Med Surge Exam 1 Review Questions

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1.Aids in exhalation 2.Moves up and inward 3.Moves downward and out 4.Makes the thoracic cage smaller

Answer 3.Moves downward and out Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

Answer: 1. Cough 2.Dyspnea 5.Chills and night sweats Rationale: The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

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 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing

Answer: 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 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.

Which are possible causes of upper airway obstruction? Select all that apply. 1.Thin secretions 2.Laryngeal edema 3.Head and neck cancer 4.Foreign body aspiration 5.Lymph node enlargement

Answer: 2.Laryngeal edema 3.Head and neck cancer 4.Foreign body aspiration 5.Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) 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? 1.Prevents the client from getting a nosebleed 2.Gives the client added fluid via the respiratory tree 3.Humidifies the oxygen that is bypassing the client's nose 4.Prevents fluid loss from the lungs during mouth breathing

Answer: 3.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).

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1.Dilate the major bronchi. 2.Increase surfactant production. 3.Maintain inflation of the alveoli. 4.Enhance ciliary action in the tracheobronchial tree.

Answer: 3.Maintain inflation of the alveoli. Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? 1."I will discard used tissues in a plastic bag." 2."I need to wash my hands at least 4 times a day." 3."I will brush my teeth and rinse my mouth once a day." 4."I will turn my head to the side if I need to cough or sneeze."

Answer: "I will discard used tissues in a plastic bag." Rationale: Used tissues are discarded in a plastic bag. The client with TB should wash the hands carefully after each contact with respiratory secretions. Oral care should be done more frequently than once a day. The client should not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? 1.Contact the health care provider (HCP). 2.Document the finding in the client's record. 3.Call the employee health service department. 4.Call the radiology department for a chest radiographic study to be done

Answer: 1.Contact the health care provider (HCP). The nurse who obtains a positive test reading should call the HCP immediately. The HCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided.

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? 1.16% 2.21% 3.30% 4.40%

Answer: 2.21% 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 is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Lying on the back in a low Fowler's position 4.Sitting up with the elbows resting on the knees

Answer: 3.Lying on the back in a low Fowler's position Rationale: The client should not lie on the back because this reduces movement of a large area of the client's chest wall. The client should use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? 1.6 to 12 hours 2.12 to 24 hours 3.24 to 28 hours 4.48 to 72 hours

Answer: 4.48 to 72 hours Rationale: The tuberculin skin test is an accurate and reliable test that will provide information to the health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result should be done 48 to 72 hours after the injection

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? 1.1 or 2 days 2.1 to 2 weeks 3.Almost 1 week 4.Several weeks to months

Answer: 4.Several weeks to months Rationale: The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? 1.The client will lose consciousness. 2.The client's sodium and chloride levels will rise. 3.The client will complain of facial numbness and tingling. 4.The client's arterial blood gas results will reflect acidosis.

Answer: 4.The client's arterial blood gas results will reflect acidosis. 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.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? 1.An uninsured man who is homeless 2.A newly immigrated woman from Korea 3.A man who is an inspector for the U.S. Postal Service 4.An older woman admitted from a long-term care facility

Answer: A man who is an inspector for the U.S. Postal Service Rationale: Clients at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus infection or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1.A shunt unit exists. 2.Anatomical dead space is present. 3.Physiological dead space is present. 4.Ventilation-perfusion matching is occurring

Answer: A shunt unit exists Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? 1.Instruct the client to limit fluid intake. 2.Place the client in low Fowler's position. 3.Administer the prescribed bronchodilator. 4.Place a continuous pulse oximeter on the client.

Answer: Administer the prescribed bronchodilator. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. 1.Dyspnea 2.Headache 3.Night sweats 4.A bloody, productive cough 5.A cough with the expectoration of mucoid sputum

Answer: Dyspnea, Night sweats, A bloody, productive cough, A cough with the expectoration of mucoid sputum Rationale:Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate 1.Increase to 3 L/min and titrate until the SpO2 is 95%. 2.Increase to 3 L/min and titrate until the SpO2 is 88%. 3.Place the client on a nonrebreather mask on 100% FiO2. 4.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

Answer: Increase to 3 L/min and titrate until the SpO2 is 88%. Rationale: Oxygen is used cautiously and should be titrated to the lowest amount needed; however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and the current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%. An SpO2 of 95% is the recommended level for a healthy individual; therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? 1.Aids in exhalation as it contracts 2.Moves up and inward as it contracts 3.Moves downward and out as it contracts 4.Makes the thoracic cage smaller as it contracts

Answer: Moves downward and out as it contracts Rationale: As the diaphragm contracts it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, the remaining options are incorrect.

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? 1.Positive 2.Negative 3.Uncertain 4.Borderline

Answer: Negative Rationale: A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. The remaining options are incorrect interpretations.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history ? 1.Focus only on the physical examination. 2.Obtain all information from family members. 3.Use the health care provider's medical history. 4.Plan short sessions with the client to obtain data.

Answer: Plan short sessions with the client to obtain data. Rationale: The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 3 is incorrect because the health care provider's medical history provides data that are different from the nurse's assessment. All efforts should be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1.Initiate and maintain supplemental oxygen as prescribed. 2.Plan activities with rest periods to conserve oxygen needs. 3.Provide nasotracheal suctioning as needed to remove secretions. 4.Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

Answer: Provide nasotracheal suctioning as needed to remove secretions Rationale: Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is in the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1.Cyanosis 2.Hyperinflated chest 3.Rapid, shallow respirations 4.Coarse crackles auscultated bilaterall

Answer: Rapid, shallow respirations Rationale: An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

A client's baseline vital signs 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 should the nurse anticipate in this client as part of the body's response to the change in status? 1.Respiratory rate of 12 breaths/min 2.Respiratory rate of 16 breaths/min 3.Respiratory rate of 18 breaths/min 4.Respiratory rate of 22 breaths/min

Answer: 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 performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1.Chest x-ray 2.Bronchoscopy 3.Sputum culture 4.Tuberculin skin test

Answer: Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? 1.The client has no risk of acquiring TB and needs no further workup. 2.The client is at increased risk for acquiring TB and needs immediate medication therapy. 3.The client's test result will be negative, and a sputum culture will be required for diagnosis. 4.The client's test result will be positive, and a chest x-ray study will be required for evaluation.

Answer: The client's test result will be positive, and a chest x-ray study will be required for evaluation Rationale: The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? 1.This is expected and will last for at least 1 year. 2.This is expected, and the client should gradually increase activity as tolerated. 3.This is an unexpected finding with TB, but it should resolve within 1 month or so. 4.This is a short-lived problem that should be gone within 1 week after beginning medication therapy.

Answer: This is expected, and the client should gradually increase activity as tolerated. Rationale:The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 3, and 4 are incorrect information.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?

Answer:3.Adjust the oxygen depending on SpO2. Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. All other options are incorrect.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? 1.Low cardiac output secondary to cor pulmonale 2.Gas exchange alteration related to ventilation-perfusion mismatch 3.Altered breathing pattern secondary to increased work of breathing 4.Inability to clear the airway related to inability to expectorate sputum

Answer:4.Inability to clear the airway related to inability to expectorate sputum Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.

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? 1.Muscle weakness in the arms and legs 2.A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C) 3.A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4.A heart rate of 80 beats/minute, decreased from 85 beats/minute

Answer: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, term-5and 4 present normal assessment findings.

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? 1.Systemic tuberculosis 2.Pulmonary tuberculosis 3.Exposure to tuberculosis 4.No evidence of tuberculosis

Answer:Exposure to tuberculosis Rationale:A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Options 1, 2, and 4 are incorrect interpretations of the data presented in the question.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing

Answer:Postive Rationale: The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? 1.Allow the client to deal with the disease in an individual fashion. 2.Ask family members whether they wish a psychiatric consultation. 3.Encourage the client to visit with the pastoral care department's chaplain. 4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

Answer:Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale:A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

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? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar

Answer:Venturi mask 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