimulate coughing

A. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma? A. Work of breathing B. Fear of suffocation C. Effects of medications D. Anxiety and restlessness

A. When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity.

which pt is at highest risk of aspiration? A. a 26 yo pt with continuous enteral tube feedings through a NGT B. a 67 year old pt with a CVA with expressive dysphagia C. a 58 yo pt with absent bowel sounds immediately after surgery D. a 92 yo pt with viral pneumonia and coarse crackles throughout lung fields

A. any continuous feedings may put the pt at risk. best prevention is maintaining HOB>30-45 degrees, and never lay pt supine while tube feeding is infusing.

when reviewing the ABGs of a pt with COPD, the RN identifies late-stage COPD with which of the following results? A. pH 7.35, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30mEq/L B. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18mEq/L C. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25mEq/L D. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35mEq/L

A. with COPD the body has compensatory respiratory acidosis. normal pH, pCO2 >45

How do you position a patient for a thoracentesis?

Sitting up, leaning forward over a table.

The client is 1 day postoperative after an open thoracotomy and has two chest tubes in place on the right side. The nurse notes that the client's trachea is pointing toward the left upper chest. What is the nurse's best first action? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Check the suction setting for chamber three and compare it with the prescribed setting. C. Assess the client's oxygen saturation, and attempt to reposition the trachea within the midline. D. No action is needed because the trachea is deviated toward the unaffected side rather than the affected side.

ANS: A Rationale: A tracheal deviation away from the midline after a thoracotomy is not normal. In this case, a tension pneumothorax is most likely because the deviation is away from the operative side. This is a life-threatening emergency. The deviated trachea cannot be manually corrected because the problem is in the chest. The suction setting is not responsible for the tension pneumothorax.

Which laboratory blood test result for a client undergoing hematologic assessment does the nurse report immediately to the prescriber? A. Red blood cell count 1.2 million/mm3 B. Platelets 185,000/mm3 C. Hematocrit 36% D. INR 1.2

ANS: A Rationale: All of these test results are in the low to low-normal range. However, the most abnormal result is the red blood cell count. The normal red blood cell range is 4.2 to 6.1 million/mm3. This client's value is dangerously below normal.

The client's oxygen saturation by pulse oximetry on the finger is 84%. What is the nurse's best first action? A. Recheck the value on the forehead. B. Assess the client's cognitive function. C. Notify the Rapid Response Team immediately. D. Apply supplemental oxygen by mask or nasal cannula.

ANS: A Rationale: Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

A client newly diagnosed with acute leukemia asks why he is at such extreme risk for infection when his white blood cell count is so high. What is the nurse's best response? A. "Even though you have many white blood cells, they are too immature to fight infection." B. "For now, your risk is low; however, when the chemotherapy begins, your risk for infection will be high." C. "These white blood cells are cancerous and live longer than normal white blood cells, so they are too old to fight infection." D. "It is not the white blood cells that provide protection; it is the red blood cells, which are very low in your blood right now."

ANS: A Rationale: For clients who understand that white blood cells are a great protection against infection, being at great risk for infection even when WBC counts are sometimes ten times normal is confusing. These are leukemic cells that overgrow at a very immature level. Therefore even though there can be huge numbers of circulating WBCs, these cells are so immature that they are nonfunctional. In addition, the heavy production of immature leukemic cells prevents normal WBCs, RBCs, and platelets from forming and maturing into functional cells.

Why can oxygen therapy cause hypoventilation in clients who have hypercarbia? A. Low arterial oxygen levels are the neurologic trigger for these clients to breathe. B. Excessive carbon dioxide levels reduce the ability of hemoglobin molecules to carry oxygen. C. High concentrations of oxygen cause sedation, which reduces the strength of respiratory muscle contractions. D. Unlike people who do not have hypercarbia, these clients are no longer sensitive to changing levels of arterial oxygen.

ANS: A Rationale: In a healthy person, a rising PaCO2 level is the drive to breathe and stimulates an increased rate and depth of respiration. When the PaCO2 rises gradually, resulting in hypercarbia, the central chemoreceptors lose their sensitivity and are no longer the drive to breathe—a condition called CO2 narcosis. Therefore the only trigger to stimulate breathing in clients with CO2 narcosis is hypoxemia, a declining PaCO2 level. When arterial oxygen levels increase with oxygen therapy, the higher oxygen level is perceived as the client no longer needing to breathe as often or as deeply.

Which assessment is most important for the nurse to perform for the client receiving one unit of packed red blood cells from an autologous donation? A. Temperature B. Blood pressure C. Oxygen saturation D. IV site for hives

ANS: A Rationale: In an autologous blood transfusion, the client receives his or her own blood components. Therefore the chances for an incompatibility type reaction do not exist. The main problems that can come from autologous transfusion are fluid overload and infection from blood contamination during the collection, storage, or infusion processes. Fluid overload is very unlikely when only one unit is being transfused. Contamination and infection are just as likely with an autologous transfusion as they are with a transfusion of donated blood products. The most important assessment is for signs of infection, including temperature.

A woman whose hemoglobin S levels are less than 1% has a brother with sickle cell disease (SCD) and both parents have been diagnosed as carriers for the disorder. She asks what her risks are of having a child with sickle cell disease. What is the nurse's best response? A. "Because you do not have the trait, you cannot have a child with SCD regardless of your partner's sickle cell status." B. "Because both your parents have the trait, it is possible for you to have a child with SCD if your partner actually has the disease." C. "Because your brother actually has SCD, the risk for your children having SCD is 50% with each pregnancy." D. "Because you are a woman, your daughters will each have a 50% risk for having the disease, and all of your sons will be carriers of the trait."

ANS: A Rationale: SCD is an autosomal recessive genetic disorder. This woman does not have SCD or a sickle cell trait, as evidenced by her HbS levels being less than 1%. Therefore regardless of her partner's sickle cell status, she will not have a child with actual SCD. However, if her partner is a carrier, any child she has with this partner has a 50% risk of having a sickle cell trait. If her partner has SCD, any child she has will be a carrier of sickle cell trait.

A client reaches for the salmeterol (Serevent) inhaler with the onset of an asthma attack. What is the nurse's best action? A. Instruct the client to use the albuterol (Proventil) inhaler instead. B. Assist the client to use oxygen for three breaths between the two puffs of the inhaled drug. C. Instruct the client to attach the spacer to the inhaler before using it and inhale as rapidly as possible. D. Remind the client to take a deep breath, hold it for 15 seconds, and then exhale before using the inhaler.

ANS: A Rationale: Salmeterol is a long-acting beta2 agonist. This type of drug needs time to build up an effect and is useful in preventing asthma attacks. The effects of this drug are longer lasting but are not of value during an acute asthma attack. The client should use albuterol in this case.

Which precaution is most important for the nurse to teach a client with autoimmune thrombocytopenic purpura who is receiving corticosteroid therapy to control the disease? A. "Avoid contact sports and any activity that could cause injury." B. "Report any rash to your health care provider immediately." C. "Be sure to drink at least 3 liters of water daily." D. "Take a low-dose aspirin daily with food."

ANS: A Rationale: The client has too few functional platelets to form clots in response to injury and is at great risk for bleeding. The corticosteroids also make tissues and blood vessels more fragile. Aspirin decreases platelet aggregation and should not be taken by anyone with this disorder. Although reporting a rash and drinking at least 3 liters of water daily are positive actions, they are not the most important precautions for this client to take.

A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Breathlessness D. Ascites E. Lung congestion

ANS: A, D Rationale: Clients diagnosed with right-sided heart failure generally retain fluid in interstitial body tissues and the abdomen due to portal (liver) congestion. Assessment findings related to this fluid gain include increased body weight, peripheral edema, and ascites (the accumulation of fluid in the peritoneal cavity). Lung congestion causing crackles and shortness of breath or breathlessness results from left-sided heart failure because fluid backs up from the left heart into the lungs.

How does aspirin interfere with blood clotting? A. Prevents vitamin K synthesis B. Inhibits the activation of platelets C. Increases the rate of platelet destruction D. Prevents fibrin molecules from assembling into long strands

ANS: B Rationale: Almost every step in the blood-clotting cascade requires activated platelets to aggregate. The substance thromboxane activates platelets, making them stick together. Aspirin disrupts the enzyme cyclooxygenase (COX), which produces thromboxane. Therefore with less thromboxane present, fewer platelets are activated and blood clotting is reduced.

A client who works in a furniture factory reports that he is worried about his health because two co-workers have been diagnosed with sinus cancer in the past year. Which suggestion does the nurse make to reduce this client's risk for sinus cancer? A. Avoid the use of over-the-counter nasal sprays. B. Wear a fine particulate mask when working with wood. C. Spend as much time as possible outdoors, away from cities. D. Wear gloves when working with paint thinners and liquid glue.

ANS: B Rationale: Chronic exposure to fine particulates, especially wood dust, is associated with an increased incidence of nose and sinus cancer. Wearing a mask that blocks the inhalation of fine particulates can help reduce this exposure.

A client with moderate chronic obstructive pulmonary disease (COPD) is preparing to go home and has thrown away the information regarding smoking cessation. He states, "Why should I quit now after I have already caused this disease." What is the nurse's best response? A. "You are not responsible for this disease. It is a matter of a gene-environment interaction." B. "Choosing to quit smoking can slow the progression of COPD and make you feel better about yourself." C. "Blaming yourself is counterproductive and is likely to make your anxiety and depressive symptoms worse." D. "You shouldn't be so negative. After all, COPD is manageable, not like lung cancer."

ANS: B Rationale: Continuing to smoke causes continuing damage to the lung tissue, which worsens symptoms and increases the progression of the disease to the severe category, resulting in severe limitations in all of the client's activities. Slowing the progression of COPD can allow the client to continue to enjoy many activities and help him retain his independence as long as possible. Although smoking cessation is not an easy task, most people who are successful experience a greatly improved self-image.

A client with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What is the nurse's best action? A. Obtain a specimen for culture and test the urine for occult blood. B. Reassure the client that this is a normal drug side effect. C. Hold the dose and contact the health care provider. D. Document the report as the only action.

ANS: B Rationale: Rifampin normally turns urine an orange color. No intervention is needed; however, the color change can be very distressing to clients. The client should be reassured that this color change is normal and taught how to manage this change so that clothing does not become stained. No documentation of this normal side effect is needed.

An older adult taking digoxin and furosemide (Lasix) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 52. A family member states that the client has fallen four times this week. What is the nurse's first action? A. Call the ED physician immediately. B. Draw a serum digoxin level. C. Assess for signs of hypokalemia. D. Establish the client's airway.

ANS: B Rationale: The client has signs and symptoms of digoxin toxicity and needs to be placed on a monitor immediately to determine the extent of effects on the heart and conduction system. Symptoms of digoxin toxicity include blurred vision or yellow or green halos around visual images, confusion, muscle weakness, and vertigo. Toxicity may be increased from furosemide-induced hypokalemia. This can lead to premature ventricular contractions (PVCs) that may lead to other life-threatening dysrhythmias and death. Clients need to be cautioned not to store both digoxin and furosemide in the same container. The most common dose of each medication is available in a small white pill (similar in appearance), increasing the chances of error. Serum digoxin levels and electrolytes need to be drawn. Symptoms of hypokalemia are mostly neuromuscular with generalized weakness. There is no indication that the client is having difficulty with breathing. Respiratory rate may be increased.

The 75-year-old client tells the nurse he is not planning to receive a "flu shot" this year because he had one just a year ago. What is the nurse's best response? A. "Because you are older and your immune system is more fragile, you should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The 'flu shot' you had last year should still protect you for seasonal influenza, but you still need a vaccination for H1N1." D. "The fact that you have been vaccinated by injection just last year makes you a candidate to use the nasal vaccination this year."

ANS: B Rationale: The influenza vaccine is changed every year because the strains of virus that hit a geographic area are usually different each year, which means that last year's vaccination is not likely to be effective against this year's influenza. The yearly vaccine is changed based on which specific viral strains are most likely to pose a problem during the influenza season. Usually, the vaccines contain three antigens for the three expected viral strains (trivalent influenza vaccine [TIV]). The nasal vaccination is an attenuated live virus and is not approved for anyone older than 49 years of age.

A client who had an abdominal aneurysm repair yesterday has a urinary output of 25 mL/hr and a blood urea nitrogen (BUN) of 68 mg/dL. What action should the nurse take first? A. Call the surgeon immediately. B. Assess the client's vital signs. C. Increase the intravenous fluid rate. D. Continue to monitor the client.

ANS: B Rationale: This client is likely experiencing acute kidney injury (formerly known as acute renal failure) related to a period of renal hypoperfusion. The nurse should assess the client's vital signs first. After obtaining this data, the nurse should call the surgeon and possibly obtain an order to increase the IV fluid infusion rate based on the client's blood pressure and fluid volume status assessment. Continuing to only monitor the client would be an inadequate response by the nurse.

A client has been taking furosemide (Lasix) for the past 3 years. This morning, the hospital laboratory notifies the nurse that the client's serum potassium level is 2.9 mEq/L. What is the nurse's best action at this time? A. Notify the health care provider. B. Ask the lab to retest the potassium level. C. Give potassium as an IV infusion. D. Withhold this morning's Lasix dose.

ANS: B Rationale: This potassium value is at a critical level. The nurse should request that the lab confirm that this value is accurate since the client has been taking furosemide for 3 years. The lab value should be confirmed prior to contacting the health care provider for orders.

Which technique or action does the nurse use to prevent tracheal stenosis in a client after a tracheotomy has been performed? A. Assessing breath sounds bilaterally every 2 hours B. Securing the tracheostomy tube in a midline position C. Holding the tube continually when changing the tracheostomy ties D. Suctioning the tracheostomy tube with as small a catheter as possible

ANS: B Rationale: Tracheal stenosis, a narrowed tracheal lumen, is the result of scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure.

Which nursing action has the highest priority when caring for a client with facial trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway

ANS: D Rationale: Facial trauma has the potential to interfere with breathing by occluding the upper airways. This can occur from swelling, tissue displacement, bleeding, emesis, or as a response to therapy. Maintaining a patent airway remains a nursing priority until the trauma has healed.

The nurse is caring for a client with coronary artery disease who has just undergone a coronary angiogram. What is the priority intervention when caring for this client immediately postprocedure? A. Place the client in high Fowler's to prevent aspiration. B. Educate the client on anticoagulant medications. C. Assess for bleeding at the insertion site. D. Monitor for elevated cardiac enzymes.

ANS: C Rationale: An angiogram is an invasive procedure into the client's artery. Because of the invasive nature of this procedure and the arterial pressure in the vessel, bleeding is the greatest risk related to this diagnostic test. Preventing aspiration is not common with angiograms and is not a high priority intervention. Although the client may be discharged on anticoagulant medications, it is not a teaching priority in the immediate postprocedure period. Teaching will occur after the client has come out of sedation for the procedure and before discharge. An elevated cardiac enzyme level is not an expected outcome related to an angiogram. Elevated cardiac enzymes are diagnostic of a myocardial infarction.

A client is being discharged home on warfarin (Coumadin) after being treated for deep vein thrombosis. What priority instruction will the nurse include in the client's discharge teaching? A. "Take one extra Coumadin the day before a blood test." B. "Eat a diet high in protein and green leafy vegetables." C. "Use a soft-bristled toothbrush to prevent bleeding of the gums." D. "Weigh yourself daily at the same time to monitor fluid balance."

ANS: C Rationale: Coumadin is an anticoagulant that increases the client's risk for bleeding. The gums are one area prone to bleeding, so the client should use a soft-bristled toothbrush and gently brush the teeth to prevent bleeding. The client should not alter the dose of warfarin unless instructed to do so by the health care provider. Altering the dose will interfere with interpretation of coagulation studies such as the PT and/or INR. Clients taking warfarin should not eat large amounts of foods high in vitamin K (e.g., liver, leafy green vegetables, vegetable oils) because vitamin K can make warfarin less effective. Warfarin has no influence on fluid balance. It is not necessary to obtain a daily weight while taking this drug.

A client with leukoplakia just above the glottis has just received the results of a biopsy and is confirmed to have squamous cell carcinoma in situ. She begins to cry and says that she would not be able to stand a surgery that would take away her ability to speak. What is the nurse's best response? A. "Your loss of speech would only be temporary until you learned to use esophageal speech." B. "Cancers at this stage are usually treated with chemotherapy alone, which does not permanently affect your ability to speak." C. "Cancers at this stage are usually treated with radiation therapy, which does not permanently affect your ability to speak." D. "A speech and language pathologist will work with you to select the method of communication that fits your lifestyle best."

ANS: C Rationale: Early-stage cancers often can be managed with less radical surgery, such as radiation therapy, that spares the vocal cords. With intact vocal cords, the client can usually speak, although the tone or timbre of the voice may be somewhat altered.

Which action does the nurse take to prevent hypoxia in a client during nasotracheal suctioning? A. Measuring pulse oximetry throughout the procedure B. Inserting the suction catheter through the vocal cords only when the client exhales C. Administering 100% oxygen by manual resuscitation bag before initiating suctioning D. Removing the suction tube from the nasopharynx as soon as the client begins to cough

ANS: C Rationale: Hyperoxygenating the client before the procedure helps to prevent hypoxia. Although measuring pulse oximetry throughout the procedure can help identify when hypoxia is occurring, it does not prevent the complication.

A client diagnosed with atherosclerosis has been prescribed simvastatin (Zocor). Which statement by the client indicates a need for further teaching? A. "I have to eat more fruits and vegetables in my diet." B. "I'll follow up with my nurse practitioner to check my lipid levels." C. "I only smoke a half-pack of cigarettes a day so I won't need to quit." D. "I'll report any leg cramps to my nurse practitioner immediately."

ANS: C Rationale: Interventions for clients with atherosclerosis or those at high risk for the disease focus on lifestyle changes. Clients should be taught about the need to make daily changes by avoiding or minimizing modifiable risk factors such as smoking, weight management, and exercise. Increasing fiber in the daily diet is recommended to assist in managing cholesterol levels. Fruits and vegetables are an excellent source of fiber. The client will require monitoring of lipid levels to see if the drug therapy is effective. Statin drugs such as Zocor can cause muscle myopathies and marked decreases in liver function. If leg cramps occur, the client must notify the practitioner and the drug will be discontinued.

The nurse is providing care to a client at high risk for deep vein thrombosis. What health teaching will the nurse provide to the client related to home management of low-molecular weight heparin? A. "You must have your partial thromboplastin time checked every 2 weeks." B. "Massage the injection site after the heparin is injected." C. "Notify your health care provider if your stools appear tarry." D. "You will have an IV catheter placed for intermittent injection of the heparin."

ANS: C Rationale: Low-molecular weight-heparin (LMWH) is an anticoagulant. Anticoagulants increase the client's risk for bleeding. Dark, tarry stools are a symptom of gastrointestinal bleeding and require prompt medical attention. Partial thromboplastin times are not checked on an ongoing basis because the doses of LMWH are not adjusted. Doses are based on the client's weight. The injection site for any type of heparin should not be massaged because it may increase the area of ecchymosis. Intermittent injections of heparin will be administered into the subcutaneous tissue of the abdomen.

Which assessment finding indicates to the nurse that the client with chronic obstructive pulmonary disease (COPD) needs to be suctioned? A. Documentation indicates the client was last suctioned 12 hours ago. B. The client is unable to speak more than six words without clearing the throat. C. Although the client is coughing, breath sounds indicate continued presence of secretions in the airways. D. The oxygen saturation, as measured by pulse oximetry, decreases while the client performs controlled coughing.

ANS: C Rationale: Suctioning is only performed when needed, not on a routine basis. The client who needs suction is one whose cough is too weak to clear secretions effectively. This problem is identified by breath sounds that indicate the presence of secretions in the airways after the client has coughed.

Six weeks after hematopoietic stem cell transplantation for leukemia, the client's white blood cell (WBC) count is 8200/mm3. What is the nurse's best action in view of this laboratory result? A. Notify the health care provider immediately. B. Assess the client for other symptoms of infection. C. Document the laboratory report as the only action. D. Remind the client to avoid crowds and people who are ill.

ANS: C Rationale: The WBC count is now within the normal range (5000 to 10,000/mm3) and is an indicator of successful engraftment. The client is not at any particular risk for infection at this time, nor is there reason to believe an infection is present. (At any post-transplantation check-up, the client is assessed for infection.)

In performing a chest assessment, the nurse observes or determines all of the following findings in a 70-year-old client. Which finding indicates to the nurse that the client may have an increased residual lung volume? A. Exhalation is twice as long as inhalation. B. Breath sounds are absent at the lung edges. C. The intercostal spaces measure 4 centimeters. D. Vibrations can be felt on the chest wall when the client speaks.

ANS: C Rationale: The expected distance between the ribs is the width of the client's fingerbreadth, or about 2 centimeters. Distances greater than this are abnormal and usually indicate some degree of air trapping that causes an increased residual lung volume.

The client, in a panicky voice, tells the nurse during a thoracentesis that he feels as if he is being pushed off the table. What is the nurse's best response? A. Stop the procedure to administer an anxiety-reducing drug. B. Remind the client not to talk or breathe during the procedure. C. Reassure the client this is a normal sensation as the needle is inserted into the chest cavity. D. Relay this information to the health care provider performing the procedure so that the needle can be repositioned.

ANS: C Rationale: The tissues of the thorax can be thick, and significant pressure may need to be applied to insert the needle. The client can indeed feel as though he is being pushed. This is a normal sensation and does not indicate a problem. Reassure the client first, then remind him not to move.

The nurse is providing education to help reduce cardiovascular risks for adults at a community health fair. Which statement made by a participant indicates understanding of the health education? A. "I can't do anything about my disease risk because it is in my genes." B. "I will take my blood pressure medication only when I have symptoms." C. "I will start walking on the treadmill each day when I watch my favorite TV show." D. "I don't need to stop smoking because damage to my blood vessels is irreversible."

ANS: C Rationale: There are several ways in which clients can reduce the risk for cardiovascular disease. Participating in exercise, such as walking, is one way to reduce the risk. A positive family history for CAD in a first-degree relative (parent, sibling, or child) is a major risk factor. Individuals with a familiar link to cardiovascular disease should be carefully attentive to the modifiable risks. Compliance with medications for chronic conditions such as hypertension is an important step in reducing cardiovascular risk. Cigarette smoking is a major modifiable risk factor for CVD, specifically coronary artery disease (CAD) and peripheral vascular disease (PVD).

Which statement made by a client with folic acid deficiency anemia indicates to the nurse a correct understanding of self-management for this health problem? A. "If my fingers and toes become numb, I will notify my health care provider immediately." B. "I will stop playing contact sports or any activity that increases my risk for injury." C. "My diet now includes more carrots, cauliflower, and apples." D. "I have stopped drinking alcohol completely."

ANS: D Rationale: A major cause of folic acid deficiency is chronic alcoholism. Stopping all intake of alcohol helps increase folic acid levels. A diet with good intake of green, leafy vegetables, liver, yeast, citrus fruits, dried beans, and nuts helps replace the deficient nutrient. Folic acid deficiency does not cause neurologic symptoms and does not reduce platelet levels. Therefore the risk for bleeding is not increased and the client should not have peripheral neuropathy from this problem.

For what reason is pandemic influenza a bigger health threat than seasonal influenza? A. No vaccines are available for immunization to prevent pandemic influenza. B. Unlike seasonal influenza, pandemic influenza does not respond to antibiotics. C. Seasonal influenza viruses are killed by exposure to heat, and pandemic viruses are not. D. Pandemic influenzas began from animal viruses, and humans have no natural immunity to them.

ANS: D Rationale: A new avian virus is the H5N1 strain, known as "avian influenza" or "bird flu," that has infected millions of birds, especially in Asia, and now has started to spread by human-to-human contact. World health officials are concerned that this strain could become a pandemic because humans have essentially no naturally occurring immunity to this virus. Therefore the infection could lead to a worldwide pandemic with very high mortality rates. There is a stockpiled vaccine for this viral strain. No viral disease responds to (is killed by) antibiotics.

Which action is most important for the nurse to teach the family of a client who is receiving oxygen therapy at home by continuous nasal cannula? A. Providing mouth care every 8 hours B. Lubricating the lips with water-soluble jelly C. Draining the condensation in the tubing every 2 hours D. Changing the position of the elastic band every 4 hours

ANS: D Rationale: Clients receiving oxygen by nasal cannula are prone to skin breakdown on the ears, back of the neck, and face. Changing the position of the elastic band relieves pressure and prevents skin breakdown.

Which laboratory value in a client with sickle cell disease does the nurse report immediately to the health care provider? A. Hematocrit 24% B. Hemoglobin S (HbS) 78% C. Platelet count 260,000/mm3 D. White blood cell (WBC) count 20,000/mm3

ANS: D Rationale: Clients with sickle cell disease are usually anemic, and the hematocrit level is not critical at this time. An HbS level of 78% is an expected finding and not one that the health care provider must be informed about at this time. The platelet count is lower than normal but is not low enough to lead to uncontrolled bleeding. The WBCs are elevated. Although most clients with SCD do have a somewhat elevated WBC level, this count is too high and indicates the presence of an acute infection. The health care provider must be notified immediately and the proper interventions instituted.

Which clinical manifestation reported by a client suggests to the nurse that anemia is a possibility? A. Difficulty sleeping B. Cold hands and feet C. Chronic headaches D. Shortness of breath

ANS: D Rationale: Shortness of breath is very common with anemia because the blood is not efficient at providing enough oxygen. Therefore to maintain adequate oxygenation to tissues, the person must increase his or her respiratory rate. Although cold hands/feet and headaches are associated with anemia, these manifestations are not specific enough to suggest anemia.

The 60-year-old client's smoking history includes smoking 2 packs of cigarettes per day since the age of 15 until the age of 40, and then smoking 3 packs per day to the present. How does the nurse document this smoking history? A. 45 pack-years B. 80 pack-years C. 90 pack-years D. 110 pack-years

ANS: D Rationale: Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). Ages 15 to 40 is 25 years × 2 packs per day = 50 pack-years. From ages 40 to 60 is 20 years × 3 packs per day = 60 pack years. 50 + 60 = 110.

The spouse of a client who has had a partial vertical laryngectomy is working with the client to use the supraglottic method of swallowing. Which direction given by the spouse to the client indicates to the nurse that more instruction is needed? A. Sit up as straight as you can when eating. B. Clear your throat before taking a bite of food. C. Only take just a teaspoonful of food at one time. D. Swallow once, then take a breath, and swallow again.

ANS: D Rationale: The supraglottic swallowing method follows this sequence: Sitting in an upright, preferably out-of-bed, position Clearing the throat Taking a deep breath Placing a small amount of food into the mouth Holding the breath, or "bearing down" (Valsalva maneuver) Swallowing twice Releasing the breath and clearing the throat Swallowing twice again Breathing normally

A client is prescribed hydrochlorothiazide (Microzide) for control of hypertension. What health teaching will the nurse provide before the client begins therapy? A. "You may develop a slower pulse rate." B. "You may notice some swelling in your feet." C. "You may develop a nagging cough." D. "Your diet should include foods high in potassium."

ANS: D Rationale: Thiazide (low-ceiling) diuretics such as hydrochlorothiazide (HydroDIURIL, Microzide, Oretic, Urozide) inhibit sodium, chloride, and water reabsorption in the distal tubules while promoting potassium, bicarbonate, and magnesium excretion. This enhanced excretion can lead to hypokalemia. Oral intake of foods rich in potassium is an excellent way to replace lost potassium and maintain normal levels. If normal levels cannot be maintained through the intake of potassium-rich foods, the client will be prescribed oral potassium supplements. Hydrochlorothiazides (Microzide) have no direct influence on heart rate, but if the client becomes dehydrated due to diuretic use, the heart rate may increase as a compensatory mechanism. Clients receiving thiazide diuretics will likely experience a decrease in peripheral edema from the diuresis effect of the drug. The development of a nagging cough is most commonly associated with ACE inhibitors, not thiazide diuretics.

A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What health teaching will the nurse include before the client is discharged? A. "Take your pulse every day and call your doctor if it is below 60." B. "Weigh yourself every day in the morning using the same scale." C. "Purchase a home kit to monitor your blood pressure every day." D. "Avoid foods that are high in vitamin K, such as kale and spinach."

ANS: D Rationale: To help warfarin work effectively, it is important to instruct the client to keep his or her vitamin K intake as consistent as possible. Sudden increases in vitamin K intake may decrease the effect of warfarin. On the other hand, greatly lowering vitamin K intake could increase the effect of warfarin. Warfarin is an anticoagulant and does not increase or decrease the heart rate, so checking the pulse daily is not necessary with warfarin therapy. Warfarin does not cause fluid loss or retention, so daily weights are not necessary. Warfarin does not increase or decrease blood pressure.

"work of breathing"

An indicator of oxygenation and ventilation. Reflects the child's attempt to compensate for hypoxia.

During admission of a patient diagnosed with non-small cell carcinoma of the lung, the nurse questions the patient related to a history of which of the following risk factors for this type of cancer (select all that apply)? Asbestos exposure Cigarette smoking Exposure to uranium Chronic interstitial fibrosis Geographic area in which he was born

Asbestos exposure Cigarette smoking Exposure to uranium Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung.

splinting

Avoiding deep inspirations due to increased pain with breathing

Which of the following is NOT a risk factor for COPD? A. tobacco smoking B. excessive alcohol use C. exposure to chemicals D. being a coal miner

B

A client who works in a furniture factory reports that he is worried about his health because two co-workers have been diagnosed with sinus cancer in the past year. Which suggestion does the nurse make to reduce this client's risk for sinus cancer? A. Avoid the use of over-the-counter nasal sprays. B. Wear a fine particulate mask when working with wood. C. Spend as much time as possible outdoors, away from cities. D. Wear gloves when working with paint thinners and liquid glue.

B Rationale: Chronic exposure to fine particulates, especially wood dust, is associated with an increased incidence of nose and sinus cancer. Wearing a mask that blocks the inhalation of fine particulates can help reduce this exposure.

A client with moderate chronic obstructive pulmonary disease (COPD) is preparing to go home and has thrown away the information regarding smoking cessation. He states, "Why should I quit now after I have already caused this disease." What is the nurse's best response? A. "You are not responsible for this disease. It is a matter of a gene-environment interaction." B. "Choosing to quit smoking can slow the progression of COPD and make you feel better about yourself." C. "Blaming yourself is counterproductive and is likely to make your anxiety and depressive symptoms worse." D. "You shouldn't be so negative. After all, COPD is manageable, not like lung cancer."

B Rationale: Continuing to smoke causes continuing damage to the lung tissue, which worsens symptoms and increases the progression of the disease to the severe category, resulting in severe limitations in all of the client's activities. Slowing the progression of COPD can allow the client to continue to enjoy many activities and help him retain his independence as long as possible. Although smoking cessation is not an easy task, most people who are successful experience a greatly improved self-image.

At the hourly assessment of an intubated client after positive end-expiratory pressure (PEEP) has been discontinued, the nurse notes all of the following changes. For which one does the nurse notify the physician? A. The client is now talking around the endotracheal tube. B. Breath sounds are reduced over the left lung compared with the right. C. Oxygen saturation has increased from 90% to 95% at an FiO2 of 40%. D. The PIP dial now drops to zero at the end of exhalation instead of to only 10 cm H2O.

B Rationale: Reduced breath sounds over the left lung indicate that the endotracheal tube has probably slipped from the trachea into the right mainstem bronchus and needs to be repositioned. The other changes are either normal or an improvement.

A client with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What is the nurse's best action? A. Obtain a specimen for culture and test the urine for occult blood. B. Reassure the client that this is a normal drug side effect. C. Hold the dose and contact the health care provider. D. Document the report as the only action.

B Rationale: Rifampin normally turns urine an orange color. No intervention is needed; however, the color change can be very distressing to clients. The client should be reassured that this color change is normal and taught how to manage this change so that clothing does not become stained. No documentation of this normal side effect is needed.

Which technique or action does the nurse use to prevent tracheal stenosis in a client after a tracheotomy has been performed? A. Assessing breath sounds bilaterally every 2 hours B. Securing the tracheostomy tube in a midline position C. Holding the tube continually when changing the tracheostomy ties D. Suctioning the tracheostomy tube with as small a catheter as possible

B Rationale: Tracheal stenosis, a narrowed tracheal lumen, is the result of scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure.

How does atelectasis reduce gas exchange? A. Airway obstruction B. Reduced alveolar surface area C. Failure of pulmonary circulation to fully perfuse lung tissue D. Increased bronchial secretions filling the alveoli with fluid rather than with air

B Rationale: With atelectasis, some alveoli are collapsed. When alveoli collapse, the surface area is unavailable for gas exchange.

infants and children

have a shorter and narrower airway which puts them at risk for infection and greater change of obstruction, respiratory rate is 30-60 -take 8 years for their alveoli to develop -takes 5 months for smooth muscles to develop -takes 6 years for accessory muscles to develop

a 56 year old normally healthy pt is diagnosed with community-acquired pneumonia. before treatment is prescribed, the RN asks the pt about an allergy to: A. amoxicillin B. erythromycin C. sulfonamides D.cephalosporins

B.

The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/ml. How many milliliters should the nurse use to prepare the patient's dose? A. 0.2 B. 2.5 C. 3.75 D. 5.0

B. 5 mg ÷ 2 mg/ml = 2.5 ml

the RN is interpreting an tuberculin skin test for a pt with ESRD. which finding would indicate a postitive reaction? A. presence of redness at the injection site B. correct 11 mm area of induration at the TST injection site C. wheal and flare reaction at the injection site D. acid-fast bacilli cultures at the injection site

B. >5 mm for the immunocompromised, HIV+, and recent contact with active TB and +CXR. >10 mm for residents/employees at LTC, institutionalized, high risk (DM, ESRD), IV drug users, and recent immigrants (<5yr), and > 15mm general public without known risk factors

The nurse is evaluating whether a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? A. Place it in water to see if it floats. B. Keep track of the number of inhalations used. C. Shake the canister while holding it next to the ear. D. Check the indicator line on the side of the canister.

B. It is no longer appropriate to see if a canister floats in water or not since this is not accurate. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing when those inhalations have been used.

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state which of the following as the primary benefit? A. "I will pay less for medication because it will last longer." B. "More of the medication will get down into my lungs to help my breathing." C. "Now I will not need to breathe in as deeply when taking the inhaler medications." D. "This device will make it so much easier and faster to take my inhaled medications."

B. A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat.

The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 min B. 5 min C. 10 min D. 15 min

B. After obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

When caring for a patient with COPD, the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which of the following would be an appropriate intervention to add to the plan of care for this patient? A. Order fruits and fruit juices to be offered between meals. B. Order a high-calorie, high-protein diet with six small meals a day. C. Teach the patient to use frozen meals at home that can be microwaved. D. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

B. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, interfering with the work of breathing. Finally, the metabolism of a high carbohydrate diet yields large amounts of CO2, which may lead to acidosis in patients with pulmonary disease. For these reasons, the patient with COPD should take in a high-calorie, high-protein diet, eating six small meals per day.

When planning patient teaching about COPD, the nurse understands that the symptoms are caused by which of the following? A. An overproduction of the antiprotease a1-antitrypsin B. Hyperinflation of alveoli and destruction of alveolar walls C. Hypertrophy and hyperplasia of goblet cells in the bronchi D.Collapse and hypoventilation of the terminal respiratory unit

B. In COPD, there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity.

The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler. Which of the following instructions given by the nurse is most appropriate to help the patient learn proper inhalation technique? A. "Avoid shaking the inhaler before use." B. "Breathe out slowly before positioning the inhaler." C. "After taking a puff, hold the breath for 30 seconds before exhaling." D. "Using a spacer should be avoided for this type of medication."

B. It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose.

While teaching a patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to do which of the following? A. Use the flow meter each morning after taking medications to evaluate their effectiveness. B. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. C. Increase the doses of the long-term control medication if the peak flow numbers decrease. D. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

B. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter, and should be assessed before and after medications to evaluate their effectiveness.

Which of the following test results identifies that a patient with an asthma attack is responding to treatment? A. An increase in CO2 levels B. A decreased exhaled nitric oxide C. A decrease in white blood cell count D. An increase in serum bicarbonate levels

B. Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following? A. Hypertension and pulmonary edema B. Oropharyngeal candidiasis and hoarseness C. Elevation of blood glucose and calcium levels D. Adrenocortical dysfunction and hyperglycemia

B. Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

Which of the following tasks can the registered nurse (RN) delegate to nursing assistive personnel (NAP) in the care of a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure

B. Providing the individual has been trained in correct technique, NAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by an RN.

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following? A. Cough reflex B. Mucociliary clearance C. Reflex bronchoconstriction D. Ability to filter particles from the air

B. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.

A patient with acute exacerbation of COPD needs to receive precise amounts of oxygen. Which of the following types of equipment should the nurse prepare to use? A. Oxygen tent B. Venturi mask C. Nasal cannula D. Partial nonrebreather mask

B. The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.

After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for am

B. The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be affected by the administration of antibiotics.

The nurse is scheduled to give a dose of salmeterol by metered dose inhaler (MDI). The nurse would administer the right drug by selecting the inhaler with which of the following trade names? A. Vanceril B. Serevent C. AeroBid D. Atrovent

B. The trade or brand name for salmeterol, an adrenergic bronchodilator, is Serevent.

When obtaining a sputum specimen for culture and gram stain, the RN should draw: A. in the evening B. before beginning antibiotic therapy C. only one culture specimen D. after starting antibiotic therapy

B. sputum cultures should be drawn in the AM before eating/drinking, BEFORE beginning antibiotic therapy, should draw 2 cultures specimens from two different sites

A patient's pulse ox is 89%. What is the nurse's priority action? A. Recheck the reading with a different oximeter. B. Apply supplemental oxygen and recheck in 15 minutes. C. Assess the patient for respiratory distress and recheck. D. Place the patient in the recovery position and recheck.

C

wheezes

high pitched musical sounds heard during inspiration and expiration caused by air flowing through narrowed airways

While inspecting a patient's chest, the nurse observes an anteroposterior diameter of the chest. When is this an expected finding? A. With a pulmonary mass B. Upon deep inhalation C. In older adult patients D. With chest trauma

C

Your patient is using accessory muscles to breathe. Which of the following is NOT considered an accessory muscle? A. Scalene muscles B. Sternocleidomastoid muscles C. Diaphragmatic muscles D. Trapezius muscles

C

Which assessment finding in a client with an endotracheal tube most strongly indicates to the nurse that the tube remains correctly in the trachea and is not in the esophagus? A. Stomach contents cannot be aspirated. B. Oxygen saturation is greater than 50%. C. End-tidal carbon dioxide level is 38 mm Hg. D. No air is heard in the stomach when auscultated with a stethoscope.

C Rationale: The end-tidal carbon dioxide level is normal. If the endotracheal tube was in the esophagus or stomach rather than the trachea, it would be very low. The lack of aspiration of stomach contents is not conclusive for correct placement and neither is the fact that air cannot be heard in the stomach.

A client with leukoplakia just above the glottis has just received the results of a biopsy and is confirmed to have squamous cell carcinoma in situ. She begins to cry and says that she would not be able to stand a surgery that would take away her ability to speak. What is the nurse's best response? A. "Your loss of speech would only be temporary until you learned to use esophageal speech." B. "Cancers at this stage are usually treated with chemotherapy alone, which does not permanently affect your ability to speak." C. "Cancers at this stage are usually treated with radiation therapy, which does not permanently affect your ability to speak." D. "A speech and language pathologist will work with you to select the method of communication that fits your lifestyle best."

C Rationale: Early-stage cancers often can be managed with less radical surgery, such as radiation therapy, that spares the vocal cords. With intact vocal cords, the client can usually speak, although the tone or timbre of the voice may be somewhat altered.

Which action does the nurse take to prevent hypoxia in a client during nasotracheal suctioning? A. Measuring pulse oximetry throughout the procedure B. Inserting the suction catheter through the vocal cords only when the client exhales C. Administering 100% oxygen by manual resuscitation bag before initiating suctioning D. Removing the suction tube from the nasopharynx as soon as the client begins to cough

C Rationale: Hyperoxygenating the client before the procedure helps to prevent hypoxia. Although measuring pulse oximetry throughout the procedure can help identify when hypoxia is occurring, it does not prevent the complication.

Which assessment finding indicates to the nurse that the client with chronic obstructive pulmonary disease (COPD) needs to be suctioned? A. Documentation indicates the client was last suctioned 12 hours ago. B. The client is unable to speak more than six words without clearing the throat. C. Although the client is coughing, breath sounds indicate continued presence of secretions in the airways. D. The oxygen saturation, as measured by pulse oximetry, decreases while the client performs controlled coughing.

C Rationale: Suctioning is only performed when needed, not on a routine basis. The client who needs suction is one whose cough is too weak to clear secretions effectively. This problem is identified by breath sounds that indicate the presence of secretions in the airways after the client has coughed.

A 6-foot, 6-inch tall 38-year-old man is being mechanically ventilated at a tidal volume of 500 mL and a respiratory rate of 16 breaths per minute. His most recent arterial blood gas (ABG) results are: pH = 7.33; PaO2 = 85 mm Hg; PaCO2 = 55 mm Hg. What is the nurse's interpretation of these results? A. Ventilation is adequate to maintain oxygenation. B. Ventilation is excessive; respiratory alkalosis is present. C. Ventilation is inadequate; respiratory acidosis is present. D. Ventilation status cannot be determined from the information presented.

C Rationale: The average-size adult has a normal tidal volume of 500 mL, and 18 breaths per minute is toward the upper end of normal for respiratory rate. However, at 6 feet, 6 inches tall, this man would have a much larger tidal volume (perhaps as high as 750 to 900 mL). The settings of the ventilator are underventilating him, causing respiratory acidosis.

stridor

high pitched, crowing sound heard on inspiration. indicated airway obstruction

In performing a chest assessment, the nurse observes or determines all of the following findings in a 70-year-old client. Which finding indicates to the nurse that the client may have an increased residual lung volume? A. Exhalation is twice as long as inhalation. B. Breath sounds are absent at the lung edges. C. The intercostal spaces measure 4 centimeters. D. Vibrations can be felt on the chest wall when the client speaks.

C Rationale: The expected distance between the ribs is the width of the client's fingerbreadth, or about 2 centimeters. Distances greater than this are abnormal and usually indicate some degree of air trapping that causes an increased residual lung volume.

The client, in a panicky voice, tells the nurse during a thoracentesis that he feels as if he is being pushed off the table. What is the nurse's best response? A. Stop the procedure to administer an anxiety-reducing drug. B. Remind the client not to talk or breathe during the procedure. C. Reassure the client this is a normal sensation as the needle is inserted into the chest cavity. D. Relay this information to the health care provider performing the procedure so that the needle can be repositioned.

C Rationale: The tissues of the thorax can be thick, and significant pressure may need to be applied to insert the needle. The client can indeed feel as though he is being pushed. This is a normal sensation and does not indicate a problem. Reassure the client first, then remind him not to move.

the RN anticipates intubation and mechanical ventilation for the pt in status asthmaticus when: A. the PaCO2 is 60 mmHg B. the PaO2 decreases to 70 mmHg C. severe respiratory muscle fatigue occurs D. the pt has extreme anxiety and fear of suffocation

C.

the RN's highest priority task when caring for a pt diagnosed with bacterial pneumonia, before beginning the prescribed antibiotic: A. teach the pt to cough and deep breathe B. take the temp, pulse, and RR C.obtain a sputum specimen for culture and gram stain D. check the pt's O2 saturation by pulse oximetry

C.

the RN interprets an induration of 5 mm resulting from tuberculin skin testing as a positive finding in: A. pts at low risk for TB B. immigrants arriving within the past 5 years from high-prevalence countries C. a pt with a 5 year history of HIV infection D. individuals with a chronic condition such as DM, cancer, or ESRD

C. (d/t decreased immune system)

Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

C. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which of the following findings? A. Absence of dyspnea B. Improved mental status C. Effective and productive coughing D. PaO2 within normal range for the patient

C. Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A. Continue with ambulation since this is a normal response to activity. B. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

C. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen.

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring which of the following patient parameters? A. Apical pulse B. Bowel sounds C. Intake and output D. Deep tendon reflexes

C. Corticosteroids such as prednisone can lead to fluid retention. For this reason, it is important to monitor the patient's intake and output.

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which of the following assessment findings? A. Decreased respiratory rate B. Increased respiratory rate C. Increased peak flow readings D. Decreased sputum production

C. Ipratropium is a bronchodilator that should lead to increased peak expiratory flow rates (PEFRs).

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I will increase my food intake to 2400 calories a day to keep my immune system well." C. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." D. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."

C. It is important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below normal.

During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes? A. Laryngospasm B. Pulmonary Edema C. Narrowing of the airway D. overdistention of the alveoli

C. Narrowing of the airway leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing.

The client is a 62-year-old man who has smoked one pack of cigarettes per day from the time he was 13 years old until he was 19 and then smoked two packs of cigarettes per day from age 19 to the present. How should the nurse calculate this client's pack-year smoking history? A. 62 pack-years B. 55 pack-years C. 92 pack-years D. 99 pack-years

C. Rationale: Smoking history is documented in pack-years (Number of packs per day smoked × Number of years the client has smoked). Ages 13 to 19 is 6 years × 1 pack per days = 6 pack years. From ages 19 to 62 is 43 years × 2 packs per day = 86 pack years. 6 + 86 = 92.

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment? A. Intravenous fluids B. Biofeedback therapy C. Systemic corticosteroids D. Pulmonary function testing

C. Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient.

The nurse reviews pursed lip breathing with a patient newly diagnosed with COPD. The nurse reinforces that this technique will assist respiration by which of the following mechanisms? A. Loosening secretions so that they may be coughed up more easily B. Promoting maximal inhalation for better oxygenation of the lungs C. Preventing bronchial collapse and air trapping in the lungs during exhalation D. Increasing the respiratory rate and giving the patient control of respiratory patterns

C. The focus of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation.

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Allow time to calm the patient. B. Observe for signs of diaphoresis. C. Evaluate the use of intercostal muscles. D. Monitor the patient for bilateral chest expansion.

C. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient.

Which of the following positions is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? A. Supine B. Lithotomy C. High Fowler's D. Reverse Trendelenburg

C. The patient experiencing an asthma attack should be placed in high Fowler's position to allow for optimal chest expansion and enlist the aid of gravity during inspiration.

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode? A. New onset of angina pectoris B. Septic embolus from the knee joint C. Pulmonary embolus from deep vein thrombosis D. Pleural effusion related to positioning in the operating room

C. The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.

During discharge teaching for a 65-year-old patient with COPD and pneumonia, which of the following vaccines should the nurse recommend that this patient receive? A. a. Staphylococcus aureus B. Haemophilus influenzae C. Pneumococcal D. Bacille-Calmette-Guérin (BCG)

C. The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.

Which of the following is the priority nursing assessment in the care of a patient who has a tracheostomy? A. Electrolyte levels and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

C. The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

The nurse is scheduled to give a dose of ipratropium bromide by metered dose inhaler. The nurse would administer the right drug by selecting the inhaler with which of the following trade names? A. Vanceril B. AeroBid C. Atrovent D. Pulmicort

C. The trade or brand name for ipratropium bromide, an anticholinergic medication, is Atrovent.

Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on right side B. Maintaining adequate fluid intake C. Positioning patient with "good lung down" D. Performing postural drainage every 4 hours

C. Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation is patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

exhalation

CO2 leaves the body

Which diagnostic test has the highest risk for the post-procedure complication of pneumothorax? A. Bronchoscopy B. Laryngoscopy C. CT of the lungs D. Percutaneous lung biopsy

D

For what reason is pandemic influenza a bigger health threat than seasonal influenza? A. No vaccines are available for immunization to prevent pandemic influenza. B. Unlike seasonal influenza, pandemic influenza does not respond to antibiotics. C. Seasonal influenza viruses are killed by exposure to heat, and pandemic viruses are not. D. Pandemic influenzas began from animal viruses, and humans have no natural immunity to them.

D Rationale: A new avian virus is the H5N1 strain, known as "avian influenza" or "bird flu," that has infected millions of birds, especially in Asia, and now has started to spread by human-to-human contact. World health officials are concerned that this strain could become a pandemic because humans have essentially no naturally occurring immunity to this virus. Therefore the infection could lead to a worldwide pandemic with very high mortality rates. There is a stockpiled vaccine for this viral strain. No viral disease responds to (is killed by) antibiotics.

Which nursing action has the highest priority when caring for a client with facial trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway

D Rationale: Facial trauma has the potential to interfere with breathing by occluding the upper airways. This can occur from swelling, tissue displacement, bleeding, emesis, or as a response to therapy. Maintaining a patent airway remains a nursing priority until the trauma has healed.

The 60-year-old client's smoking history includes smoking 2 packs of cigarettes per day since the age of 15 until the age of 40, and then smoking 3 packs per day to the present. How does the nurse document this smoking history? A. 45 pack-years B. 80 pack-years C. 90 pack-years D. 110 pack-years

D Rationale: Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). Ages 15 to 40 is 25 years × 2 packs per day = 50 pack-years. From ages 40 to 60 is 20 years × 3 packs per day = 60 pack years. 50 + 60 = 110.

The client with severe dyspnea has all of the following ABG results. Which one does the nurse report immediately to the health care provider? A. pH = 7.18 B. HCO3 = 31 mEq/L C. PaCO2 = 68 mm Hg D. PaO2 = 68 mm Hg

D Rationale: The elevated carbon dioxide level, or hypercarbia, is expected and not really that high for someone with COPD. The elevated bicarbonate level demonstrates kidney compensation. The low arterial oxygen level (hypoxemia) is a cause for concern and may indicate a sudden worsening of the client's condition.

A client who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report immediately to the prescriber? A. Activated partial thromboplastin time 1.5 B. International normalized ratio 1.7 C. Red blood cells 4.2 million/mm3 D. Platelets 20,000/mm3

D Rationale: The normal range for platelets is 200,000 to 400,000/mm3. Platelets are needed for blood clotting. This client's platelet count is extremely low and he or she is at grave risk for severe bleeding. The low platelet count is an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued and the client needs to receive platelet therapy before life-threatening hemorrhage occurs.

The spouse of a client who has had a partial vertical laryngectomy is working with the client to use the supraglottic method of swallowing. Which direction given by the spouse to the client indicates to the nurse that more instruction is needed? A. Sit up as straight as you can when eating. B. Clear your throat before taking a bite of food. C. Only take just a teaspoonful of food at one time. D. Swallow once, then take a breath, and swallow again.

D Rationale: The supraglottic swallowing method follows this sequence: -Sitting in an upright, preferably out-of-bed, position -Clearing the throat -Taking a deep breath -Placing a small amount of food into the mouth -Holding the breath, or "bearing down" (Valsalva maneuver) -Swallowing twice -Releasing the breath and clearing the throat -Swallowing twice again -Breathing normally

Which of the following is not a priority problem for someone with head or neck cancer? A. Potential for respiratory obstruction B. Risk for aspiration C. Anxiety D. Risk for skin breakdown E. Reduced self-concept

D.

an older adult pt is admitted to the hospital with a diagnosis of pneumococcal pneumonia. which clinical manifestation indicates the pt is hypoxic? A. oral temp is 102.3 degrees F B. presence of pleuritic chest pain C. coarse crackles in lung bases D. sudden onset of confusion

D.

during the assessment of a pt with pneumonia, the RN suspects the development of a pleural effusion upon finding: A. a barrel chest B. paradoxical respirations C. hyperresonance on percussion D. localized absence of breath sounds

D.

the RN teaches a pt how to administer fluticasone (Flovent HFA) by metered dose inhaler (MDI). which statement by the pt indcates an understanding about the instructions? A. my breathing will improve slowly over the next 2-3 days B. a spacer is used with this inhaler to prevent mouth dryness C. I should use this inhaler immediately if I have trouble breathing D. It is important to remember to rinse my mouth after using this inhaler.

D.

Which lab assessment is least helpful in diagnosing COPD? A. ABGs B. HGB & HCT C. Chest x-ray D. Methylcholine challenge

D. (That'd be the best way to piss off someone with COPD)

The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 1 mg/ml. How many milliliters should the nurse use to prepare the patient's dose? A. 0.2 B. 2.5 C. 3.75 D. 5.0

D. 5 mg ÷ 1 mg/ml = 5 ml

Which of the following is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able B. Administer cough suppressant q4hr C. Teach patient to splint the affected area D. Increase fluid intake to 3 L/day if tolerated

D. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A. Perform a comprehensive health history with the patient to review prior respiratory problems. B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion. B.Spinal curvatures. C. The respiratory pattern. D. The fingernails and their base

D. Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

Nursing assessment findings of jugular vein distention and pedal edema would be indicative of which of the following complications of emphysema? A. Acute respiratory failure B. Secondary respiratory infection C. Pulmonary edema caused by left-sided heart failure D. Fluid volume excess resulting from cor pulmonale

D. Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. Which of the following would be the most appropriate response by the nurse? A. "Long-term home oxygen therapy should be used to prevent respiratory failure." B. "Oxygen will not be needed until or unless you are in the terminal stages of this disease." C. "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." D. "Oxygen will be needed when your oxygen saturation drops to 88% and you have symptoms of hypoxia."

D. Long-term oxygen therapy in the home should be considered when the oxygen saturation is ≤88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, the primary care provider is likely to order a: A. Thoracentesis. B. Pulmonary angiogram. C. CT scan of the patient's chest. D. Positron emission tomography (PET).

D. PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses an IV radioactive glucose preparation, can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

Which of the following statements made by a patient with COPD indicates a need for further teaching regarding the use of an ipratropium inhaler? A. "I should rinse my mouth following the two puffs to get rid of the bad taste." B. "I should wait at least 1 to 2 minutes between each puff of the inhaler." C. "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." D. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

D. The patient should not take extra puffs of the inhaler at will to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status.

The nurse is assisting a patient to learn self-administration of beclomethasone two puffs inhalation every 6 hours. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques? A. Chew a hard candy before the first puff of medication. B. Rinse the mouth with water before each puff of medication. C. Ask for a breath mint following the second puff of medication. D. Rinse the mouth with water following the second puff of medication.

D. The patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

Before discharge, the nurse discusses activity levels with a 61-year-old patient with COPD and pneumonia. Which of the following exercise goals is most appropriate once the patient is fully recovered from this episode of illness? A. Slightly increase activity over the current level. B. Swim for 10 min/day, gradually increasing to 30 min/day. C. Limit exercise to activities of daily living to conserve energy. D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

D. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate <75% to 80% of maximum heart rate (220 - patient's age).

In the case scenario in question 146 above, which of the following actions should the nurse take first? A. Notify the physician. B. Administer a nitroglycerine tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

D. The patient's clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.

kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body (DKA)

Loss of lung elasticity and hyperinflation of the lung is indicative of ____.

Emphysema

nasal flaring

Enlargement of nostrils with breathing (sign of respiratory distress)

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for which of the following potential triggers (select all that apply)? Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections

Exercise Allergies Emotional stress Upper respiratory infections Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD)

tachypnea

Increased breathing rate

To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to do which of the following (select all that apply)? Maintain adequate fluid intake Splint the chest when coughing Maintain a high Fowler's position Maintain a semi-Fowler's position Instruct patient to cough at end of exhalation

Maintain adequate fluid intake Splint the chest when coughing Maintain a high Fowler's position Instruct patient to cough at end of exhalation The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which of the following risk factors (select all that apply)? Obesity Pneumonia Hypertension Cigarette smoking Recent long distance travel

Obesity Hypertension Cigarette smoking Recent long distance travel

Which precaution is most important for the nurse to teach a client with leukemia to prevent an infection by autocontamination? A. Take antibiotics exactly as prescribed. B. Perform mouth care three times daily. C. Avoid the use of pepper and raw foods. D. Report any burning on urination immediately.

Rationale: Autocontamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Performing frequent mouth care can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from autocontamination. Taking antibiotics does not prevent autocontamination, nor does reporting symptoms of an infection. Avoiding exposure to environmental organisms does not prevent autocontamination.

The nurse is caring for a client with peripheral arterial disease. Which statement made by the client concerning positioning of edematous lower extremities requires further health teaching? A. "I can sleep with my affected leg hanging from the bed." B. "I will elevate my legs above the level of my heart." C. "I can sit upright in a chair for comfort." D. "I will avoid crossing my legs at all times."

Rationale: The nurse should teach the client to avoid raising the legs above the heart level because extreme elevation slows arterial blood flow to the feet. In severe cases, clients with PAD and swelling may sleep with the affected leg hanging from the bed or sit upright in a chair for comfort. Clients with PAD should avoid crossing the legs and should avoid wearing restrictive clothing (e.g., garters to hold up nylon stockings, particularly common among older women), which interfere with blood flow.

shallow respirations

Respirations that are charcterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.

accessory muscle use

The use of muscles not normally used for breathing (indicates respiratory distress).

barrel chested

Thin barrel chested appearance from chronic air trapping in alveoli causing the anterior -posterior diameter of the chest to increase

Your 20 year old patient's hobbies include making resin-cast jewelry and cooking meth. What education should you give him about how to protect himself against future lung issues?

Wear a mask. Don't smoke the meth, or anything else. Provide adequate ventilation when casting your jewelry.

unproductive cough

a cough that does not produce sputum

productive cough

a cough that is effective at bringing up sputum

cheyne-stokes respirations

a pattern of alternating periods of hypopnea or apnea, followed by hyperpnea

In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the client states: a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "Insulin dosage will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months." d. "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding."

a. "I will need to increase my insulin dosage during the first 3 months of pregnancy."

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that: a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b. Hydramnios occurs approximately twice as often in diabetic pregnancies. c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. d. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.

When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient: a. Eat six saltine crackers. b. Drink 8 oz of orange juice with 2 tsp of sugar added. c. Drink 4 oz of orange juice followed by 8 oz of milk. d. Eat hard candy or commercial glucose wafers.

a. Eat six saltine crackers.

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia b. Hypercalcemia c. Hypobilirubinemia d. Hypoinsulinemia

a. Hypoglycemia

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: a. Macrosomia. b. Congenital anomalies of the central nervous system. c. Preterm birth. d. Low birth weight.

a. Macrosomia.

orthopnea

ability to breathe only in an upright position

apnea

absence of breathing

Ipratropium bromide (Atrovent)

anticholinergic drug, maintenance therapy NOT rescue

With oxygen therapy, monitor..

arterial blood gas (ABG) values and oxygen sats

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a. Frequent episodes of maternal hypoglycemia. b. Congenital anomalies in the fetus. c. Polyhydramnios. d. Hyperemesis gravidarum.

b. Congenital anomalies in the fetus.

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time? a. Deficient fluid volume b. Imbalanced nutrition: less than body requirements c. Imbalanced nutrition: more than body requirements d. Disturbed sleep pattern

b. Imbalanced nutrition: less than body requirements

An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than about her recent diagnosis of diabetes. Several nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is: a. Risk for injury to the fetus related to birth trauma. b. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan. c. Deficient knowledge related to insulin administration. d. Risk for injury to the mother related to hypoglycemia or hyperglycemia.

b. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan.

Maternal phenylketonuria (PKU) is an important health concern during pregnancy because: a. It is a recognized cause of preterm labor. b. The fetus may develop neurologic problems. c. A pregnant woman is more likely to die without dietary control. d. Women with PKU are usually retarded and should not reproduce.

b. The fetus may develop neurologic problems.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d. At birth the neonate of a diabetic mother is no longer in any risk.

b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations.

In terms of the incidence and classification of diabetes, maternity nurses should know that: a. Type 1 diabetes is most common. b. Type 2 diabetes often goes undiagnosed. c. Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth. d. Type 1 diabetes may become type 2 during pregnancy.

b. Type 2 diabetes often goes undiagnosed.

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply. Bakers Coal miners Electricians Furniture refinishers Plumbers Potters

bakers (flour), coal miners (coal dust), furniture refinishers (chemicals), and potters (silica dust)

COPD characteristics

barrel chest, slow moving, out of breath, slightly stooped, rapid, shallow respirations, fatigue, finger clubbing, cyanosis, edema, using accessory muscles in breathing, excess CO2, wheezing and crackles

hempotysis

bloody respiratory secretions

cyanosis

bluish color often around the mouth

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.

c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by: a. Eating six small equal meals per day. b. Reducing carbohydrates in her diet. c. Eating her meals and snacks on a fixed schedule. d. Increasing her consumption of protein.

c. Eating her meals and snacks on a fixed schedule.

Which factor is known to increase the risk of gestational diabetes mellitus? a. Underweight before pregnancy b. Maternal age younger than 25 years c. Previous birth of large infant d. Previous diagnosis of type 2 diabetes mellitus

c. Previous birth of large infant

Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin: a. Increases throughout pregnancy and the postpartum period. b. Decreases throughout pregnancy and the postpartum period. c. Varies depending on the stage of gestation. d. Should not change because the fetus produces its own insulin.

c. Varies depending on the stage of gestation.

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: a. Is now done for all pregnant women, not just those with or likely to have diabetes. b. Is a snapshot of glucose control at the moment. c. Would be considered evidence of good diabetes control with a result of 5% to 6%. d. Is done on the patient's urine, not her blood.

c. Would be considered evidence of good diabetes control with a result of 5% to 6%.

parathyroid controls

calcium levels

chest wall retrations

caused by reduced air pressure inside the chest

elderly

chest wall becomes stiffer, respiratory muscles become weaker/ reduces effectiveness of coughing and immune system decreases

Asthma

chronic inflammatory disorder characterized by episodic airflow obstruction and inflammation

tracheal deviation

clinical sign that results from unequal intrathoracic pressure within the chest cavity.

rhonchi

continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions; most prominent on expiration; change often evident after coughing or suctioning.

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)? a. 75 mg/dL before lunch. This is low; better eat now. b. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time. c. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin. d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: a. Mother's age. b. Number of years since diabetes was diagnosed. c. Amount of insulin required prenatally. d. Degree of glycemic control during pregnancy.

d. Degree of glycemic control during pregnancy.

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include: a. A regular heart rate and hypertension. b. An increased urinary output, tachycardia, and dry cough. c. Shortness of breath, bradycardia, and hypertension. d. Dyspnea; crackles; and an irregular, weak pulse.

d. Dyspnea; crackles; and an irregular, weak pulse.

Glucose metabolism is profoundly affected during pregnancy because: a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b. The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman. c. The pregnant woman increases her dietary intake significantly. d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? Select all that apply. Encourage frequent sipping from a cup. Encourage water with meals. Inflate the tracheostomy cuff during meals. Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow.

maintain the client upright for 30 min after eating (30 minutes is required for thinner liquids in the stomach to be thickened), provide small frequent meals (to decrease energy expended, as aspiration is more common when a client is tired), and teach the client to 'tuck' the chin down in the forward position to swallow (which opens the upper esophageal sphincter). the trach cuff should be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

Theo-dur

maintenance, take once a day, 1 hour before or 2 hours after a meal, bronchodilator, long acting, slow release side effects: irritability, nervousness, insomnia

nail clubbing

nail base angle increases and approaches or exceeds 180 degrees caused by low oxygenation

anoxia

no oxygen

interview

nurse asks patient to describe when they have symptoms

auscultation

nurse hears crackles in the left lung using a stethescope

palpation

nurse places their hands over the left lung to feel for vibrations

COPD

obstruction of airflow (chronic bronchitis and emphysema)

Your patient is irritable, complains of feeling tired despite sleeping all night, and says his wife makes him sleep on the couch because he snores so loud. He is obese and has enlarged adenoids related to seasonal allergies. What might his deal be?

obstructive sleep apnea

pneumothorax

partial or complete collapse of lung in which air or gas enters the pleural space

tracheostomy

placed for someone who can't breath well from obstructions, secretions, edema, or foreign matter Interventions: assess, monitor, suction

diagnostics

pulse oximetry, arterial blood gases (ABG), complete blood count, sputum studies, pulmonary function test, chest xrays, bronchoscopy

hypoxemia

reduced oxygenation in the blood

Albuterol inhaler

rescue, fast onset, bronchodilator side effects: tachycardia, palpitations, n/v, anxiety, irritability, hypertension

bradypnea

slow breathing rate

with atelectasis..

some alveoli are collapsed and the surface area is unavailable for gas exchange

Perfusion

the actual movement of air across the alveolar membrane (O2 and CO2) (problems from blood clots and plaque build up)

hypoxia is when

the cells do not have enough oxygen

Ventilation

the movement of air from the outside tot he inside (problems from obstruction, inflammation and mucous)

inspection

the nurse examines the clients use of accessory muscles during inspiration

Percussion

the nurse taps on the clients lung field and evaluates the sound

gas exchange

the process by which oxygen is transported to cells and carbon dioxide is transported to cells

parathyroidectomy monitor for

thyroid storm and hypocalcemia

the most preventable cause of death

tobacco use

Pulmicort

used to decrease or prevent the respiratory tissue response to the inflammatory process, used for long term management of asthma, gargle and rinse after each use to prevent thrush side effects: dry, irritate throat, hoarseness, bad taste in mouth, runny nose or nose bleeds

normal breathing sounds auscultated throughout most of the lung fields that are soft and low pitched

vesicular (rustling sound from air moving over small airways)