NUR356 Exam 3 Review Questions

What are the 3 main causes of anemia? (Select all that apply). 1.Blood loss 2.Impaired red blood cell (RBC) production 3.Impaired white blood cell (WBC) production 4.Increased red blood cell (RBC) destruction 5.Increased white blood cell (WBC) destruction

1.Blood loss 2.Impaired red blood cell (RBC) production 4.Increased red blood cell (RBC) destruction Rationale: Anemia is a deficiency in the number of erythrocytes (red blood cells [RBCs]), the quantity or quality of hemoglobin (Hgb), and/or volume of packed RBCs (hematocrit). Anemia is not a specific disease but is a manifestation of a pathologic process. It is a common condition with many diverse causes. These include blood loss, impaired RBC production, or increased RBC destruction.

What are the 3 major functions of blood? (Select all that apply). 1.Transport 2.Metabolism 3.Excretion 4.Regulation 5.Protection

1.Transport 4.Regulation 5.Protection Rationale: Blood is a type of connective tissue. It has 3 major functions: transportation, regulation, and protection. Metabolism and excretion are not major functions of blood.

A cltient with a history of chronic heart failure is hospitalized with severe dyspnea and a dry, hacking cough. Assessment findings include pitting edema in both ankles, BP 170/100 mm Hg, pulse 92 beats/minute, and respirations 28 breaths/minute. Which explanation, if made by the nurse, is most accurate? 1."The assessment indicates that venous return to the heart is impaired, causing a decrease in cardiac output." 2."The manifestations indicate impaired emptying of both the right and left ventricles, with decreased forward blood flow." 3."The myocardium is not receiving enough blood supply through the coronary arteries to meet its oxygen demand." 4."The patient's right side of the heart is failing to pump enough blood to the lungs to provide systemic oxygenation."

2."The manifestations indicate impaired emptying of both the right and left ventricles, with decreased forward blood flow." Rationale: The patient is experiencing acute decompensated heart failure with symptoms of both right- and left-sided heart failure. Left-sided heart failure prevents normal, forward blood flow and causes pulmonary congestion. Right-sided heart failure causes a backup of blood and results in venous congestion

A client with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these drugs? 1.Observe skin turgor 2.Auscultate lung sounds 3.Measure blood pressure 4.Review intake and output

2.Auscultate lung sounds Rationale: Left-sided heart failure will prevent normal blood flow and will cause blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium and then the alveoli, which manifests as pulmonary congestion and edema. The most important assessment to determine if the drugs are improving the patient's condition is to auscultate lung sounds. The other assessments are important, but the best indicator of improvement of left ventricular function is a reduction in adventitious lung sounds (crackles).

The home care nurse visits a client with chronic heart failure who is taking digoxin (Lanoxin) and furosemide (Lasix). The client complains of nausea and vomiting. Which action is most appropriate for the nurse to take? 1.Perform a dipstick urine test for protein. 2.Notify the health care provider immediately. 3.Have the client eat foods high in potassium. 4.Ask the client to record a weight every morning.

2.Notify the health care provider immediately. Rationale: Administration of furosemide increases excretion of potassium and may cause hypokalemia. The risk for digitalis toxicity increases if potassium levels are below normal and digoxin is administered. Signs and symptoms of digitalis toxicity include anorexia, nausea and vomiting, visual disturbances (such as "yellow" vision), and dysrhythmias.

What are the anticipated clinical manifestations of a 40% acute blood loss? 1.Shock, lactic acidosis, and potential death. 2.No detectable signs or symptoms at rest. ↑ HR with exercise and slight postural hypotension. 3.BP, central venous pressure, and cardiac output below normal at rest. 4.Normal supine BP and pulse at rest. Postural hypotension and ↑ HR with exercise

3.BP, central venous pressure, and cardiac output below normal at rest. Rationale: Clinical manifestations of blood loss are caused by the body's attempts to maintain adequate blood volume and meet oxygen requirements. As per the chart, losing 40% (equivalent to 2000mL) would cause: BP, central venous pressure, and cardiac output below normal at rest. 10%: 500 mL: None or rare vasovagal syncope. 20%: 1000 mL: No detectable signs or symptoms at rest. ↑ HR with exercise and slight postural hypotension. 30%: 1500 mL: Normal supine BP and pulse at rest. Postural hypotension and ↑ HR with exercise. 40%: 2000 mL: BP, central venous pressure, and cardiac output below normal at rest; air hunger; rapid, thready pulse and cold, clammy skin. 50%: 2500 mL: Shock, lactic acidosis, and potential death.

A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? A. This is a side effect of therapy B. He probably has an upper respiratory infection C. He needs to have his blood counts checked D. A chest x-ray is required because the cough is a sign of heart failure

A. This is a side effect of therapy Rationale: One common side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is a persistent dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the health care provider if the cough becomes troublesome to them. The cough is reversible with discontinuation of the therapy. The other options are incorrect interpretations of the client's complaint.

Which order should the nurse question regarding oxygen therapy? A.10L via nasal cannula B.15L via 100% Non-rebreather C.6 L via simple mask D.3 L via nasal cannula

A.10L via nasal cannula Rationale: Nasal cannulas should only be set up to a maximum concentration of 6 L. All the other concentrations are ordered correctly for the specific oxygen delivery device.

A client with a recent diagnosis of DVT has sudden shortness of breath and chest pain that increases with a deep breath. The nurse should first... A.Assess the oxygen saturation B.Call the healthcare provider C.Administer morphine sulfate 2mg IV D.Perform range of motion exercises in the involved leg

A.Assess the oxygen saturation Rationale: Most pulmonary emboli (PEs) arise from deep vein thrombosis (DVT) in the deep veins of the legs. The thrombus may detach and result in an embolus that flows through the venous circulation to the heart and legs in the pulmonary circulation becoming a PE. Dyspnea is the most common presenting symptom in clients with PE.

A nurse is completing a respiratory assessment on a newly admitted 65-year-old client. What information would be considered subjective data? SATA A.Clients' past medical history, including surgeries and current job description. B.Client complaints of increased SOB when getting dressed and cutting the grass. C.Respirations 14 bpm, regular, non-labored. D.Smoking 15-20 cigarettes everyday, since 15 years of age. E.Chest clear with no adventitious sounds. F.O2 sats at 98% on room air.

A.Clients' past medical history, including surgeries and current job description. B.Client complaints of increased SOB when getting dressed and cutting the grass. D.Smoking 15-20 cigarettes everyday, since 15 years of age. Rationale: Subjective data includes information obtained through interview. This includes information regarding the clients PMHx including surgeries and occupational hazards (A), activity (B) medications, including-licit and illicit drug use (smoking) (D). Obtaining information regarding the client's respiratory rate, rhythm and lung sound characteristics are included in the physical assessment (C, E, F).

A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement? (Select all that apply). A.Elevating the foot of the bed 6 inches (15 cm) B.Placing ice packs on and under the right leg C.Documenting the need for hourly calf measurements D.Have patient placed on strict bed rest E.Performing passive range-of-motion exercises of the right leg

A.Elevating the foot of the bed 6 inches (15 cm) E.Performing passive range-of-motion exercises of the right leg Rationale: For clients with acute VTE with severe edema and limb pain, bed rest with limb elevation will initially be prescribed. A.Elevating the foot of the bed 6 inches (15 cm) - Yes! B.Placing ice packs on and under the right leg - no! increases vasoconstriction C.Documenting the need for hourly calf measurements - not needed hourly D.Have patient placed on strict bed rest - Yes! E.Performing passive range-of-motion exercises of the right leg - no, may disrupt the clot.

The nurse is providing teaching about home care to the guardian of a child who has hemophilia. Which of the following pieces of information should the nurse provide? A.Encourage the child to participate in non-contact sports. B.Provide the adolescent with a firm-bristled toothbrush. C.Administer aspirin to the adolescent for episodes of pain. D.Provide disposable razors to the adolescent for shaving.

A.Encourage the child to participate in non-contact sports. Rationale: The nurse should instruct the guardian that the adolescent should be allowed to participate in non-contact sports, such as walking, swimming, bowling and golf. Contact sports should be discouraged. If the adolescent is adamant of playing contact sports, the adolescent must wear protective gear and receive routine recombinant Factor-8 infusions.

A nurse is caring for a client who has a deep vein thrombosis (DVT) and has been taking unfractionated heparin (enoxaparin (Lovenox®)) for one week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the follow statements should the nurse give? A."I will remind your provider that you are already receiving heparin" B."Your laboratory findings indicated that two anticoagulants were needed" C.It takes 3-4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued" D."Only one of these medications is being given to treat your DVT"

A.It takes 3-4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued"

A nurse in the clinic is caring for a client whose partner states the client woke up this morning , did not recognize him, an did not know where she was. The client reports chills and chest pain that is worse on inspiration. Which of the following action is the nurse's priority? A.Obtain baseline vitals and oxygen saturation B.Obtain past medical history form the client C.Provide a pneumococcal vaccine D.Obtain a sputum specimen

A.Obtain baseline vitals and oxygen saturation Rationale: Complete a focused assessment, prioritizing assessing ABCs. VS and oxygenation status first before completing a thorough history (PMHx), collecting a sputum sample or providing any interventions (vaccine).

Which findings are significant data to gather from a client who has been diagnosed with pneumonia? (Select all that apply). A.Quality of breath sounds B.Presence of bowel sounds C.Color of nail beds D.Occurrence of chest pain E.Amount of peripheral edema

A.Quality of breath sounds C.Color of nail beds D.Occurrence of chest pain

The nurse is providing teaching about safe sports and activities to the guardian of a child who has hemophilia. Which activities would the nurse encourage the guardians suggest to the child? (Select all that apply). A.Swimming and bowling. B.Ice hockey and wrestling. C.Golfing and walking. D.Lacrosse and rugby. E.Boxing and football. F.Snowboarding and karate.

A.Swimming and bowling. C.Golfing and walking. Rationale: Teaching the client how to prevent injuries in critical. Teach the client/family to take part only in low risk, noncontact sports (e.g., walking, golf, bowling, swimming). The other sports are identified as 'contact sports' and should be discouraged.

Interventions to prevent DVT include: A: ambulation B: wearing clothing that constrict the legs C: massaging the legs D: placing pillow under the knees when in bed

A: Early ambulation is one of the primary prevention and prophylactic initiatives as identified by the Joint Commission (TJC) and the National Quality Forum. Proper positioning also reduces the risk of thrombus formation. Incorrect: Caution to prevent pressure on the posterior knee is accomplished by avoiding wearing clothing that constricts the legs, massaging the legs, and placing pillows under the knees.

A client is displaying the following symptoms after undergoing a complex surgical procedure. The client has normal BP and HR at rest, however is experiencing postural hypotension and increased HR with excise. Based on this information, the nurse would assume the client lost approximately how much blood during the procedure? A.250 mL (<10%) B.1500 mL (30%) C.2000 mL (40%) D.2500 mL (50%)

B.1500 mL (30%) Rationale: A person who lost 1500 mL of blood, is equivalent to 30% of their overall blood volume. The clinical manifestations that are common with this volume of blood loss includes: a normal supine BP and normal pulse at rest, however they will likely experience postural hypotension and ↑ HR with exercise. 10%: 500 mL: None or rare vasovagal syncope. 20%: 1000 mL: No detectable signs or symptoms at rest. ↑ HR with exercise and slight postural hypotension. 30%: 1500 mL: Normal supine BP and pulse at rest. Postural hypotension and ↑ HR with exercise. 40%: 2000 mL: BP, central venous pressure, and cardiac output below normal at rest; air hunger; rapid, thready pulse and cold, clammy skin. 50%: 2500 mL: Shock, lactic acidosis, and potential death. *refer to chart in Lewis on page 724

The nurse knows that blood reactions are based on ABO incompatibilities resulting from RBC hemolysis. Agglutination will occur in the blood of a person with type A blood if the person receives a blood transfused from a person with which antigens? (Select all that apply). A.A B.B C.O D.A, B

B.B D.A, B Rationale: Agglutination will occur in the blood of a person with type A blood if they receive blood transfused from a person with B antigens (i.e., type B or AB). The anti-B antibodies in the type A blood would react with the B antigens, starting the process that results in RBC hemolysis.

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is: A: amniotic fluid bolus B: deep vein thrombosis C: fat embolus D: vegetation from infected CVC

B: Although all are possible, the most common cause of a PE is a DVT

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? A: suction the patients oropharynx B: increase the prescribed oxygen flow rate C: instruct the patient to cough and deep breathe D: help the patient sit in a more upright position

B: Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

Diagnostic tests to determine whether a patient has developed a DVT include: A: a positive Homan's sign (pain on dorsiflexion of the foot) B: ultrasound and venography C: infused CT scan D: all of the above

B: Tests to determine whether a patient has developed a DVT include ultrasound scans, magnetic resonance imaging, and venography.

Signs and symptoms of DVT are related to: A: an increase of blood flow in the peripheral veins B: inflammation of the vein and the surrounding skin C: system-wide hypercoagulability and uncontrolled bleeding D: all of the above

B: The inflammation of a vein can cause the surrounding skin to be warm and tender to the touch, visibly reddened and swollen when compared to the non-involved extremity, and painful for the patient.

A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? A. The client's ankles are swollen. B. The client's weight has increased. C. The client's blood pressure has decreased. D. The client has wheezes in the lower lobes of the lungs.

C. The client's blood pressure has decreased. Rationale: Metoprolol is a cardioselective beta-blocking agent used after myocardial infarction, as well as for hypertension and angina. Adverse effects include bradycardia and such symptoms of heart failure as weight gain and increased edema. Lowering BP is the desired effect of metoprolol..

The nurse is caring for a client with COPD who complains of poor quality of sleep. Which question should the nurse ask next? A."Does your partner snore heavily?" B."Do you get exercise during the day?" C."How many pillows do you sleep on?" D."Do you eat large meals right before bed?"

C."How many pillows do you sleep on?" Rationale: Asking the client how many pillows she sleeps on evaluates the client for orthopnea, which is shortness of breath caused by lying down. The more pillows the client requires, the worse the orthopnea. This provides important information to the health care provider. Snoring partners, the amount of daily exercise the client gets, and eating heavy meals before bed also affect sleep; however, in the client with COPD, determining the extent of orthopnea will best help prescribe treatments.

A client with anemia related to an acute blood loss is to receive a blood transfusion. The client has type B+ blood. Which of the following orders would be safe for this client? A.A B.AB C.B D.They are a universal recipient and can receive all blood types.

C.B Rationale: Reactions will occur when a person with type B blood receives a blood transfused from a person with A antigens (i.e., type A or AB). The only safe blood for the client to receive is c: B. They cannot receive any blood with A antigens. They are also not a universal recipient, people who are AB+ are universal recipients.

The nurse teaches a client who has recently been diagnosed with HTN about following a low-calorie, low-fat, low sodium diet. Which of the following menu selections would best meet the client's needs? A.mix green salad with blue cheese dressing, crackers, and cold cuts B.Ham sandwich on rye bread and an orange C.Baked chicken, an apple, and a slice of white bread D.Hot dogs, baked beans, and celery and carrot sticks

C.Baked chicken, an apple, and a slice of white bread Rationale: A, B and D all contain processed meats which are exceptionally high in sodium!!

A client with pneumonia has a temperature of 102.6 ° F (39.2 ° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? A.Position changes every 4 hours. B.Nasotracheal suctioning to clear secretions. C.Frequent linen changes D.Frequent offering of a bedpan.

C.Frequent linen changes Rationale: Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

The plan of care for the client with chronic obstructive pulmonary disease (COPD) should include. (Select all that apply). A.Exercise such as hiking outdoors in the cold. B.High flow rate of O2 administration. C.Frequent small meals that include protein. D.Smoking cessation resources. E.Breathing exercises, such as pursed-lip breathing that focuses on exhalation.

C.Frequent small meals that include protein. D.Smoking cessation resources. E.Breathing exercises, such as pursed-lip breathing that focuses on exhalation.

A client's BP has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is due to... A.progressive target organ damage. B.the possibility of drug interactions. C.the patient not adhering to therapy. D.the patient's possible use of recreational drugs.

C.the patient not adhering to therapy. Rationale: Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not comply with therapy.

A definitive diagnosis of pulmonary embolism can be made by: A: ABG's B: CXR C: spiral CT D: V-Q Scan

C: A spiral CT scan is one of the definitive tests for PE. The pulmonary angiogram is the other. Both tests have the limitation of not always being able to visualize small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is inconclusive.

Which of the following is the most common life-threatening complication of deep vein thrombosis (DVT)? A: Disseminated intravascular coagulation (DIC) B: Myocardial infarction (MI) C: Pulmonary embolism (PE) D: Transient ischemic attack (TIA)

C: All of those are potential complications, however, the most common and most likely to be life-threatening is PE. With a DVT, it is possible for part of the blood clot to dislodge, move through the heart into the pulmonary circulation system, and become lodged in the lungs blocking an artery. This is a medical emergency.

The nurse is caring for a client with COPD. The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this client? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C. Encourage coughing and deep breathing to clear the airway. D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min.

D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min. Rationale: The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would diminish his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

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

D."I will take in a deep breath and hold it before exhaling" Rationale: Incentive spirometry is used to maintain lung function in those with COPD. It will not reverse damage in the lungs, but can help improve ventilation and prevent lung complications. Incentive spirometry works by breathing in through the mouthpiece until the ball hits the mark. The person is asked to hold in for 3-5 seconds (on the mark) before exhaling. Repeating 10x/hour.

A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level 4/10, on a scale of 0 to 10. Which of the following actions should the nurse take? A.Administer an NSAID. B.Perform passive range-of-motion exercises on the joint. C.Administer cryoprecipitate. D.Apply an ice pack to the joint.

D.Apply an ice pack to the joint. Rationale: Immediately following an injury, the joint should be rested, apply ice, and elevate to minimize bleeding into the joint.

The client is being discharged from the hospital and asks what "hemoptysis" is, it's in her discharge teaching. The best response from the nurse is? A.Its frothy sputum B.Its green-tinged sputum C.Its any type of productive cough D.Its blood in the sputum

D.Its blood in the sputum

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A.Chronic GI blood loss. B.Glossitis and pallor. C.Uncontrolled bleeding and hemarthrosis. D.Petechiae and bruising.

D.Petechiae and bruising. Rationale: In aplastic anemia all 3 blood components are reduced or absent, called pancytopenia. A client with aplastic anemia will have manifestations of petechiae and bruising due to thrombocytopenia. The other manifestations listed are associated with different types of anemia and bleeding disorders.

In order to prevent the development of a VTE following an abdominal surgery, the nurse should: A.Limit fluid intake to 1,000 mL in 24 hours B.Encourage cough and deep breathing C.Assist the client to remain sedentary D.Use pneumatic compression stockings

D.Use pneumatic compression stockings Rationale: Graduated compression stockings (e.g., thromboembolic deterrent [TED] hose) are a part of VTE prevention in hospitalized patients. VTE prevention is enhanced if the stockings are used along with anticoagulation.

O2 therapy for COPD is used for what?

Keep PaO2 > 60 mm Hg Use caution with O2 - there is a risk of altering the drive to breathe Normally the drive to breath is based on high CO2 - but in COPD it evolves to low O2 Slowly titrate O2 - pay attention to SpO2 values

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min

a. Basilar crackles Rationale: 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 rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

An older adult client living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the client is likely to be hypoxic? a.Sudden onset of confusion b. Oral temperature of 102.3oF c. Coarse crackles in lung bases d. Clutching chest on inspiration

a.Sudden onset of confusion Rationale: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

When caring for a client with COPD, the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this client? 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, non irritating, frequent feeding diet.

b. Order a high-calorie, high-protein diet with six small meals a day. Rationale: 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, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with nonprotein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM

b. Sputum culture and sensitivity Rationale: The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. 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, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

A nurse is caring for a client who has HF and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A.Obtain the client's weight B.Assist the client into high-Fowler's position C.Auscultate lung sounds D.Check the client's pulse oximetry

b.Assist the client into high-Fowler's position Rationale: If the patient has dyspnea, place in a high-Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return by pooling the blood in the extremities and increases the thoracic capacity for breathing. Priority is ABCs.

When teaching the client with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? a. Smoking causes a hoarse voice. b. Cough will become nonproductive. c. Decreased alveolar macrophage function d. Sense of smell is decreased with smoking.

c. Decreased alveolar macrophage function Rationale: The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.

The nurse teaches pursed-lip breathing to a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? 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. Preventing bronchial collapse and air trapping in the lungs during exhalation Rationale: The purpose 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. It does not affect secretions, inhalation, or increase the rate of breathing.

The nurse is caring for a client with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? a.Barrel-shaped chest b.Paradoxical respirations c.Hyperresonance on percussion d.Localized decreased breath sounds

d.Localized decreased breath sounds Rationale: Clinical manifestations of pleural effusion include diminished breath sounds over the affected area, decreased movement of the chest on the affected side, dullness to percussion, dyspnea, cough, and occasional sharp and nonradiating chest pain that is worse on inhalation.

What are the clinical manifestations of a PE? how are they different from a DVT?

●varied and nonspecific, making diagnosis difficult. ●Manifestations depend on the type, size, and extent of emboli ●Small emboli may go undetected or cause vague, transient symptoms. Symptoms may begin slowly or appear suddenly ●Dyspnea is the most common presenting symptom in patients with PE. Mild to moderate hypoxemia may occur. ●Other manifestations include tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, accentuation of pulmonic heart sound, tachycardia, and syncope. ●Massive PE may cause a sudden change in mental status, hypotension, feelings of impending doom, and cardiorespiratory arrest.