HESI Review
A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 Crackles 2 Cyanosis 3 Chest pain 4 Bradypnea 5 Frothy sputum
1 Crackles 2 Cyanosis 5 Frothy Sputum Crackles signify fluid in the alveoli because of increased capillary permeability associated with pulmonary edema. Cyanosis is evidence of inadequate oxygenation. Frothy sputum results because of the large amount of fluid in the lungs; it may or may not be blood tinged. Chest pain is not a symptom of acute pulmonary edema; this is associated with a pneumothorax. Dyspnea, not bradypnea, is associated with pulmonary edema.
A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply. 1 Oliguria 2 Seizures 3 Vomiting 4 Polydipsia 5 Polyphagia
1 Oliguria 2 Seizures 3 Vomiting Cancerous cells of small cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake.
The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list? 1 Dyspnea 2 Aphonia 3 Hoarseness 4 Subcutaneous emphysema
1. Dyspnea Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore, dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly since it does not threaten the client's life. Subcutaneous emphysema is of moderate priority since it does not affect the client's life directly.
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine 2 Methyldopa 3 Levothyroxine 4 Ferrous sulfate
2 Methyldopa Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
A client returned to the unit following abdominal surgery. Which assessment finding should be reported to the surgeon immediately? 1 Respiratory rate of 10 to 12 during deep sleep. 2 Oxygen saturation drops to 90% from admission 99% saturation. 3 Complaints of pain during deep breathing and coughing exercises. 4 Breath sounds diminished in lung bases prior to deep breathing exercises.
2 Oxygen saturation drops to 90% from admission 99% saturation. If the oxygen saturation drops below 95% (or below the client's presurgery baseline), the nurse should notify the surgeon or anesthesia provider. If it drops by 10 percentage points and it is an accurate measure, the rapid response team should be called. The other findings, lower respiratory rate during sleep, pain on cough and deep breathing exercises and diminished breath sounds from shallow breathing prior to exercises are normal findings.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. 1 Anxiety 2 Oxygenation 3 Drowsiness 4 Mental confusion 5 Increased respirations
2 Oxygenation 3 Drowsiness 4 Mental confusion Clients with chronic obstructive pulmonary disease (COPD) respond to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will decrease the stimulus to breathe, leading to decreased respirations, lethargy, and drowsiness. Oxygenation should be monitored to keep levels within a range to provide adequate oxygen without decreasing the client's drive to breathe. Clients with COPD experience the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Increased levels of carbon dioxide depress the central nervous system, causing mental confusion and a lowered level of consciousness. Rising carbon dioxide levels cause lethargy rather than anxiety.
In what position should the nurse place a client recovering from general anesthesia? 1 Supine 2 Side-lying 3 High Fowler 4 Trendelenburg
2 Side-lying Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client, because it interferes with breathing.
A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? 1 Provide small, frequent meals 2 Encourage pursed-lip breathing 3 Schedule nursing activities to allow for rest 4 Encourage bed rest until energy level improves
3 Schedule nursing activities to allow for rest Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.
A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply. 1 Fever 2 Stridor 3 Wheezing 4 Tachycardia 5 Hypotension
3 Wheezing 4 Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase. An increased temperature is characteristic of sepsis, not asthma. Stridor is due to foreign body obstruction, not asthma. Hypertension, not hypotension, may occur with asthma.
A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound? 1 Inflammation of the pleura 2 Muscular spasms in the larger airways 3 Sudden reinflation of groups of alveoli 4 High velocity airflow through an obstructed airway
4 High velocity airflow through an obstructed airway Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? 1 Forced vital capacity 2 Functional residual capacity 3 Forced expiratory volume in 1 second 4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.
