ATI MS Vascular and Circulatory

A client is 1-day postop following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make? "You should ask your family to bring you some food from home." "Clients frequently complain about the taste of hospital food." "I would be happy to get you food that you prefer to eat." "Because of your surgery, you have an altered ability to smell and taste."

"Because of your surgery, you have an altered ability to smell and taste." Clients who have lost their larynx commonly complain of poor ability to smell and taste. This is because they now breathe through the tracheal stoma, rather than the mouth and nose, which bypasses the location of the olfactory and gustatory nerve cells. "You should ask your family to bring you some food from home." This closed-ended, nontherapeutic response is an example of giving advice. Additionally, in this situation, food from home is unlikely to improve the situation. "Clients frequently complain about the taste of hospital food." This closed-ended, nontherapeutic response focuses on other clients rather than this client. "I would be happy to get you food that you prefer to eat." A new set of food is unlikely to improve the situation.

A client has emphysema. Which statement indicates UNDERSTANDING of the teaching? "I will inhale slowly through pursed lips to help me breathe better." "I will avoid getting a flu shot." "I will follow a daily diet high in calories and protein." "I will lie on my stomach to practice abdominal breathing every day."

"I will follow a daily diet high in calories and protein." Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals. INCORRECT "I will inhale slowly through pursed lips to help me breathe better." The client should first inhale slowly through the nose, then exhale slowly through pursed lips. "I will avoid getting a flu shot."The client is at risk for respiratory infections. Therefore, the client should avoid crowds and should get an annual vaccination against influenza. "I will lie on my stomach to practice abdominal breathing every day." The client should practice abdominal (diaphragmatic) breathing exercises daily while lying on his back with his knees flexed. The client should focus on using the diaphragm to achieve maximum inhalation and to slow his respiratory rate.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Nausea Dysphagia Agitation Hypotension

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange. INCORRECT: Nausea The nurse would not expect the client to be nauseated during an asthma attack. Dysphagia The nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack. Hypotension The nurse should expect hypertension due to increased work load of the heart from decreased oxygenation.

A nurse is caring for a client who is postoperative and is at risk for developing deep venous thromboembolism (VTE). The nurse should instruct the client to AVOID which of the following unsafe actions? Massaging her legs Foot Pain Elevating the leg Flexing ankles

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? Place the client in protective isolation Minimize environmental stimuli Elevate the head of the client's bed 45 degrees Limit the client's ambulation to once a day

Minimize environmental stimuli A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights. WRONG: Elevate at 45 degrees, no, they need to be elevated at 15-30 degrees to promote venous return and to reduce intracranial pressure Limit ambulation to once a day- NO, client should be on bed rest

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care? Patency of the intravenous line. Level of pain. Integrity of the dressing. Need for suctioning.

Need for suctioning. Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

Client is in ED and reports dyspnea, chest pain and tachycardia. Pt has become diaphoretic, increasingly dyspneic and chest pain has gotten worse. Crackles auscultated in bilateral lower lobes. S3 and S4 sounds noted. PE protocol indicated: What is FIRST priority: Place pt in high-fowlers position Obtain a doppler ultrasound Administer an anticoagulant obtain ABG's

Place the client in high-Fowler's position is correct. When using the airway breathing and circulation approach to client care, the nurse should first place the client in high-Fowler's position to promote gas exchange. Obtain a doppler ultrasound, administer an anticoagulant, and obtain ABGs are incorrect. The nurse might obtain a doppler ultrasound at some point to detect presence of a venous thromboembolism; however, there is another the action the nurse should take first. The nurse might need to administer an anticoagulant at some point, but at this time there is another action that the nurse should take first. The nurse might need to obtain ABGs at some point: however, there is another action that the nurse should take first.

A nurse is admitting a client who is having an exacerbation of his asthma. Propranolol Theophylline Montelukast Prednisone

Propranolol Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma. INCORRECT Theophylline Theophylline, one of the methylxanthines, is commonly used in the treatment of asthma. Montelukast Montelukast, a leukotriene antagonist, is commonly used in the treatment of asthma. Prednisone Prednisone, a corticosteroid, is commonly used in the treatment of asthma.

A patient in the ED presents with: Sudden onset of dyspnea while taking a shower. PT is pale, restless, and diaphoretic. Pt keeps saying "I think I am going to die." Pulse is tachycardia and crackles hear bilaterally in lower base as well as friction rub. What does the patient have and what interventions will you take?

Pulmonary Embolism. Tachycardia and white out appearance. Place client in high fowler's position to promote optimal gas exchange and obtain venous access for PE meds. Monitor for: petechiae on chest and cardiac dysrhythmias. Monitor aPTT prior to anticoagulant administration.

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing the disorder? Maintenance of ideal weight Annual influenza immunization Smoking cessation Regular moderate exercise

Smoking cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? Withhold food and liquids until the client's gag reflex returns. Irrigate the client's throat every 4 hr. Have the client refrain from talking for 24 hr. Suction the client's oropharynx frequently.

Withhold food and liquids until the client's gag reflex returns. Until the gag reflex returns, and the sedation effects have resolved, the client is at high risk for aspirating food or fluids. Also, oxygen saturation should be checked every 15 min. for 2 hr.

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was: dysphagia. hoarseness. dyspnea. weight loss.

hoarseness. Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal. INCORRECT: dysphagia. Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the tumor grows in size and impedes the esophagus. dyspnea.Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the tumor grows in size and impedes the airway opening. weight loss.Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? "Tuck your chin when you swallow so you won't choke." "It is no longer possible for you to choke on or aspirate food." "You should have no trouble swallowing fluids." "I will add a thickener to your liquids to prevent aspiration."

"It is no longer possible for you to choke on or aspirate food." The surgical procedure of total laryngectomy provides complete anatomical separation of the trachea and esophagus. Choking and aspiration of food and liquids is no longer possible. INCORRECT "Tuck your chin when you swallow so you won't choke." Tucking the chin when swallowing helps prevent aspiration in clients who have dysphagia, but this is not a risk for this client. "You should have no trouble swallowing fluids."Immediately after NG tube removal, swallowing is usually uncomfortable. The client might need an analgesic prior to his initial attempts to swallow. "I will add a thickener to your liquids to prevent aspiration." Thickening liquids helps prevent aspiration in clients who have dysphagia, but this is not a risk for this client.

A nurse is caring for a client who develops a pulmonary embolism. Which intervention is FIRST? Give morphine IV Administer oxygen therapy Start an IV infusion of lactated Ringer's Initiate cardiac monitoring

Administer Oxygen Therapy (ABC's!!): The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation. Morphine: it is important to manage pain but not priority Start an Infusion of Lactated Ringer's: Yes tis is administered via continuous IV bolus, but not priority. It is important to monitor the client's cardiac rhythm for T-wave and ST-segment changes as well as right ventricular failure or myocardial infarction. There is, however, another intervention that is the priority.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first. Auscultate lung fields. Assess pulse and respirations. Assess characteristics of her sputum. Instruct to slowly exhale with pursed lips.

Auscultate lung fields. The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure. INCORRECT Assess pulse and respirations. The nurse should assess vital signs every shift and during the procedure to determine the client's tolerance to positioning, but this is not the first actions the nurse should take. Assess characteristics of her sputum. The nurse should assess the characteristics of the sputum following the procedure, but this is not the first action the nurse should take. Instruct to slowly exhale with pursed lips. The nurse should instruct the client to slowly exhale with pursed lips and use diaphragmatic breathing techniques to expel mucus during and following the procedure, but this is not the first action the nurse should take.

A nurse is monitoring an older client immediately following bronchoscopy. The nurse's priority is to monitor for which of the following? Observing for confusion Auscultating breath sounds Confirming the gag reflex Measuring blood pressure

Confirming the gag reflex When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway. Observing for confusion Following a bronchoscopy, an older adult client is at risk for confusion due to medications use for sedation. However, there is another assessment that is the nurse's priority. Auscultating breath sounds The client is at risk for hypoxia following a bronchoscopy and the nurse should auscultate the client's breath sounds. However, there is another assessment that is the nurse's priority. Measuring blood pressure The client is at risk for hypotension due to the medications used for sedation during the procedure. However, there is another assessment that is the nurse's priority.

Which symptoms, also seen in gastroespophageal reflux disease may also be seen in patients experiencing MI? Nausea Eructation (belching) Hoarseness Dyspnea Indigestion

Indigestion: Pain with myocardial infarction can be described as indigestion and occurs due to decreased blood flow to the myocardium. Nausea: Nausea is a common symptom of myocardial infarction and gastroesophageal reflux disease. Dyspnea: Dyspnea is a result of cardiac disease or pulmonary disease. INCORRECT: Eructation and Hoarseness

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Clamp the chest tube prior to transferring the client to a wheelchair. Disconnect the chest tube from the drainage system during transport. Keep the drainage system below the level of the client's chest at all times. Empty the collection chamber prior to transport.

Keep the drainage system below the level of the client's chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity. INCORRECT Clamp the chest tube prior to transferring the client to a wheelchair. Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased intrathoracic pressure from gas and fluid that cannot be drained from the pleural space. Disconnect the chest tube from the drainage system during transport.The chest tube should not be disconnected from the drainage system. Empty the collection chamber prior to transport. Emptying the collection chamber prior to transport is unnecessary.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? Increase the client's wall suction. Strip the client's chest tube. Clamp the client's chest tube. Reposition the client.

Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube. INCORRECT: Increase the client's wall suction. The nurse increasing the wall suction does not affect the amount of negative pressure of the chest tube and would not relieve the client's chest burning. Strip the client's chest tube. The nurse stripping the chest tube increases negative pressure and may damage lung tissue and would not resolve the client's chest burning. Clamp the client's chest tube. The nurse clamping the chest tube briefly to change the chamber or check for an air leak is recommended but would not resolve the client's chest burning.

A patient presents with a Troponin T 0.7 ng/mL (less than 0.1 ng/mL), reports of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort . O2 is 88%. What are your TWO priority interventions. Request a prescription for Morphine 6mg IV blus Request a prescription for verapamil 100 mg PO Administer transdermal nitroglycerin Administer oxygen via nasul cannula Request a prescription for aspirin 325 mg.

The nurse should administer oxygen to the client at 2 L/min via nasal cannula and request a prescription for aspirin 325 mg because the client is likely experiencing a myocardial infarction. When hypoxemia is present, oxygen is prescribed to maintain the arterial oxygen saturation at 90% or greater. Aspirin therapy inhibits platelet aggregation and vasoconstriction, decreasing the likelihood of thrombosis.

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? Keep the client's affected leg elevated while in bed Have the client ambulate prior to applying antiembolic stockings Apply ice packs to the affected leg Massage the client's legs twice a day

The nurse should keep the client's leg elevated when he is in bed to decrease edema. Nurse should apply antiembolic stockings BEFORE ambulating b.c legs are less edamatous when they have been in an elevated position. Nurse should apply warm, moist soaks to the client's leg. NO MASSAGING for DVT!!!

A patient presents with a Troponin T 0.7 ng/mL (less than 0.1 ng/mL), reports of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort . O2 is 88%. What are the TWO main things you will monitor? Platelet count Glucose level Electrocardiogram Vital signs

The nurse should monitor the client's electrocardiogram (ECG) rhythm. Dysrhythmias are the leading cause of prehospital death in clients who have acute coronary syndrome (ACS). The nurse should also monitor the client's vital signs to ensure there are no complications such as cardiogenic shock.

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? Apply Ice packs to your legs Use elastic Stockings Remain on bed rest Place your legs in a dependent position while in bed

Use of elastic stockings Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart. A dependent position would be recommended for a patient with arterial insufficiency!! NOT DVT!!

Which of the following clients should the nurse identify as being at risk for development of pressure ulcers? SELECT ALL THAT APPLY A client who is ambulatory following a cardiac catheterization 4 hr ago A client who has type1 diabetes mellitus and is hyperglycemic A client who has protein calorie malnutrition A client who has right-sided heart failure and 4+ edema to the lower extremities A client who has postoperative delirium

A client who has right-sided heart failure and 4+ edema to the lower extremities is correct. A client who has poor skin perfusion resulting from a condition such as peripheral edema is at risk for the development of pressure ulcers. A client who has postoperative delirium is correct. A client who has a decreased level of consciousness, such as delirium, is at risk for the development of pressure ulcers. A client who has protein calorie malnutrition is correct. A client who has poor nutritional status is at risk for the development of pressure ulcers.

A nurse in an urgent care center is caring for a client who is having acute asthma exacerbation. Which of the following actions is the nurse's highest priority. Initiating oxygen therapy Providing immediate rest for the client Positioning the client in high-Fowler's Administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation. INCORRECT: Initiating oxygen therapyMY ANSWERClients who have an acute asthma exacerbation may require oxygen therapy, but this is not the nurse's highest priority. Providing immediate rest for the clientAdequate rest is essential for the client's recovery from the asthma exacerbation, but it will not relieve the client's dyspnea and wheezing, thus it is not the nurse's priority action. Positioning the client in high-Fowler'sAlthough not the highest priority when a client has an acute asthma exacerbation, it is an important early measure for managing the client's dyspnea. Positioning the client in high Fowler's, leaning forward with the arms propped on an overbed table, promotes chest expansion and optimal gas exchange.

A nurse is caring for a client who is in the immediate postop period following a partial laryngectomy. Which of the following parameters should the nurse assess first? Pain severity Wound drainage Tissue integrity Airway patency

Airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? Cromolyn via metered-dose inhaler Montelukast orally Budesonide via dry-powder inhaler Albuterol via jet nebulizer

Albuterol via jet nebulizer The nurse should identify that albuterol is a bronchodilator used as the first medication of choice to stop bronchospasm or constriction in clients who have acute asthma exacerbation.

12 lead EKG report indicates that ST depression and T-wave inversion. This can be consistent with (select all that apply) Angina STEMI (ST Elevated Myocardial Infarction) NSTEMI (Non ST Elevated Myocardial Infarction)

Angina and NSTEMI The 12 lead EKG report indicates that ST depression and T-wave inversion can be consistent with both angina and a non-ST segment myocardial infarction (MI).

A nurse is caring for a client who has hypertension and develops epitaxis. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) Apply pressure to the nares. Place ice to the bridge of the client's nose. Instruct the client to blow his nose. Tilt the client's head backward Move the client into high-Fowler's position.

Apply pressure to the nares is correct. Applying direct pressure to the lateral aspects of the nose helps to clot the blood. The nurse should apply firm and consistent pressure for several minutes until coagulation occurs. Place ice to the bridge of the client's nose is correct. Placing an ice pack on the nose causes the blood vessels to vasoconstrict, which decreases bleeding. The nurse should use a barrier, such as a wash cloth, to avoid skin damage from the direct application of ice to the skin. Ice packs should not be left on the skin for longer than 20 min. Move the client into high-Fowler's position is correct. Sitting upright facilitates breathing and decreases the risk for aspiration. INCORRECT Instruct the client to blow his nose is incorrect. The nurse should instruct the client to avoid blowing his nose for 24 hr as this can cause dislodgement of clots. The nurse should also discourage coughing, straining, or sneezing as these activities can also cause the blood vessels to weaken, which can trigger rebleeding. Tilt the client's head backward is incorrect. The nurse should tilt the client's body and head forward to decrease the risk for aspiration and swallowing of blood.

A nurse is planning care for a client who has quadriplegia :(. Which of the following actions should the nurse take to prevent Pulmonary Embolism (PE)?SELECT ALL THAT APPLY Assess leg for redness Apply elastic compression stockings Perform passive range of motion exercises Place pillows under the client's knees when in bed Massage the calves every shift

Asses Legs for redness - Redness is an indication of thrombophlebitis formation which can lead to PE. Apply elastic stockings- To prevent thrombophlebitis formation Perform passive range of motions - Helps improve blood return to heart NOT CORRECT: Place pillows under knees- Nurse should avoid any pressure under the popliteal space Massage legs- this can dislodge a thrombus and CAUSE a PE

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? Dependent Rubor Edema Hair loss Thick, deformed toenails

Edema: An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema. Dependent rubor, hair loss and thick gross toenails: are signs of PAD!! not PVD!!

A nurse is caring fora client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? Maintaining a semi-Fowler's position as often as possible Administering oxygen via nasal cannula at 2 L/min Helping the client select a low-salt diet Encouraging the client to drink 2 to 3 L of water daily

Encouraging the client to drink 2 to 3 L of water daily COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration. INCORRECT: Maintaining a semi-Fowler's position as often as possible Although a semi-Fowler's position can help the client breathe more easily, it will not alter the consistency of secretions. Administering oxygen via nasal cannula at 2 L/minAdministration of oxygen helps correct hypoxemia, but it will not alter the consistency of secretions. Helping the client select a low-salt diet Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of secretions.

A nurse is caring for a client who has just developed a pulmonary Embolism. Which of the following medications should the nurse anticipate administering? Furosemide Dexamethasone Heparin Atropine

HEPARIN A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots. term-7 Not Correct: Furosemide: Diuretic, Used to treat pulmonary EDEMA, but not pulmonary embolism Dexamethasone: GC, Used for inflammatory conditions, not pulm. emboli. Atropine: anticholinergic used for bradycardia. Client who has pulmonary embolism will be tachycardic!!

A client is 24-36 hr postoperative. Which surgical procedures places the client at risk for deep-vein thrombosis DVT? Myringotomy Laparoscopic appendectomy Hip Arthroplasty Cataract Extraction

Hip Arthroplasty Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively. Myringotomy-short procedure that promotes fluid drainage through tympanic membrane, pt's are not at risk for DVT. Appendectomy is low risk procedure, no DVT risk. Cataracts-pt's are at risk for infection, and eye damage but NOT DVT!!

A client has varicose veins with ulcerations and lower extremity edema with a report of feeling heaviness. Which nursing diagnosis should the nurse identify as being priority? Impaired tissue perfusion Alteration in body image Alteration in activity tolerance Impaired skin integrity

Impaired Tissue Perfusion: When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? Restrict the client's fluid intake to less than 2 L/day. Provide the client with a low-protein diet. Have the client use the early-morning hours for exercise and activity. Instruct the client to use pursed-lip breathing.

Instruct the client to use pursed-lip breathing. Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD. INCORRECT: Restrict the client's fluid intake to less than 2 L/day. Unless the client has another medical disorder that warrants fluid restriction, he should drink 2 to 3 L of fluid each day. Provide the client with a low-protein diet. Clients who have COPD should consume a high-calorie, high-protein diet to prevent weight loss. Have the client use the early-morning hours for exercise and activity. Clients who have COPD have poor exercise tolerance in the early morning due to the pulmonary secretions that accumulate while the client has been recumbent during the night.

A nurse is caring for a client who has Peripheral Arterial Disease (PAD), which of the following symptoms should the nurse expect to find in the early stage of the disease Pain at Rest Intermittent Claudication Dependent Rubor Foot Pain

Intermittent Claudication Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention.

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? Loud, scratchy sounds Squeaky, musical sounds Popping sounds Snoring sounds

Loud, scratchy sounds Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy. INCORRECT: Squeaky, musical sounds Squeaky, musical sounds caused by air whoosh through narrowed airways are a manifestation of bronchospasms. Popping sounds Popping sounds caused by moving into deflated airways are a manifestation of atelectasis and pneumonia. Snoring sounds Snoring sounds, known as rhonchi, are heard when a client has thick, tenacious secretions.

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following should the nurse notify the provider? Movement of the trachea toward the unaffected side Bubbling of the water in the water seal chamber with exhalation Crepitus in the area above and surrounding the insertion site Eyelets are not visible

Movement of the trachea toward the unaffected side A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately. INCORRECT: Bubbling of the water in the water seal chamber with exhalation The water seal chamber prevents air from re-entering the pleural space. Bubbling in this chamber indicates air is being removed from the client's pleural space, allowing re-expansion of the lung. It should occur during exhalation, coughing, and sneezing. When the air from the pleural space is removed, the bubbling will stop. Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse. Crepitus in the area above and surrounding the insertion site Crepitus, or subcutaneous emphysema, sounds like a crackling noise when palpated. It can be an expected finding in the client who has a pneumothorax and will persist for several hours (or longer, depending on how long it takes the air to be reabsorbed) following evacuation of the pneumothorax. Eyelets are not visibleThe observation of eyelets would indicate to the nurse that the chest tube has been become dislodged from the pleural space and would necessitate reporting to the provider.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate the nurse that the client's lung has re-expanded? Oxygen saturation of 95% No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning. INCORRECT Oxygen saturation of 95% A client can have an oxygen saturation of 95% with or without lung re-expansion. No reports of pleuritic chest pain The client might not report pain if his pain management is effective, not because his lung has re-expanded. Occasional bubbling in the water-seal chamber Occasional bubbling indicates the removal of air from the pleural space, indicating that the lung is not fully re-expanded.