2nd sem
A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." The nurse's initial response should be to: 1 Discuss the client's concerns 2 Clarify the misconception 3 Explain measures to prevent pulmonary emboli 4 Teach recognition of early symptoms of pulmonary embol
1 Addressing the client's feelings and then exploring preventive measures should reduce anxiety. The risk of a pulmonary embolus is a real concern, not a misconception, associated with thrombophlebitis. Explaining measures to prevent a pulmonary embolus is not the client's concern; this response does not address the client's feelings concerning the risk of sudden death. Teaching recognition of early signs and symptoms of pulmonary emboli disregards the client's expressed fears and may increase anxiety.
What information should the nurse include when teaching a client about antacid tablets?
Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, some antibiotics, and cardiac drugs. They may be taken as frequently as every one to two hours without adverse effects. Antacids should be given one or two hours after meals and at bedtime. Liquid antacids have a faster onset of action than tablets.
The nurse who is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB) is aware that this is beneficial for the client through which mechanism?
Prolonged exhalation to decrease air trapping
A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? 1 Observe for fluid fluctuations in the water-seal chamber. 2 Obtain a prescription for morphine to minimize agitation. 3 Apply a thoracic binder to prevent excessive tension on the tube. 4 Clamp the tubing securely to prevent a rapid decline in pressure
1. Fluctuations occur with inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged. The client may not be agitated; morphine depresses respirations and usually is avoided. The binder does not prevent tension on the tube; its use is contraindicated because it limits thoracic expansion. The tube should be clamped only if prescribed or if an air leak is suspected.
A client with tuberculosis is to begin Rifater (combination of isoniazid [INH], rifampin [RIF], and pyrazinamide [PZA]), and streptomycin sulfate (streptomycin) therapy. The client says, "I've never had to take so much medication for an infection before." The nurse should explain: "This type of organism is difficult to destroy." 2 "Streptomycin prevents side effects of Rifater." 3 "You'll only need to take the medications for a couple of weeks." 4 "Aggressive therapy is needed because the infection is well advanced."
1. Multiple drugs are administered because of the concern regarding drug resistance. Streptomycin sulfate is an antibiotic; it does not prevent the side effects of Rifater therapy. Multiple antitubercular drugs are necessary for an extended period, approximately six to eight months depending on the individual. Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.
A client has a leak of thoracic duct following a radical neck surgery. The nurse expects that the postoperative plan of care will include: 1 A gastrostomy tube, a high fat diet, and bed rest 2 A chest tube, total parenteral nutrition (TPN), and bed rest 3 A rectal tube, a low-fat diet, and increased activity 4 A nasogastric tube, a moderate-fat diet, and increased activity
2 A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow. Bed rest is recommended because lymphatic flow increases with activity. A gastrostomy tube is not used because the client can eat and drink; a high-fat diet is contraindicated, but bed rest is recommended. A rectal tube has no relationship to the drainage of chyle from the thoracic area; a low-fat diet and bed rest are recommended. The nasogastric tube does not drain fluid from the thoracic area; a low-fat diet and bed rest are recommended. A low-fat diet of medium-chain triglycerides will reduce the production and flow of chyle.
A client with gastric ulcers has episodes of vomiting blood. What change in the client's blood gases should the nurse expect because of the large amount of blood lost? 1 Hypocapnea 2 Metabolic acidosis 3 Respiratory acidosis 4 Negative nitrogen balance
2 Inadequate tissue perfusion as a result of blood loss leads to anaerobic metabolism and lactic acid production, causing metabolic acidosis. Hypocapnea occurs with respiratory alkalosis; it does not result from loss of blood. Respiratory acidosis may occur as a result of hypoventilation, such as in clients with chronic obstructive pulmonary disease (COPD). Loss of body protein, not blood, over time will lead to a negative nitrogen balance.
A nurse provides smoking cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client states: 1 "I'll just finish the carton that I have at home." 2 "I'll cut back to a half pack a day." 3 "I find that smoking is the only way I can relax." 4 "I should find this easy because I don't smoke when I drink.
2. The response "I'll cut back to a half pack a day" is a positive step in reducing smoking; it is the first step toward stopping. The response "I'll just finish the carton that I have at home" is postponing the decision to quit. The response "I find that smoking is the only way I can relax" is rationalizing why quitting smoking is too difficult. The response "I should find this easy" is unrealistic because giving up smoking is difficult regardless of if the client smokes when alcoholic beverages are consumed.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify: 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing
3 Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.
nurse provides instructions about an appropriate breathing technique to a client with emphysema. The nurse determines that the teaching has been effective when the client states: 1 "I should inhale through my mouth." 2 "I should increase my respiratory rate." 3 "I should hold my breath for one second at the end of inspiration." 4 "I should progressively increase the length of the inspiratory phase."
3 Holding each breath for a second at the end of inspiration allows added time for gaseous exchange at the alveolar capillary beds. Inhalation should be through the nose to moisten, filter, and warm the air. Increasing the respiratory ratedecreases the effectiveness of respirations. The expiratory phase should be lengthened, and exhalation should be through pursed lips.
On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 1 5 mm erythema with no induration 2 No erythema with 3 mm induration 3 7 mm erythema with 5 mm induration 4 5 mm erythema with 10 mm induration
3 Induration of 10 mm or greater is a positive test result in clients with effective immune systems. Erythema without induration is not considered a positive test result. Induration of 0 to 4 mm is not considered a positive test result. Induration of 7 mm erythema with 5 mm is considered a positive reaction in individuals who are immunocompromised or at high risk for tuberculosis.
The postoperative arterial blood gas values are pH 7.32, Pco2 53 mm Hg, and HCO3 25 mEq/L. What action should the nurse take? 1 Obtain a prescription for a diuretic 2 Have the client breathe into a rebreather bag 3 Encourage the client to take deep, cleansing breaths 4 Obtain a prescription for the administration of sodium bicarbonate
3 The client is in respiratory acidosis, probably caused by the depressant effects of an anesthetic or a compromised airway; deep breaths blow off CO2 and encourage coughing. Obtaining a prescription for a diuretic will not correct respiratory acidosis and may aggravate hypokalemia if present. Having the client breathe into a rebreather bag is the treatment for respiratory alkalosis; the client is in respiratory acidosis. Obtaining a medical prescription for the administration of sodium bicarbonate is not necessary if clearing of the airway corrects the problem.
A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position? 1 Supine 2 Contour 3 Orthopneic 4 Semi-Fowler
3 The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.
When clients develop respiratory alkalosis, the nurse expects lab values to reflect: 1 An elevated pH, elevated Pco2 2 A decreased pH, elevated Pco2 3 An elevated pH, decreased Pco2 4 A decreased pH, decreased Pco2
3 an respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the Pco2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated Pco2 partially is compensated metabolic alkalosis. A decreased pH, elevated Pco2 is respiratory acidosis. A decreased pH, decreased Pco2 is metabolic acidosis with some compensation
A client with a history of pulmonary emboli is taking warfarin (Coumadin) daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client states: 1 "Eggs provide a good source of iron, which is needed to prevent anemia." 2 "Yellow vegetables are high in vitamin A and should be included in the diet." 3 "Milk and other high-calcium dairy products are necessary to counteract bone density loss." 4 "Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting."
4. Foods high in vitamin K should be avoided because vitamin K is part of the body's blood clotting mechanism and will counter the effects of warfarin. Foods containing protein and iron are permitted because they are unrelated to blood clotting. Foods containing vitamin A are permitted because vitamin A is unrelated to blood clotting. Foods containing calcium are permitted because calcium is unrelated to blood clotting.
On which of the following should the nurse focus when caring for a client after abdominal surgery? 1 Identifying signs of bleeding. 2 Preventing pressure on the suture site. 3 Encouraging use of an incentive spirometer. 4 Detecting clinical manifestations of inflammation
1 Bleeding and hemorrhage are the most serious concerns. Bleeding disorders are common when bile does not flow through the intestine. Vitamin K, a fat-soluble vitamin synthesized in the small intestine, requires bile salts for its absorption; vitamin K is used by the liver to synthesize prothrombin necessary for clotting. Preventing pressure on the suture site, encouraging use of an incentive spirometer, and detecting clinical manifestations of inflammation are not as serious concerns.
The nurse who cared for a client during the night informs the day shift primary nurse that the client did not tolerate the intermittent gavage feeding. What should be the primary nurse's first action? 1 Assess the night nurse's technique. 2 Change the feeding schedule to omit nights. 3 Request that the type of solution be changed. 4 Suggest that the prescribed antiemetic be given first.
1 Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance; the day shift primary nurse should inquire about the night nurse's technique. Gavage feedings are better tolerated if given continuously or in smaller amounts divided over the entire 24 hours. Requesting that the type of solution be changed is inappropriate and premature at this time. Suggesting that the prescribed antiemetic be given first is inappropriate and premature at this time.
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished?
Airway
Common cause of ARDS?
Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not a common cause.
A client is receiving dexamethasone (Decadron) to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client
Dexamethasone increases gluconeogenesis, which may cause hyperglycemia
A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take?
Rifampin causes a reddish orange discoloration of secretions such as urine, sweat, and tears. While liver enzymes should be monitored because of the risk of hepatitis, this action is not addressing the client's statement. Straining the urine for stones is indicated for renal calculi, which are not related to rifampin. The medication, not food, is responsible for the urine color.
The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis?
TB Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells; it does not cause hemoptysis.
A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1 prepare to intubate the client. 2 Increase the oxygen flow rate per facility protocol. 3 Decrease the tension of oxygen in the plasma. 4 Have the arterial blood gases redone to verify accuracy
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO2 of 65 mm Hg is not severe enough to intubate the patient without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long.
What can be consumed on a clear liquid diet
Water (plain, carbonated or flavored) Fruit juices without pulp, such as apple or white grape Fruit-flavored beverages, such as fruit punch or lemonade Carbonated drinks, including dark sodas (cola and root beer) Gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth (bouillon or consomme) Honey or sugar Hard candy, such as lemon drops or peppermint rounds Ice pops without milk, bits of fruit, seeds or nuts
The nurse is proving education to a client who has a serum albumin value of 2.8 g/dL. The nurse evaluates that teaching is successful when the client says, "For lunch I am going to have:
his serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL; white meat turkey (two slices 4 x 2 x ¼ inch) contains approximately 28 grams of protein. A six-ounce serving of mixed fruit contains approximately 0.5 gram of protein. A three-ounce serving of spinach salad contains approximately 9 grams of protein. A four-ounce serving of beef broth contains approximately 2.4 grams of protein.
