Adult II - Exam 2 practice questions

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? - Bronchogenic carcinoma - Pleurisy - A lung infection - Bacterial pneumonia

- Pleurisy

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 120 mm Hg 45 mm Hg 58 mm Hg 84 mm Hg

84 mm Hg 60 to 95 mm Hg is norm

A postop patient who had a bronchoscopy two hours ago is NPO and states that he is hungry. What should the nurse do? A. Check for a gag reflex return B. Notify the physician C. Calmly tell the patient that he must remain NPO until another four hours D. Order food since the patient is A&O

A. Check for a gag reflex return

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension

Which of the following assessment should be completed if suspecting immune dysfunction in the neurosensory system? Ataxia Hematuria Burning on urination Urinary frequency

Ataxia

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? Auscultation Chest X-ray Arterial blood gas (ABG) levels Inspectio

Auscultation

Which of the following cell types are involved in humoral immunity? Memory T lymphocyte B lymphocytes Helper T lymphocyte Suppressor T lymphocyte

B lymphocytes

The nurse comes into the patient's room and discovers that the patient's pulse oximetry reading is 91%. The nurse should first: A. Notify the Rapid Response Team B. Assess the patient's respiratory status C. Apply supplemental oxygen D. Place patient in high-Fowler's position

B. Assess the patient's respiratory status

A nurse is caring for a patient who had a thoracentesis eight hours ago. While assessing the patient, the nurse observes that the patient has a rapid heart rate, rapid, shallow respirations, and has absent breath sounds to the left upper lobe of the lung. The nurse interprets this complication as: A. Pulmonary embolism B. Respiratory distress C. Pneumothorax D. Flail chest

C. Pneumothorax

A client suspected of having HIV has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? CBC ELISA Western Blot Schick

ELISA [enzyme-linked immunosorbent assay (ELISA) test = initial HIV screening test, is positive when there are sufficient HIV antibodies; also is positive d/t antibodies from other infectious dz's. If ELISA is positive 2X then Western Blot test is run > CBC and a Schick test are not screening tests for HIV

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Delirium Hyperventilation Hypoxia Semiconsciousness

Hypoxia

HIV is harbored within which type of cell? Platelet Erythrocyte Nerve Lymphocyte

Lymphocyte

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Hypoxia Oxygen-induced atelectasis Oxygen toxicity Oxygen-induced hypoventilation

Oxygen toxicity

Which assessment finding is *not* likely to cause noncompliance with antiretroviral treatment? Past substance abuse Lack of social support Depression Active substance abuse

Past substance abuse > all others are RF for poor compliance

Which type of ventilator has a present volume of air to be delivered with each inspiration? Negative-pressure Pressure-cycled Time-cycled Volume-controlled

Volume-controlled

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. - "I just changed into my running suit; we can do my CPT now." - "I have been coughing all morning and am barely bringing anything up." - "I just finished eating my lunch, I'm ready for my CPT now." - "I received my pain medication 10 minutes ago, let's do my CPT now."

- "I just finished eating my lunch, I'm ready for my CPT now." For CPT: no restrictive clothing, not after meals d/t aspiration risk - give med's for pain PRN, splint any incision & provide pillows for support before any percussion/vibration Goal of CPT: mobilize secretions, meaning pt's w/ unproductive cough (d/t low viscosity secretions) are candidates for CPT

The nurse is instructing a male client about safer sexual behaviors. Which client statement indicates a need for additional instruction? - "I will apply baby oil to lubricate the condom." - "I should use a new condom each time I have sex." - "After having sex, I should hold onto the condom when pulling out." - "My partner and I should avoid manual-anal intercourse."

- "I will apply baby oil to lubricate the condom." > use only water-soluble lubricant, such as K-Y jelly or glycerin

The nurse receives a phone call at the clinic from the family of a patient with AIDS. They state that the patient started "acting funny" after complaining of headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? - "This is one of the side effects from antiretroviral therapy and will require changing the medication." - "The patient probably has pneumocystis pneumonia and will need to be evaluated by the physician." - "The patient probably has a case of the flu and you should give Tylenol." - "The patient may have cryptococcal meningitis and will need to be evaluated by the physician."

- "The patient may have cryptococcal meningitis and will need to be evaluated by the physician." This dz l/t nero dz: Cryptococcal meningitis characterized by s/s: fever, headache, malaise, stiff neck, n/v, mental status changes, & seizures.

The nurse is instructing client's about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? - A 17-year-old client who will be attending college and living in a dormitory - A 65-year-old client who had chicken pox when he was 12 years old - A 32-year-old client who has never had chickenpox - A 24-year-old client who is pregnant

- A 65-year-old client who had chicken pox when he was 12 years old Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential seriousness and risk for complications.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? - A client experiencing hypothermia - A client sitting in a chair after prolonged bed rest - A client receiving oxygen therapy via Venturi mask - A client on a ventilator with PEEP

- A client experiencing hypothermia

The nurse is suctioning a patient with an endotracheal tube. Which of the following is a correct technique for this procedure? A. Suction for 5 seconds B. Apply suction during insertion C. Suction the mouth before suctioning the airway D. Hyperoxygenate before and after suctioning

D. Hyperoxygenate before and after suctioning

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? - A partial rebreathing mask - A Venturi mask - A nasal cannula - An oropharyngeal catheter

- A partial rebreathing mask

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? - Increased drainage - Air leak - Tension pneumothorax - Tidaling

- Air leak

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking? - Aspirin - Bronchodilators - Cardiac glycosides - Angiotensin converting enzyme (ACE) inhibitors

- Angiotensin converting enzyme (ACE) inhibitors

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by ____. - HIV-1 is more prevalent than HIV-2 subtypes - Means of transmission - Cure rate of the virus - The fact that it is a mutated virus originally thought to be bovine in nature

- HIV-1 is more prevalent than HIV-2 subtypes ~HIV-1 mutates easily & frequently, producing multiple substrains identified by letters A thru O ~HIV-2 is less transmittable; interval between initial infection & dvlpmnt AIDS is longe ~HIV-1 = >prevalent in US & rest of world.; Western Africa= primary site of HIV-2. ~no cure for HIV/AIDS; hence, no cure rate. T ~HIV thought to be a mutation of a simian virus

A patient undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The patient becomes anxious because the area begins to swell. Which of the following may be used to decrease anxiety in this patient? - Advise the patient to use prescribed analgesics - Assure the patient that this is a normal reaction - Apply ice packs to reduce the swelling - Gently rub the swollen area to accelerate the blood flow

- Assure the patient that this is a normal reaction > injection area swells d/t developing antibodies against antigen introduced > pt not necessarily actively infectious if results are positive. Rubbing area gently or applying ice packs may only aggravate swelling.--area should be left open to heal by itself

A client is prescribed didanosine (Videx) as part of his highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? - "When you take this drug, eat a high-fat meal immediately afterwards." - "It doesn't matter if you take this drug with or without food." - "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." - "You should take the drug with an antacid."

- Be sure to take this drug about 1/2 hour before or 2 hours after you eat." > take 30 to 60 min before or 2 hr after meal. ~Other antiretroviral rx's [i.e. abacavir, emtricitabine, lamivudine] don't matter in r/t meals. > atazanavir should be taken w/ food & not w/ antacids. > avoid High-fat when taking amprenavir.

Diagnosis of Kaposi's sarcoma (KS) is made by which of the following? - Skin scraping - Visual assessment - Biopsy - CT scan

- Biopsy

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? - By placing the call button under the client's pillow - By providing a tracheostomy plug to use for verbal communication - By supplying a magic slate or similar device - By suctioning the client frequently

- By supplying a magic slate or similar device use nonverbal communication method, such as magic slate, note pad, pencil, picture boards (if pt can't write or speak English). Use tracheostomy plug when pt is being weaned off tracheostomy; doesn't enable the client to communicate.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse - Contacts the respiratory therapy department to report the ventilator is malfunctioning - Changes the setting on the ventilator to increase breaths to 14 per minute - Consults with the physician about removing the client from the ventilator - Continues assessing the client's respiratory status frequently

- Continues assessing the client's respiratory status frequently > SIMV setting allows pt to breathe spontaneously w/ no assistance from ventilator for those extra breaths. > Data in the stem suggest that the ventilator is working correctly. >Not sufficient data to suggest pt could be removed from venti. > no reason to increase to 14 rr or to contact respiratory therapy to report machine not working

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? - Deflating the cuff routinely - Ensuring that humidified oxygen is always introduced through the tube - Checking the cuff pressure every 6 to 8 hours - Deflating the cuff prior to tube removal

- Deflating the cuff routinely > Routine deflation not recommended d/t increased risk of aspiration & hypoxia. ~Deflated before ET is removed ~pressures should be checked q6-8 hr ~Humidified oxygen should always be intro thru the tube

A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used? - The medication, given orally, will cause diarrhea. - Digestive enzymes destroy its protein structure. - The taste of the medication is not palatable. - The medication will work more rapidly parenterally.

- Digestive enzymes destroy its protein structure.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? - Suction the patient since the patient may be obstructed by secretions. - Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. - Call respiratory therapy and wait until they arrive to determine what is happening. - Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops.

- Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. > manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? - Don't cough. - Don't eat. - Don't walk. - Don't talk.

- Don't eat.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? - Encourage the patient to take approximately 10 breaths per hour, while awake. - Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. - Encourage the patient to try to stop coughing during and after using the spirometer. - Have the patient lie in a supine position during the use of the spirometer.

- Encourage the patient to take approximately 10 breaths per hour, while awake. > semi-Fowler's or upright before initiating thx > coughing during & after sessions encouraged > pt can splint incision when coughing post-op > use spirometer despite pain.

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons? - Blood products cause a high risk for hepatitis B. - Blood products cause a high risk for exposure to HIV. - Blood products cause lower antibody titers. - Exposure to foreign antigens may cause altered immune function.

- Exposure to foreign antigens may cause altered immune function. > past exposure to foreign antigens via transfusion may be r/t abnormal immune fxn. > only very sm risk for HIV transmission w/ transfusions after 1985. > risk for hepatitis B via blood transfusions is extremely sm

Geoffrey, an 8-year-old boy, attends the grammar school where you practice nursing. Geoffrey has a known allergy to peanuts. If Geoffrey has any contact with peanuts, he will develop a severe allergic reaction. The school nurse meets with all of Geoffrey's teachers to explain the process involved. In her discussion, the nurse explains that Geoffrey's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if Geoffrey should come in contact with peanuts again. The formation of these specific cells is known as which of the following? - Humoral response - Cell-mediated response - Inflammatory response - Memory response

- Humoral response > Plasma cells produce antibodies. Formation of antibodies is called a humoral response.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? - Decreased cardiac output - Ineffective airway clearance - Impaired spontaneous ventilation - Impaired gas exchange

- Impaired gas exchange

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? - Perform this measure with the client once a day. - Administer bronchodilators and mucolytic agents following the sequence. - Use aerosol sprays to deodorize the client's environment after postural drainage. - Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

- Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. > done 2-4 times/day > before meals ppx N/V, aspiration > done at bedtime To reduce bronchospasm, thickness of mucus and sputum, and combat edema of the bronchial walls, use of bronchidilators before, water/saline via nebulizer > if sputum smells bad, isolate pt during procedure from other pt's/family--deoderizers may be used sparingly to counteract odor, but extreme caution w/ aerosols d/t ability to l/t spasm/irritation

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: - Lymphocytes migrate to areas of the lymph node - Antibodies are released into the bloodstream - B-lymphocytes respond to a specific antigen - Antibodies reside in the plasma

- Lymphocytes migrate to areas of the lymph node > Lymphocytes migrate to become plasma cells

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? - Manual resuscitation bag - Water-seal chest drainage set-up - Tracheostomy cleaning kit - Oxygen analyzer

- Manual resuscitation bag

Matt Carson, a 20-year-old college student, was riding his motorcycle home from class when he lost control of the bike and sustained serious internal injuries, including a ruptured spleen. Matt has been taken to the OR to remove his spleen and the ED nurse is meeting with Matt's parents to answer some of their additional questions. Which of the following will be included in the nurse's discussion regarding special considerations following the removal of Matt's spleen? - Matt will be susceptible to acidosis because the spleen maintains acid-base balance. - Matt will be susceptible to anemia because the spleen produces red blood cells. - Matt will be susceptible to infection because the spleen removes bacteria from the blood. - Matt will be susceptible to bleeding because the spleen synthesizes vitamin K.

- Matt will be susceptible to infection because the spleen removes bacteria from the blood.

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? - There is no immunity passed down from mother to child. - Naturally acquired active immunity - Artificially acquired active immunity - Passive immunity transferred by the mother

- Passive immunity transferred by the mother

A patient with HIV develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this patient? - Tuberculosis - Pneumocystis pneumonia - Community-acquired pneumonia - Mycobacterium avium complex (MAC)

- Pneumocystis pneumonia

What is the function of the thymus gland? - Produce stem cells - Programs B lymphocytes to become regulator or effector Bcells. - Develop the lymphatic system - Programs T lymphocytes to become regulator or effector T cells.

- Programs T lymphocytes to become regulator or effector T cells.

A nurse is preparing to administer saquinavir, which is prescribed for a client who is HIV positive. The nurse integrates knowledge of this drug, identifying it as which of the following? - Protease inhibitor (PI) - Fusion inhibitor - Nucleoside reverse transcriptase inhibitor (NRTI) - Non-nucleoside reverse transcriptase inhibitor (NNRTI)

- Protease inhibitor (PI) > Enfuvirtide, maraviroc = fusion inhibitors. > delavirdine , nevirapine = NNRTIs > abacavir, didanosine, lamivudine, zalcitabine = NRTIs

A client with HIV will be started on a medication regimen of three medications. Which medication will be given that will interfere with the virus's ability to make a genetic blueprint. What drug will the nurse instruct the client about? - Protease inhibitor - Integrase inhibitors - Reverse transcriptase inhibitors - Hydroxyurea (Hydrea)

- Reverse transcriptase inhibitors

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? -Plasma, which depletes the body's store of catecholamines -Serum, which depletes the body's store of glucagon -Plasma, which depletes the body's store of calcitonin - Serum, which depletes the body's store of immunoglobulins

- Serum, which depletes the body's store of immunoglobulins depletes essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: - Cool air humidified through the tube - Symmetry of the client's chest expansion - A scheduled time for deflation of the tracheal cuff - Tracheal cuff pressure set at 30 mm Hg

- Symmetry of the client's chest expansion

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: - Lay in bed with the head on a pillow. - Perform drainage 1 hour after meals. - Hold each position for 5 minutes. - Take prescribed albuterol (Ventolin) before performing postural drainage.

- Take prescribed albuterol (Ventolin) before performing postural drainage. will open airways & promote drainage. Pt is to perform postural drainage before meals, not after. -Will ppx N/V & aspiration. For secretions accumulated in upper lobes, sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? - The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC). - The nurse should send the client to have the blood drawn without informing him about the specific screening test. - The nurse ensures a written consent is obtained prior to testing. - The nurse will call the client with the results of the test.

- The nurse ensures a written consent is obtained prior to testing. > nurse ensures consent is obtained before HIV testing & keeps results of HIV testing confidential

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? - The patient is in a hypermetabolic state. - The patient is having a stress reaction. - The patient is having a myocardial infarction. - The patient is hypoxic from suctioning.

- The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating catheter 360 degrees (no > 10-15 seconds). Prolonged suctioning may l/t hypoxia & dysrhythmias, L'ing/t cardiac arrest.

A patient arrives at the clinic and informs the nurse that she has a very sore throat as well as a fever. A rapid strep test returns a positive result and the patient is given a prescription for an antibiotic. How did the streptococcal organism gain access to the patient to cause this infection? - Breathing in airborne dust - From being outside in the cold weather and decreasing resistance - Through the skin - Through the mucous membranes of the throat

- Through the mucous membranes of the throat

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? - Tidal volume - Maximal voluntary ventilation - Vital capacity - Functional residual capacity

- Tidal volume

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the: - Lower margin around the liver. - Lower right abdomen. - Upper left quadrant of the abdomen. - Upper mediastinum.

- Upper left quadrant of the abdomen.

A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which of the following reasons? - Use of anti-rejection drugs - Excess circulating lymphocytes - Excess circulating hemoglobin - Deficient circulating antibodies

- Use of anti-rejection drugs

You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client? - Ventilation is breathing air in and out of the lungs. - Ventilation provides a blood supply to the lungs. - Ventilation is when the body changes oxygen into CO2. V- entilation helps clients who cannot breathe on their own.

- Ventilation is breathing air in and out of the lungs.

A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test? - p24 antigen capture assay - OraSure test - Nucleic acid sequence-based amplification - Western blot assay

- Western blot assay

For a client with an endotracheal (ET) tube, which nursing action is the most important? - Monitoring serial blood gas values every 4 hours - Providing frequent oral hygiene - Turning the client from side to side every 2 hours -Auscultating the lungs for bilateral breath sounds

-Auscultating the lungs for bilateral breath sounds to ensure proper tube placement & oxygen delivery. turning from side to side q2h, monitoring serial blood gas q4h, & providing frequent oral hygiene are appropriate, they're s/t o ensuring adequate oxygenation.

A client visits the nurse complaining of diarrhea every time they eat. The client has AIDS and wants to know what they can do to stop having diarrhea. What should the nurse advise? -Increase the intake of iron and zinc. -Encourage large, high-fat meals. -Avoid residue, lactose, fat, and caffeine. - Reduce food intake.

-Avoid residue, lactose, fat, and caffeine. pt will tolerate a low-fat, high-carbohydrate, soft or liquid diet better than large, high-fat meals -limiting intake will encourage wasting in AIDS pt's -AIDS pt's should avoid lg amts of Zn or Fe d/t impairment of immune fxn

Which blood test confirms the presence of antibodies to HIV? -p24 antigen -Erythrocyte sedimentation rate (ESR) -Enzyme-linked immunosorbent assay (ELISA) -Reverse transcriptase

-Enzyme-linked immunosorbent assay (ELISA) > ESR indicates inflammation in body > p24 antigen is blood test to measure viral core protein > reverse transcriptase is retroviral RNA replication process, not test

A nurse is monitoring a patient who has a chest tube drainage system and notices that there is gentle bubbling in the suction control chamber. What is the appropriate nursing action for this scenario? A. Document this finding. B. Check to see if the chest tube is blocked or kinked C. Check for an air leak D. Notify the physician immediately

A. Document this finding.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? -Risk for infection related to endotracheal intubation and suctioning -Impaired gas exchange related to ventilator setting adjustments - Risk for trauma related to endotracheal intubation and cuff pressure - Impaired physical mobility related to being on a ventilator

-Impaired gas exchange related to ventilator setting adjustments All of these diagnoses are appropriate for this patient--ABC's. Allegedly, 91% is concerning.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? -Kinking of the ventilator tubing -A change in the oxygen concentration without resetting the oxygen level alarm -A disconnected ventilator tube -An ET cuff leak

-Kinking of the ventilator tubing

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? -Keeping the collection chamber at chest level -Measuring and documenting the drainage in the collection chamber -Stripping the chest tube every hour -Maintaining continuous bubbling in the water-seal chamber

-Measuring and documenting the drainage in the collection chamber

You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV? -Advise the client to take off any ornaments and metallic objects. -Obtain a written consent from the client. -Advise the client to avoid excess fluid intake. -Advise the client to abstain from having intercourse

-Obtain a written consent from the client.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? -Partial pressure of arterial carbon dioxide (PaCO2) - Bicarbonate (HCO3-) -pH -Partial pressure of arterial oxygen (PaO2)

-Partial pressure of arterial oxygen (PaO2)

The nurse is taking the health history of a newly admitted client. Which of the following conditions would place the client at risk for impaired immune function? -Previous organ transplantation -Negative history for radiation therapy - Surgical removal of the appendix -Surgical history of a partial gastrectomy

-Previous organ transplantation immunosupressive drugs HX

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? -The chest tube is obstructed. -The system has an air leak. -The client has a pneumothorax. - The system is functioning normally.-

-The system has an air leak. > pneumothorax will have intermittent bubbling in water-seal chamber > If obstructed, fluid would stop fluctuating in water-seal chamber.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? -Air-leak chamber -Suction control chamber -Collection chamber -Water-seal chamber

-Water-seal chamber

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.) 1) Take rapid, deep breaths. 2) Frequently evaluate progress. 3) Cough frequently. 4) Hold the breath at the end of inspiration for a few seconds. 5) Prolong the expiratory phase after using the nebulizer.

2) , 3) , 4) > breathe thru mouth, taking slow, deep breaths--then hold breath for few sec @ end of inspiration to ↑ intrapleural pressure & reopen collapsed alveoli, [thus ↑'ing fxn'al residual capacity] > Encourages coughing > monitor effectiveness of THX > Edu pt&family purpose of TX, equip. setup, med. additive, proper cleaning & storage equip.

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximetery D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABGs. D. Administer benzocaine spray.

A. Position the client in an upright position, leaning over the bedside table.

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, fever, and respiratory infections.

A patient with a chronic lung disease arrives on the med-surg unit. Which delivery system would offer the most precise oxygen concentration for this patient? A. Nonrebreather B. Venturi facemask C. Nasal cannula D. Face tent

B. Venturi facemask

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated? B cells Helper T cells Macrophages Cytotoxic T cells

Cytotoxic T cells

A nurse is caring for a patient who had a surgical placement of a tracheostomy 48 hours ago. What should the nurse's initial action be if tube dislodgement occurs? A. Re-insert the tube and notify the physician B. Place a 4x4 sterile gauze over the stoma to prevent infection C. Obtain the patient's vital signs D. Ventilate the patient using a manual resuscitation bag as another nurse notifies for help from the resuscitation team

D. Ventilate the patient using a manual resuscitation bag as another nurse notifies for help from the resuscitation team

The nurse completes a history and physical assessment on a patient with AIDS who was admitted to the hospital with respiratory complications. The nurse knows to assess for the most common infection in persons with AIDS (80% occurrence). This is: Cytomegalovirus. Legionnaire's disease. Mycobacterium tuberculosis. Pneumocystis pneumonia.

Pneumocystis pneumonia. [may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.]