Saunders STUDY QUESTIONS 225
The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication the nurse would employ? Select all that apply. A. Timing B. Volume C. Voice tone D. Eye contact E. Hand gestures F. Ability to share thoughts and feelings
A, B, C, F Rationale: Verbal communication includes not only one's language or dialect but also voice tone, volume, timing, and ability to share thoughts and feelings. It does not include eye contact or hand gestures.
The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? A. Hyperoxygenate the client. B. Set the suction pressure range at 150 mm Hg. C. Place the catheter into the tracheostomy tube. D. Apply suction on the catheter, and insert it into the tracheostomy tube.
A. Hyperoxygenate the client. Rationale: The nurse needs to hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the primary health care provider with this procedure, which is the initial nursing action? A. Deflate the cuff. B. Suction the ET tube. C. Turn off the ventilator. D. Obtain a code cart, and place it at the bedside.
B. Suctioning the ET Tube. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment would already be available at the client's bedside. Option 3 is not the initial action.
The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment would the nurse plan to have at the bedside when the client returns from surgery? A. Obturator B. Oral airway C. Epinephrine D. Tracheostomy set with the next larger size
A. Obturator Rationale: A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. In addition, a curved hemostat that could be used to hold the trachea open if dislodgment occurs needs to be kept at the bedside. An oral airway and epinephrine would not be needed.
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client? A. Five blood cultures are negative. B. Three sputum cultures are negative. C. A blood culture and a chest x-ray are negative. D. A sputum culture and a tuberculin skin test are negative.
B. Three sputum cultures are negative. Rationale: The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? A. Excessive secretions. B. Kinks in the ventilator tubing. C. The presence of a mucous plug D. Disconnection of the ventilator tube
D. Disconnection of the ventilator tube Rationale: The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. A. Water or a kink in the tubing. B. Biting on the endotracheal tube. C. Increased secretions in the airway. D. Disconnection or leak in the system. D. The client ceasing spontaneous breathing
A, B, C Rationale: Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.
The nurse is preparing to suction a client via a tracheostomy tube. The nurse would plan to limit the suctioning time to a maximum of which time period? A. 5 seconds B. 10 seconds C. 30 seconds D. 60 seconds
B. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? A. Continue to suction. B. Stop the procedure and reoxygenate the client. C. Ensure that the suction is limited to 15 seconds. D. Notify the primary health care provider immediately.
B. Stop the procedure and reoxygenate the client. Rationale: During suctioning, the nurse would monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. A. Touch B. Eye contact C. Personal space D. Family presence E. Time orientation F. Facial expression
A, B, C, E Rationale: The most important cultural and communication considerations the nurse must be aware of are touch, eye contact, personal space, and time orientation. Family presence and facial expression are not important concepts.
Which interventions would the nurse take for a deceased client whose eyes will be donated? Select all that apply. A. Close the client's eyes. B. Elevate the head of the bed. C. Place a warm compress on the eyes. D. Place a dry sterile dressing over the eyes. E. Place wet saline gauze pads and a cool pack on the eyes.
A, B, E Rationale: When a cornea donor dies, the eyes are closed, the head of the bed is elevated to prevent edema, and gauze pads wet with saline are placed over the eyes with a cool pack or small ice pack. Antibiotic eyedrops may also be prescribed. A warm compress will promote edema. Placing dry sterile dressings over the eyes serves no useful purpose. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours.
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? A. Assault B. Battery C. Slander D. Invasion of privacy
A. Assault Rationale: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.
The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? A. Hyperoxygenate the client. B. Set the suction pressure range at 150 mm Hg. C.Place the catheter into the tracheostomy tube. D.Apply suction on the catheter, and insert it into the tracheostomy tube.
A. Hyperoxygenate the client. Rationale: The nurse needs to hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.
The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? A. Rhonchi are auscultated. B. Pleural friction rub is heard. C. Fine crackles are auscultated. D. Pulse oximetry reading is 96%.
A. Rhonchi are auscultated. Rationale: The presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli.
The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? A. Pain B. Anxiety C. Depression D. Withdrawal
B. Anxiety Rationale: Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptoms.
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the primary health care provider with this procedure, which is the initial nursing action? A. Deflate the cuff. B. Suction the ET tube. C. Turn off the ventilator. D. Obtain a code cart, and place it at the bedside.
B. Suction the ET tube. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment would already be available at the client's bedside. Option 3 is not the initial action.
A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? A. "The decision is made by the medical examiner." B. "An autopsy is mandatory for any client who is DOA." C. "I will contact the medical examiner regarding your request." D. "It is required by federal law. Tell me why you don't want the autopsy done."
C. "I will contact the medical examiner regarding your request." Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? A. Notify the surgeon. B. Clamp the surgical drain. C. Change the dressing as prescribed. D. Remove and replace the perineal packing.
C. Change the dressing as prescribed. Rationale: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed. A surgical drain would not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time because this is expected. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse would not remove the perineal packing.
The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? A. The skin color becomes cyanotic. B. Secretions are becoming bloody. C. Coughing occurs with suctioning. D. Heart rate decreases from 78 to 54 beats/minute.
C. Coughing occurs with suctioning. Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the primary health care provider. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.
The nurse is caring for a client with a pneumothorax who has a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? A. Suction the client. B. Increase the suction. C. Document the findings. D. Encourage coughing and deep breathing.
C. Document the findings. Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.
The nurse caring for a client who sustained a chest injury and who has a chest tube drainage system notes constant bubbling in the water seal chamber. Which nursing action is appropriate? A. Reposition the client. B. Change the chest tube drainage system. C. Notify the primary health care provider (PHCP). D. No action is necessary because this is a normal, expected finding.
C. Notify the primary health care provider (PHCP). Rationale: Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the PHCP. The remaining options are incorrect.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? A. The informed consent does not need to be obtained. B. The informed consent would be obtained from the family. C. The informed consent needs to be obtained from the client. D. The primary health care provider will provide the informed consent.
C. The informed consent needs to be obtained from the client. Rationale: Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.
The nurse is changing the tracheostomy securement device on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? A. The ties leave no marks on the neck. B. The tracheotomy can be pulled slightly away from the neck. C. The nurse places 1 finger loosely between the tie and the neck. D. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.
C. The nurse places 1 finger loosely between the tie and the neck. Rationale: The nurse needs to assess the tracheostomy securement device to ensure that it is not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the device. Options 1, 2, and 4 are incorrect actions.
The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action would the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? A. Allow family members to name the infant. B. Encourage the client to talk about the dead fetus. C. Allow the client and the spouse to hold the infant. D. Assess the client's and the spouse's perception of the event.
D, Assess the client's and the spouse's perception of the event. Rationale: The initial intervention in planning to meet the emotional needs of the client and spouse is to assess their perception of the event. Although the actions in the remaining options are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event.
The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action would the nurse perform prior to reinserting the inner cannula? A. Suction the client's airway. B. Wipe the inner cannula off with a clean washcloth. C. Dry the inner cannula thoroughly with sterile gauze. D. Allow the inner cannula to dry after washing it with sterile water.
D. Allow the inner cannula to dry after washing it with sterile water. Rationale: After washing the inner cannula with half strength peroxide and rinsing it with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. The nurse would not suction a client without an inner cannula in place. This is a sterile procedure; therefore, it is inaccurate to use a clean washcloth. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.
The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? A. Planning meals B. Decorating the room C. Scheduling haircut appointments D. Allowing the client to choose social activities
D. Allowing the client to choose social activities Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.
The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse would implement which intervention? A. Comply with the client's wishes at all times. B. Encourage the client to be dependent on hospital staff. C. Refuse to answer questions related to impending death. D. Encourage the client to maintain maximum self-control.
D. Encourage the client to maintain maximum self-control. Rationale: Interventions appropriate when caring for a terminally ill adolescent include avoiding alliances with either the parent or the child, structuring hospital admission to allow for maximum self-control and independence, and answering the adolescent's questions honestly. Complying with the client's wishes at all times is not therapeutic.
The nurse is assisting a primary health care provider with the removal of a chest tube in a client with a resolved pneumothorax. The nurse would instruct the client to take which action? A. Stay very still. B. Exhale very quickly. C. Inhale and exhale quickly. D. Perform the Valsalva maneuver.
D. Perform the Valsalva maneuver. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath and hold it, bear down, and exhale). After premedicating the client for pain 30 minutes prior to the procedure if desired, the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
The nurse caring for a client with pneumothorax who has a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? A. The system needs changing. B. Suction needs to be increased. C. Suction needs to be decreased. D. The chest tube may be obstructed.
D. The chest tube may be obstructed. Rationale: Fluid in the water seal chamber would rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.
The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? A. Actual or life-threatening concerns B. Completing care in a reasonable time frame C. Time constraints related to the client's needs D. Obtaining needed supplies to care for the client
A. Actual or life-threatening concerns Rationale: Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? A. Check for an air leak. B. Document the findings. C. Notify the primary health care provider. D. Change the chest tube drainage system.
B. Document the findings. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the primary health care provider and changing the chest tube drainage system are not indicated at this time.
The baseline vital signs for a client with pneumonia are as follows: temperature 98.8° F (37.1° C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F (39.4° C). Which corresponding respiratory rate would the nurse anticipate in this client as part of the body's response to the change in status? A. Respiratory rate of 12 breaths/min B. Respiratory rate of 16 breaths/min C. Respiratory rate of 18 breaths/min D. Respiratory rate of 22 breaths/min
D. Respiratory rate of 22 breaths/min Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? A. Muscle weakness in the arms and legs B. A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C) C. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg D. A heart rate of 80 beats/minute, decreased from 85 beats/minute
C. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg Rationale: Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.
A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? A. Assessing lung sounds B. Monitoring temperature C. Administering intravenous (IV) fluids D. Performing range-of-motion exercises to the extremities
C. Administering intravenous (IV) fluids Rationale: Perfusion to the kidney is affected by blood pressure, which in turn is affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated with medications to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse would prepare to infuse IV fluids as prescribed and continue to monitor urine output. The remaining options will not maintain viability of the kidneys.
The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions would the nurse plan to include in performing this procedure? Select all that apply. A. Explaining the procedure to the client B. Clamping the tubing of the drainage bag C. Obtaining the specimen from the urinary drainage bag D. Aspirating a sample from the port on the drainage tubing E. Wiping the port with an alcohol swab before inserting the syringe
A, B, D, E Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.
A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest feeding? Select all that apply. A. 1% milk B. Egg yolk C. Dried beans D. Hard cheeses E. Green leafy vegetables
B ,C ,E Rationale: Breast-feeding or chest-feeding parents with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the parent include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.
C. Respiratory acidosis. Rationale:The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse educator asks a student to list the five main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? A. "CAM includes biologically based practices." B. "Whole medical systems are a component of CAM." C. "Mind-body medicine is part of the CAM approach." D. "Magnetic therapy and massage therapy are a focus of CAM."
D. "Magnetic therapy and massage therapy are a focus of CAM." Rationale: The five main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM.
A client who sustained a chest injury has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse would ensure that which intervention is implemented? A. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. B. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. C. The suction control chamber has sterile water added every shift, and the system is kept below waist level. D. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.
D. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.
The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? A. 16% B. 21% C. 30% D. 40%
B. 21% Rationale: Room air contains 21% oxygen. It is not possible to give a client 16% oxygen because that is less than room air. Options 3 and 4 specify oxygen amounts that commonly are used to supplement clients who are experiencing respiratory difficulty.
The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. A. The nurse encourages the client and family to identify and discuss feelings openly. B. The nurse assists the client and family in carrying out spiritually meaningful practices. C. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. D. The nurse makes decisions for the client and family to relieve them of unnecessary demands. E. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.
A, B, E Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further.
The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse would implement which interventions? Select all that apply. A. Retain ritualism. B. Avoid significant changes in lifestyle. C. Maintain sensitivity toward the parents. D. Encourage the parents to be near the child. E. Encourage as normal an environment as possible. F. Discourage the parents from verbalizing their feelings.
A,B,C,D,E Rationale: Once infants and toddlers have established trust with a parent, separation from the parent, even if temporary, is profound. Prolonged separation during the first several years is thought to be more significant in terms of future physical, social, and emotional growth than at any subsequent age. The parents of a terminally ill toddler need to be assisted in verbalizing and dealing with their feelings and encouraged to remain as near to the child as possible. It is also important to maintain as normal an environment as possible to retain ritualism.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client? A. "Take a deep breath when I tell you, and hold it while I remove the tube." B. "Take a deep breath when I tell you, and bear down while I remove the tube." C. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." D. "Take a deep breath when I tell you, and breathe normally while I remove the tube."
A. "Take a deep breath when I tell you, and hold it while I remove the tube." Rationale: The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.
The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? A. "The enema will be given while I am sitting on the toilet." B. "I would try and hold the fluid as long as possible after it is run in." C. "I know that there will be some cramping after the enema solution is run in." D. "I would tell the nurse if cramping occurs when the fluid is running in."
A. "The enema will be given while I am sitting on the toilet." Rationale: The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.
The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? A. Deflate the cuff on the tube. B. Place the inner cannula into the tube. C. Ensure that the client is able to speak. D. Ensure that the client is able to swallow.
A. Deflate the cuff on the tube. Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.
The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? A. It is painless and safe. B. It causes only mild discomfort at the site. C. It requires insertion of only a very small catheter. D. It has an alarm to signal dangerous drops in oxygen saturation levels.
A. It is painless and safe. Rationale: The nurse would reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.
The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse would plan to perform which action? A. Suction the client. B. Evaluate the cuff for a leak. C. Assess for a disconnection. D. Notify the respiratory therapist.
A. Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucous plugging that requires suctioning. A cuff leak and disconnection would cause the low-pressure alarm to sound, so options 2 and 3 can be eliminated. Notifying the respiratory therapist delays necessary treatment.
The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? A. Suctioning the client every hour B. Applying suction only during withdrawal of the catheter C. Hyperventilating the client with 100% oxygen before suctioning D. Applying suction intermittently during withdrawal of the catheter
A. Suctioning the client every hour Rationale: The client would be suctioned as needed. Unnecessary suctioning would be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client needs to be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.
The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? A. suctioning the client every hour. B. Applying suction only during withdrawal of the catheter. C. Hyperventilating the client with 100% oxygen before suctioning. D. Applying suction intermittently during withdrawal of the catheter.
A. Sunctioning the client every hour. Rationale: The client would be suctioned as needed. Unnecessary suctioning would be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client needs to be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.
The nurse caring for a terminally ill client has developed a close relationship with the client's family. Which interventions would the nurse include in dealing with the family during this difficult time? Select all that apply. A. Making decisions for the family B. Encouraging family discussion of feelings C. Accepting the family's expressions of anger D. Preserving the family's sense of self-direction and control E. Maintaining open communication among family members F. Facilitating the use of spiritual practices identified by the family
B,C,D,E,F Rationale: Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication as well as preserve the family's sense of self-direction and control. The incorrect option removes autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that could impair communication. Encouraging family discussion of feelings and maintaining open communication among family members are likely to enhance communication. Spiritual practices give meaning to life and have an impact on how people react to crisis, so this option needs to be included. Accepting the family's expression of anger and preserving the family's sense of self-direction and control are effective techniques so that the family knows there is someone there who is supportive and nonjudgmental.
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? A. Do nothing because this is an expected finding. B. Check for an air leak because the bubbling needs to be intermittent. C. Increase the suction pressure so that the bubbling becomes vigorous. D. Clamp the chest tube and notify the primary health care provider immediately.
B. Check for an air leak because the bubbling needs to be intermittent. Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, would be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this would decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse would check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes would be clamped only with a primary health care provider's prescription.
The nurse has assisted the primary health care provider (PHCP) with the insertion of a chest tube in a client who sustained a chest injury and has a pneumothorax. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? A. Inform the PHCP. B. Continue to monitor the client. C. Reinforce the occlusive dressing. D. Encourage the client to deep breathe.
B. Continue to monitor the client. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. Because this finding is expected, it is not necessary to notify the PHCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.
The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings? A. It is at the first tracheal cartilaginous ring. B. It is at the bifurcation of the right and left main bronchi. C. It is at the point at which the larynx connects to the trachea. D. It is at the area connecting the oropharynx to the laryngopharynx.
B. It is at the bifurcation of the right and left main bronchi. Rationale: The carina is a cartilaginous ridge that separates the openings of the 2 main (right and left) bronchi. The optimal position of the endotracheal tube is approximately 2.0 cm above the carina so that movement of the head does not raise the tube out of the airway nor push it into the bronchus. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation. Options 1, 3, and 4 are incorrect interpretations.
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse would make which interpretation? A. There is a leak in the system. B. The chest tube is functioning as expected. C. The amount of suction needs to be decreased. D. The occlusive dressing at the insertion site needs reinforcement.
B. The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water seal chamber.
The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death following a severe head injury. Which finding indicates to the nurse that the standard for ongoing care has been maintained? A. Pao2 70 mm Hg B. Urine output 100 mL/hr C. Heart rate 52 beats/min D. Blood pressure 90/48 mm Hg
B. Urine Output 100 mL/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. Guidelines may be used to maintain organ viability, but adequate perfusion is necessary. The correct option is the only one that indicates adequate perfusion. The incorrect options identify lower-than-normal values, thus adequate perfusion would not be maintained.
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar
B. Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? A. Bradycardia and hyperactivity B. Decreased respiratory rate and depth C. Headache, restlessness, and confusion D. Bradypnea, dizziness, and paresthesias
C. Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? A. Prevents the client from getting a nosebleed B. Gives the client added fluid via the respiratory tree C. Humidifies the oxygen that is bypassing the client's nose D. Prevents fluid loss from the lungs during mouth breathing
C. Humidifies the oxygen that is bypassing the client's nose Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. A client who is breathing through the mouth is not at risk for nosebleeds. The humidified oxygen may help keep mucous membranes moist, but it will not substantially alter fluid balance (options 2 and 4).
A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? A. "You'll wear a lead shield to partially protect your organs from harm." B. "The amount of x-ray exposure is not sufficient to cause DNA damage." C. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." D. "The x-ray exam itself is painless, and a lead shield protects you from the minimal.
D. "The x-ray exam itself is painless, and a lead shield protects you from the minimal. Rationale: Clients would be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? A. A client requiring frequent temperature checks B. A client requiring assistance with ambulation every 4 hours C. A client on a mechanical ventilator requiring frequent assessment and suctioning D. A client with a spinal cord injury requiring urinary catheterization every 6 hours
D. A client with a spinal cord injury requiring urinary catheterization every 6 hours. Rationale: When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the APs, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning would most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.
The nurse is monitoring the chest tube drainage system in a client with a pneumothorax. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? A. Continue to monitor. B. Document the findings. C. Change the chest tube drainage system. D. Perform a focused respiratory assessment.
D. Perform a focused respiratory assessment. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment needs to be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system is not indicated at this time. Continuing to monitor the bubbling delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.
A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? A. Side-lying with a pillow under the hip. B. Prone with a pillow under the abdomen. C. Prone in slight Trendelenburg's position. D. Side-lying with the legs pulled up and the head bent down onto the chest
D. Side-lying with the legs pulled up and the head bent down onto the chest Rationale: A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.
The nurse is caring for a hospitalized client with chronic obstructive pulmonary disease who is retaining carbon dioxide (CO2). The nurse anticipates which physical response will initially occur?? A. The client will lose consciousness. B. The client's sodium and chloride levels will rise. C. The client will complain of facial numbness and tingling. D. D. The client's arterial blood gas results will reflect acidosis.
D. The client's arterial blood gas results will reflect acidosis. Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.
