MedSurg-PPT NCLEX Q's Exam 1

The nurse understands which is the primary risk factor for lung cancer? A.Air pollution B.Cigarette smoking C.Chronic exposure to asbestos D.Occupational radiation exposure

Answer: B Rationale: According to the American Cancer Society, cigarette smoking remains the primary risk factor and is responsible for 9 out of 10 cases of lung cancer. Occupational exposure, secondhand smoke, asbestos, advancing age, and family history are additional risk factors

A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to implement which intervention? 1.Administering nasal oxygen 2.Placing the client on a cardiac monitor 3.Preparing the client for a perfusion scan 4. Ensuring that the intravenous (IV) line is patent

1 Rationale: Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. The electrocardiogram (ECG) is monitored for the presence of dysrhythmias. A perfusion scan, among other tests, may be performed. IV infusion lines are needed to administer medications or fluids. Additionally a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1.Pleural pain and fever 2.Decreased respiratory rate 3.Diaphoresis during the day 4.Hyperresonant breath sounds over the left thorax

1 Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

The nurse is monitoring a client for bradypnea. Which description is characteristic of this respiratory pattern? 1.Regular but abnormally slow 2.Labored and increased in depth and rate 3.Regular but interspersed with periods of apnea 4.Abnormally deep, regular, with increased rate

1 Rationale: Bradypnea is characterized by respirations that are regular but abnormally slow. Hyperpnea is characterized as respirations that are labored and increased in depth and rate. Respirations that cease for a number of seconds are identified as apnea. Kussmaul's respirations are abnormally deep, regular, and increased in rate.

A clinic nurse notes that large numbers of clients present with flu like symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. 1.Get plenty of rest. 2.Increase intake of liquids. 3.Take antipyretics for fever. 4.Get a flu shot immediately. 5.Eat fruits and vegetables high in vitamin C

1,2,3,5 Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client? Select all that apply. 1.Supplemental oxygen 2.High-Fowler's position 3.Semi-Fowler's position 4.Morphine sulfate intravenously 5.Two tablets of acetaminophen with codeine 6.Meperidine hydrochloride intravenously

1,2,4 Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation. From Professor Roberts A better piece of information for this question would be a dose. We would want to give the lowest dose with effect as not to suppress the respiratory system.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1,3,4,5 Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse knows that an inflated cuff for a tracheostomy is indicated for which client? Select all that apply. 1.A client at risk for aspiration 2.A client who is physically dependent 3.A client who needs to be able to speak 4.A client who requires mechanical ventilation 5.A client who requires assistance with activities of daily living

1,4 Rationale: For clients who require a tracheostomy, the primary health care provider may choose to use an inflated cuff. This is indicated for clients who are at risk for aspiration and who require mechanical ventilation. Inflated cuffs exert pressure on the tracheal mucosa. Inflated cuffs cannot be used for clients who need to speak; a fenestrated-type of cuff needs to be used in order for the client to be able to speak. A client who is physically dependent and who requires assistance with activities of daily living are not indications for this type of cuff.

The nurse is suctioning a client who has an endotracheal tube in place. Which finding indicates that the client is experiencing an adverse effect of this procedure? 1.Cardiac irregularities 2.Oxygen saturation level of 95% 3.A reddish coloration in the client's face 4.Apical pulse rate of 80 beats per minute

1. Rationale: Adverse effects of suctioning include hypoxemia, cardiac irregularities caused by vagal stimulation, mucosal trauma, and paroxysmal coughing. If these occur during the procedure, the procedure is stopped and the client is reoxygenated. Options 2 and 4 are normal findings. A reddish coloration in the client's face may occur during suctioning but should quickly resolve when the suction catheter is removed from the client.

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. 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, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe.

2 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 a dependent loop exists, the suction is not working properly, or the lung has re-expanded. Because this finding is expected, it is not necessary to notify the HCP. 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. What if the chest tube dislodges from the chest. Cover with a gauze dressing and call MD - p. 592 Even though dressed with occlusive dressing.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? 1. Place the client in supine position 2.Apply an ice collar round clients neck 3.Assist the client in a sitting position with the head tilted forward 4.Instruct the client to swallow the blood until the bleeding an be controlled

3 Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? 1.Equal bilateral chest expansion 2.Respiratory rate of 22 breaths per minute 3.Diminished breath sounds on the affected side 4.Few scattered wheezes, unchanged from baseline

3 Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.

The nurse is caring for a client with a newly placed tracheostomy. Which emergency equipment should be available at the bedside? Select all that apply. 1.Tongue blade 2.Endotracheal tube 3.Tracheostomy tube 4.Tracheostomy insertion tray 5.Manual resuscitation bag with face mask

3,4,5 Rationale: When a new tracheostomy is placed, the nurse must plan for accidental dislodgment. Emergency equipment at the bedside would include an additional tracheostomy tube, an emergency tracheostomy tray (in case of difficulty placing the new tracheostomy), and a manual resuscitation bag with a face mask to ventilate the client during tube replacement. Options 1 and 2 are not necessary equipment for the client with a newly placed tracheostomy.

A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? 1.Thyroid cancer 2.Acute laryngitis 3.Laryngeal cancer Bronchogenic cancer

3. Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.

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

4 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 student nurse is listening to a respiratory lecture on wheezing. Which statement by the student nurse indicates that the teaching has been effective? 1."Wheezing is caused by a grating noise heard on expiration." 2."Wheezing consists of a gurgling noise heard on expiration." 3."A creaking noise heard on inspiration indicates wheezing." 4."Wheezing sounds like a musical or hissing noise heard on inspiration."

4 Rationale: A wheeze is a continuous musical or hissing noise that results from the passage of air through a narrowed airway. Wheezes are heard during inspiration or expiration or both. Severe wheezes are audible without a stethoscope. Wheezing is commonly associated with asthma and bronchoconstriction and edema, but foreign body obstruction can also cause airway narrowing and wheezing. Options 1 and 3 describe a pleural friction rub. Option 2 describes rhonchi.

A client is experiencing difficulty coping with decreased ability to tolerate activity because of respiratory disease. The home care nurse determines that the client is showing an adaptive response when which behaviors are observed? 1.Has learned to scale back expectations related to activity 2.Increases the use of medication in order to sleep 8 hours nightly 3.Spends most of the day in one room of the home to decrease fatigue 4.Tries to increase ambulation and complete some small tasks each day

4 Rationale: The client with respiratory disease may have difficulty coping with decreased ability to tolerate activity and social isolation. The client demonstrates adaptive responses by increasing the activity to the highest level possible before symptoms are triggered, using relaxation or other learned coping skills, or enrolling in a pulmonary rehabilitation program. Enhancing self-seclusion, minimizing expectations, and medicating for insomnia are not adaptive responses.

A nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest drainage system accidentally disconnects. Which is the initial nursing action? 1. Call a respiratory therapist. 2. Contact the health care provider (HCP). 3. Encourage the client to perform the Valsalva maneuver. 4. Place the end of the chest tube in a container of sterile water.

4 Rationale: If a chest tube becomes disconnected, the nurse should as quickly as possible place the end of the tube in a container of sterile water or saline until the drainage system can be replaced. It is not necessary to contact a respiratory therapist at this time. It may be necessary to contact the HCP, but this would not be the initial nursing action. Asking the client to perform a Valsalva maneuver is not appropriate and could be harmful.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Exhale slowly. 2. Stay very still. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4 Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). 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 client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years? Fill in the blank and record your answer using one decimal place.

7.5 Rationale: The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked three-fourths of a pack per day for 10 years is 0.75 pack × 10 years = 7.5 pack-years.

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A.Administer the rescue drugs. B.Take the patient's vital signs. C.Notify the patient's prescriber. D.Repeat the PEF reading to verify the results.

Answer: A Rationale: A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive rescue drugs immediately, and then the prescriber should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs.

An 83-year-old patient is brought to the ED reporting a productive cough with fever for the last 48 hours. She appears flushed and very short of breath when answering questions. She has a history of type 2 diabetes mellitus and hypertension, but no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) are drawn in the ED. A saline lock is inserted into her right forearm. She is admitted to the medical-surgical unit with a diagnosis of suspected pneumonia. The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG - 239 mg/dL BP - 138/88 mm Hg HR - 128 RR - 36 breaths/min O2 saturation - 88% (room air) Temp - 101.6º F Which vital sign or test result requires the nurse's immediate attention? A.Blood pressure B.Respiratory rate C.Temperature D.Blood glucose

Answer: B All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.

While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The provider writes several orders. Which order is most important for the nurse to implement immediately? A.Transfer to ICU B.Increase O2 to 3 L per nasal cannula C.ABGs 30 min after oxygen is increased D.Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP

Answer: B All of the provider's orders are very important, but based on the patient's severe shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU as soon as possible. Once the patient arrives in the ICU, they can administer the one-time dose of Solu-Medrol.

After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr. Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hr. for temp above 101º F Cefazolin (Ancef) 1 g IVP every 8 hr. Which of the provider's orders should the nurse implement first? A.IV fluids 1000 mL .9 NS at 60 mL/hr. B.Oxygen at 2 L per nasal cannula C.Blood cultures and urinalysis D.Cefazolin (Ancef) 1 g IVP every 8 hr.

Answer: B All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.

The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)? A.29-year old male who is overweight B.32-year-old female with a family history of PH C.43-year-old male with history of right-sided heart failure D.50-year-old female with history of blood clots in the pulmonary artery

Answer: B Rationale: Family history is a primary risk assessment variable related to pulmonary hypertension (PH) and pulmonary artery hypertension (PAH). The disease usually develops between the ages of 20 to 60, and occurs more often in women. Other risk factors include obesity, heart and lung diseases, HIV infection, and history of pulmonary embolisms.

A 55-year-old woman with a long history of COPD and 40 years of smoking cigarettes is being admitted to the pulmonary step-down unit from the ED. The ED nurse reports that the patient is on oxygen at 2 L per nasal cannula after having bronchodilator respiratory treatment in the ED. She has bilateral expiratory wheezes and crackles both anteriorly and posteriorly. A saline lock was placed in her right forearm for intermittent medications. Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.) A.Bradycardia B.Shortness of breath C.Use of accessory muscles D.Sitting in a forward posture E.Barrel chest appearance

Answer: B, C, D, E The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.

A patient is admitted with cough, fever, sore throat, progressive shortness of breath, diarrhea, and vomiting that developed after returning from a business trip overseas. The nurse suspects which illness is the likely cause of the patient's symptoms? A.Pneumonia B.Viral influenza C.Avian influenza D.Tuberculosis exposure

Answer: C Rationale: The initial manifestations of avian influenza are similar to other respiratory infections but include cough, fever, sore throat, shortness of breath, pneumonia, diarrhea, vomiting, abdominal pain, and bleeding from the nose and gums. Assess whether the patient has recently (within the past 10 days) traveled to areas of the world affected by H5N1. Pneumonia and tuberculosis exposure will not present with gastrointestinal symptoms.

The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? A.Fever B.Cough C.Confusion D.Weakness

Answer: C Rationale: The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.

A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? A.Influenza B.Pneumonia C.Tuberculosis D.Pulmonary empyema

Answer: D Rationale: Patients with pneumonia, tuberculosis, and influenza may experience some or all of the symptoms of fever, chills, night sweats, and weight loss. However, because pulmonary empyema is a collection of pus in the pleural space that may cause compromised cardiac function, displaced point of maximal impulse (PMI), and hypotension may result.

Is the following statement true or false? Bradypnea is the most common sign for a possible pulmonary embolism

False Rationale: Tachypnea is the most common sign for a possible pulmonary embolism

The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath when resting during the assessment. The provider plans to discharge the patient on home oxygen in the morning. What should the nurse include in this patient's discharge teaching?

Make sure that the patient understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.

When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula. Based on these findings, what should the nurse do next?

The Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC.

Two hours later, the patient has a weak cough, crackles in both lower lobes, and an SaO2 reading of 90% by pulse oximetry. What interventions should be implemented by the nurse at this time?

The patient has developed problems with her airway. Interventions should include helping her to cough and deep breathe at least every 2 hours; teaching incentive spirometry every hour while awake; encouraging the patient to consume 3 L of fluid per day; monitoring intake and output; and administering bronchodilators if ordered.