All Saunders Nclex-Q that pertain to exam 2

he nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? 1.Frequent swallowing 2.A decreased pulse rate 3.Complaints of discomfort 4.An elevation in blood pressure

1 Rationale: A tonsillectomy is the surgical removal of the tonsils. Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding.

A child is scheduled for a tonsillectomy. A nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery? 1.Presence of loose teeth 2.Bleeding during surgery 3.Difficulty in swallowing 4.Exudate in the throat area

1 Rationale: A tonsillectomy is the surgical removal of the tonsils. In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Bleeding during surgery will be controlled via packing and suction as needed. Difficulty in swallowing and exudate in the throat area are incorrect because these are characteristics that may indicate the need for the surgery.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1.pH 7.25, Pco2 50 mm Hg 2.pH 7.35, Pco2 40 mm Hg 3.pH 7.50, Pco2 52 mm Hg 4.pH 7.52, Pco2 28 mm Hg

1 Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn? 1.Allen's test 2.Goodell's sign 3.Babinski reflex 4.Brudzinski's sign

1 Rationale: Before radial artery puncture for obtaining a blood sample for ABG analysis, an Allen test should be performed to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Goodell's sign is used during pregnancy and indicates a softening of the cervix at the beginning of the second month of pregnancy. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign is nuchal rigidity on bending the head down toward the chest.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determine the adequacy of which? 1.Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Popliteal circulation

1 Rationale: Before radial puncture is performed to obtain an arterial specimen for determination of arterial blood gases, an Allen's test should be performed to determine the adequacy of the ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 2, 3, and 4 are incorrect because these anatomical areas are not associated with adequate circulation to the hand.

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH? 1.Fall 2.Rise 3.Double 4.Remain unchanged

1 Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

A client is determined to be in respiratory alkalosis by blood gas analysis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base balance? 1.Hypokalemia 2.Hypercalcemia 3.Hypochloremia 4.Hypernatremia

1 Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

A client has begun using a methylxanthine bronchodilator. What beverage should the nurse plan to teach the client to avoid while taking this medication? 1.Coffee 2.Orange juice 3.Mineral water 4.Cranberry juice

1 Rationale: Cola, coffee, and chocolate contain methylxanthine and should be avoided by the client taking a methylxanthine bronchodilator. The additional methylxanthine could lead to increased incidence of cardiovascular and central nervous system side effects. Options 2, 3, and 4 identify fluids that are allowed.

A nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer? 1. Cough 2. Hoarseness 3. Hemoptysis 4. Pleuritic pain

1 Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. Hoarseness indicates that the affected tissue is in the upper airway. Wheezing and blood-streaked sputum (hemoptysis) are later signs of lung cancer. Pain is a very late sign and is usually pleuritic in nature.

A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse should develop a plan of care because the client is at risk for the development of which type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1 Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.

A nurse is reviewing the health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question? 1.Suction the child frequently if coughing. 2.Discharge to home when alert and tolerating fluids. 3.Provide clear cool liquids to the child when awake. 4. Instruct the parent not to give the child milk products.

1 Rationale: Following tonsillectomy, suction equipment should be available, but the child is not suctioned unless there is an airway obstruction. Clear cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the child to clear his or her throat and thereby increasing the risk of bleeding. Option 2 is an appropriate intervention following tonsillectomy.

The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1 Rationale: Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamental Skills: Acid-Base Strategy(s): Strategic Words, Subject Priority Concepts: Acid-Base Balance, Clinical Judgment

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instruction is needed when the client makes which statement? 1."I use my corticosteroid inhaler each time I feel short of breath." 2."I see my doctor if I have an upper respiratory infection and always get a flu shot." 3."I use my bronchodilator inhaler before walking so I don't become short of breath." 4."I use my bronchodilator inhaler before I visit places like the zoo because of my allergies."

1 Rationale: Most asthma medications are administered via inhalation because of their fast action via this route. Inhaled corticosteroids are preferred for long-term control of persistent asthma. They decrease inflammation and reduce bronchial hyperresponsiveness. Bronchodilator medications are considered "rescue" types because their onset is faster. Clients would use this type of medication to provide rapid relief of symptoms such as bronchospasm, which can be caused by a variety of triggers. Clients need to be evaluated for understanding of their disease, identifying triggers, and the proper use of equipment and medications.

The client has a prescription to receive pirbuterol (Maxair Autoinhaler) two puffs and beclomethasone dipropionate (Beclovent) two puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness? 1.Administering the pirbuterol before the beclomethasone 2.Alternating a single puff of each hourly, beginning with the beclomethasone 3.Alternating a single puff of beclomethasone with pirbuterol; repeat the steps 4.Administering the pirbuterol; wait 30 minutes and administer the beclomethasone

1 Rationale: Pirbuterol is a bronchodilator. Beclomethasone is a glucocorticoid. Bronchodilators are administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective

A nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching? 1."I should place a steam vaporizer in my child's room." 2."I will take my child out into the cool, humid night air." 3."I could place a cool mist humidifier in my child's room." 4."I will have my child inhale the steam from warm running water."

1 Rationale: Steam from running water in a closed bathroom or from a vaporizer will assist in keeping secretions thin so that they can be easily expectorated. A cool mist from a bedside humidifier may be effective in reducing mucosal edema. Cool mist humidifiers are recommended over steam vaporizers, which present a danger of scald burns. Taking the child out into the cool, humid night air may also relieve mucosal swelling.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position? 1.Prone 2.Supine 3.High Fowler's 4.Trendelenburg

1 Rationale: The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

A client has a prescription for a set of arterial blood gas (ABGs) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? 1.Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 2.Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. 3.Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn. 4.Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.

1 Rationale: The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore the remaining options are incorrect.

A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. What statement by the client indicates the need for further education regarding his prescription? 1."I will take the daily dose at bedtime." 2."I need to drink at least 2 liters of fluid per day." 3."I know to avoid changing brands of the medication without my health care provider's approval." 4."I'll avoid over-the-counter cough and cold medications unless approved by my health care provider (HCP)."

1 Rationale: The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. Additionally, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the HCP before changing brands of the medication because levels of bioavailability may vary for different preparations. The client also should check with the HCP before taking over-the-counter cough, cold, or other respiratory preparations because they could have interactive effects, increasing the side and adverse effects of theophylline and causing dysrhythmias.

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result? 1.Normal results 2.Metabolic acidosis 3.Metabolic alkalosis 4. Respiratory acidosis

1 Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45 mm Hg), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1. Dyspnea 2. Bradypnea 3. Bradycardia 4. Decreased respirations

1 Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? 1.Administer prescribed antibiotics. 2.Have the client breathe into a paper bag. 3.Administer antipyretics as needed (on PRN basis). 4.Request a prescription for a partial rebreather oxygen mask.

1 Rationale: The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the health care provider, should the nurse question? 1.Obtain a throat culture. 2.Obtain axillary temperatures. 3.Administer humidified oxygen. 4.Administer acetaminophen (Tylenol) for fever.

1 Rationale: The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics are components of management. Axillary rather than oral temperatures should be taken to avoid stimulation and resultant laryngospasm.

A client has begun therapy with theophylline (Theo-24). The nurse should plan to teach the client to limit the intake of which items while taking this medication? 1.Coffee, cola, and chocolate 2.Oysters, lobster, and shrimp 3.Melons, oranges, and pineapple 4.Cottage cheese, cream cheese, and dairy creamers

1 Rationale: Theophylline (Theo-24) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.

obstructive pulmonary disease (COPD) who is receiving theophylline (Theo-24). The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted? 1. 5 mg/mL 2. 10 mg/mL 3. 15 mg/mL 4. 20 mg/mL

1 Rationale: Theophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and monitor for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL. If the laboratory result indicated a level of 5 mg/mL, the dosage of the medication would need to be increased.

A client receiving oral theophylline is due to have a theophylline level drawn. The nurse should question the client to ensure that the client has not ingested which substance before the blood sample is drawn? 1.Coffee 2.Oatmeal 3.Ginger ale 4.Bagel with cream cheese

1 Rationale: Theophylline is a xanthine bronchodilator. Before a serum level of the medication is drawn, the client should avoid taking foods or beverages that contain xanthine, such as colas, coffee, or chocolate; therefore the client is told to avoid coffee before the test. The items in the other options do not need to be avoided before this test.

A nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse plans care, anticipating that which physical response will initially occur? 1. The client's pH will fall. 2. The client will lose consciousness. 3. The client's sodium and chloride level will rise. 4. The client will complain of facial numbness and tingling.

1 Rationale: 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 is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1.Place the infant in a private room. 2.insure that the infant's head is in a flexed position. 3.Wear a mask at all times when in contact with the infant. 4.Place the infant in a tent that delivers warm humidified air. 5.Position the infant on the side, with the head lower than the chest. 6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1, 6 Rationale: Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduces nosocomial transmission of RSV. A mask is unnecessary. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.

An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse should place which instruction(s) on the list? Select all that apply. 1. Avoid hot fluids. 2.Avoid raw vegetables. 3.Consume pudding products. 4.Rest in bed or on a couch for 24 hours. 5.Drink fruit smoothies to soothe the throat.

1,2,4 Rationale: After tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products (pudding) are avoided because they may cause the client to cough, which could cause pain at the surgical site. Foods and snacks that are rough in texture, such as raw fruits or vegetables, should be avoided for 10 days to protect the operative site and prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. 1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 4. Decreased respiratory rate 5. Increased body temperature 6. Prolonged expiratory breathing phase

1236Rationale: The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.

The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1.Nausea 2.Confusion 3.Bradypnea 4.Tachycardia 5.Hyperkalemia 6.Lightheadedness

124 6 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.

A client has begun therapy with oxtriphylline (Choledyl). The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply. 1.Milk 2.Coffee 3.Oysters 4.Oranges 5.Pineapple 6.Chocolate

2 6 Rationale: Oxtriphylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These include coffee and chocolate. The other food items are acceptable to consume.

After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question? 1.Monitor for bleeding. 2.Suction every 2 hours. 3.Give no milk or milk products. 4.Give clear, cool liquids when awake and alert.

2 Rationale: A tonsillectomy is the surgical removal of the tonsils. After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the surgical site. Monitoring for bleeding is an important nursing intervention after any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged

The nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review? 1. Creatinine leve 2. Prothrombin time 3. Sedimentation rate 4. Blood urea nitrogen level

2 Rationale: A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. Creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? 1.Supine 2.Side-lying 3.High Fowler's 4.Trendelenburg's

2 Rationale: A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage. Options 1, 3, and 4 would not achieve this goal.

The nurse should monitor the client receiving the first dose of albuterol (Proventil HFA) for which side effect of this medication? 1.Drowsiness 2.Tachycardia 3.Hyperkalemia 4.Hyperglycemia

2 Rationale: Albuterol is a bronchodilator. Side effects can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache, among others. The nurse monitors for these effects during therapy. The items in the other options are not side effects of this medication.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1.Put the client in a supine position. 2.Provide emotional support and reassurance. 3.Withhold all sedative or antianxiety medications. 4.Tell the client to breathe very deeply but more slowly.

2 Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client should try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1.Warm, dry skin 2.Decreased wheezing 3.Pulse rate of 90 beats/minute 4.Respirations of 18 breaths/minute

2 Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/minute.

The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF? 1.Transmitted as an autosomal dominant trait 2.A chronic multisystem disorder affecting the exocrine glands 3.A disease that causes the formation of multiple cysts in the lungs 4.A disease that causes dilation of the passageways of many organs

2 Rationale: CF is a chronic multisystem disorder that affects the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1.The child exhibits nasal flaring and bradycardia. 2.The child is leaning forward, with the chin thrust out. 3.The child has a low-grade fever and complains of a sore throat. 4.The child is leaning backward, supporting himself or herself with the hands and arms.

2 Rationale: Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes tachycardia and a high fever.

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome (SIDS). The student plans to write on a handout that it is best to place an infant in which position for sleep? 1.On the back, or prone 2.On the back, or supine 3.On the stomach, or prone 4.On the stomach, or supine

2 Rationale: Healthy infants should only be placed on their backs for sleep. This is also referred to as the supine position. Options 1, 3, and 4 are not suggested recommendations to assist in preventing SIDS.

client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse develops a plan of care to support the client physiologically until the tubular cells secrete a sufficient amount of which substance? 1.Phosphates 2.Hydrogen ions 3.Ammonium ions 4.Carbon dioxide molecules

2 Rationale: Hydrogen ions are cations that contribute to a state of acidosis in the body. The renal tubules secrete hydrogen ions and potassium effectively, and in lesser amounts they secrete ammonia and uric acid. Phosphates are anions that tend to neutralize cations. The tubules reabsorb carbon dioxide molecules.

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

2 Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

The nurse is caring for a client with chronic kidney disease. Arterial blood gas (ABG) results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. Which laboratory value should the nurse expect to note? 1.Sodium level of 145 mEq/L 2.Potassium level of 5.2 mEq/L 3.Phosphorus level of 4.0 mg/dL 4.Magnesium level of 2.0 mg/dL

2 Rationale: Interpretation of the ABG indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

2 Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamental Skills: Acid-Base Strategy(s): Subject Priority Concepts: Acid-Base Balance, Clinical Judgment

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 to 4 L/min. The nurse responds that this would be harmful because a higher oxygen flow rate could lead to which physical responses? 1. Drying of nasal passages 2. Decrease in the client's oxygen-based respiratory drive 3. Increase for the risk of pneumonia from drier air passages 4. Decrease in the client's carbon dioxide-based respiratory drive

2 Rationale: Normally respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural regulator becomes ineffective owing to exposure to high carbon dioxide levels for prolonged periods. Thus, the level of oxygen provides the respiratory stimulus for these clients. The client with COPD should be instructed not to increase the oxygen flow rate level independently because a higher oxygen level could obliterate the respiratory drive, leading to respiratory failure. Options 1, 3, and 4 are not physical responses that would occur.

The nurse instructs a client regarding pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.

2 Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1.Sodium level of 145 mEq/L 2.Potassium level of 3.0 mEq/L 3.Magnesium level of 2.0 mg/dL 4.Phosphorus level of 4.0 mg/dL

2 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1.Initiate strict enteric precautions. 2.Move the infant to a room with another child with RSV. 3.Leave the infant in the present room because RSV is not contagious. 4.Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2 Rationale: Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing techniques and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are unnecessary.

The nurse has a prescription to give a client salmeterol (Serevent Diskus), two puffs, and beclomethasone dipropionate (Qvar), two puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? 1.Beclomethasone first and then the salmeterol 2.Salmeterol first and then the beclomethasone 3.Alternating a single puff of each, beginning with the salmeterol 4.Alternating a single puff of each, beginning with the beclomethasone

2 Rationale: Salmeterol (Serevent Diskus) is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

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 anticipate to be prescribed? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2 Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation 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.

A nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? 1.Disorientation and dyspnea 2.Drowsiness, headache, and tachypnea 3.Tachypnea, dizziness, and paresthesias 4.Decreased respiratory rate and depth, cardiac irregularities

2 Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours post-overdose, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 1 and 3 indicate respiratory acidosis and alkalosis, respectively.

A nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client's safety knowing the risks of this imbalance, by carefully implementing which prescribed precaution? 1.Contact isolation 2.Seizure precautions 3.Bleeding precautions 4.Neutropenic precautions

2 Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. Options 1, 3, and 4 are unnecessary in the care of the client experiencing metabolic alkalosis.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? 1.Metabolic acidosis, compensated 2.Respiratory alkalosis, compensated 3.Metabolic alkalosis, uncompensated 4.Respiratory acidosis, uncompensated

2 Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? 1.Sodium 2.Potassium 3.Magnesium 4.Phosphorus

2 Rationale: The serum potassium level tends to rise with metabolic acidosis. This is becausepotassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte should be monitored closely while the client is treated.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1. Sitting position 2. Tripod position 3. Supine position 4. High Fowler's position

2 Rationale: The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high-Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. 1. Hypocapnia 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

23 Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1. Reduce fluid intake to less than 1500 mL/day. 2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. 5. Keep the client in a supine position as much as possible.

234Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and ease dyspnea. The client should be encouraged to perform activities and exercise as tolerated, such as dressing and walking, with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The client questions the nurse as to why the health care provider switched the usual prescription from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI). The nurse should respond correctly by providing which fact? Select all that apply. 1.Dry powder inhalers have fewer side effects. 2.Dry power inhalers pose no environmental risks. 3.Dry powder inhalers deliver more medication to the lungs. 4.Dry power inhalers can be administered more frequently. 5.Dry powder inhalers require less hand-to-lung coordination.

235Rationale: DPIs are used to deliver medications in the form of a dry, micronized powder directly to the lungs. DPIs do not require the hand-to-lung coordination needed with MDIs, thus DPIs are much easier to use. Compared with MDIs, DPIs deliver more medication to the lungs (20% of the total released versus 10%) and less to the oropharynx. Because DPIs do not require propellant, they are not a risk to the environment. Both types of inhalers have side effects. Frequency of use is prescribed by the health care provider.

A nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1. pH, 7.40; Pao2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; Pao2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; Pao2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; Pao2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

2Rationale: A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicates respiratory acidosis. Increased CO2 acts as an acid in the body, and is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which signs/symptoms? 1.Disorientation and dyspnea 2.Decreased respiratory rate and depth 3.Drowsiness, headache, and tachypnea 4.Tachypnea, dizziness, and paresthesias

2Rationale: A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. A client with metabolic acidosis would display the symptoms noted in option 3. The client with respiratory acidosis and alkalosis would display the symptoms noted in options 1 and 4, respectively.

A nurse is caring for a client with emphysema who has chronic hypercarbia and is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed which value? 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min

2Rationale: Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission work-up on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention? 1.Perform the Allen's test. 2.Apply a warm compress. 3.Administer the antidote for heparin. 4.Notify the hospital laboratory supervisor.

2Rationale: The application of a warm compress enhances the absorption of blood in the hematoma. Allen's test is performed before the collection of the specimen to assess collateral blood flow. Heparinized syringes are used for the collection of an arterial blood gas but no heparin is administered to a client. The antidote for heparin is not administered at this time unless prescribed. The laboratory department is not responsible for collecting the ABG specimen. Additionally, there is no useful reason to notify the hospital laboratory supervisor.

A client taking albuterol (ProAir HFA) by inhalation cannot cough up secretions. What should the nurse suggest that the client do to assist in expectoration of secretions? 1.Get more exercise each day. 2.Use a dehumidifier in the home. 3.Drink increased amounts of fluids every day. 4.Take an extra dose of albuterol before bedtime.

3 Rationale: A client should drink increased fluids (2000 to 3000 mL/day) to decrease viscosity and increase expectoration of secretions. This is standard advice for clients receiving any of the adrenergic bronchodilators, unless the client has another health problem that contraindicates an increased fluid intake. Additional exercise will not effectively clear bronchial secretions. A dehumidifier will dry secretions, making the situation worse. The client should not take additional medication.

A nurse is preparing to administer albuterol (Proventil HFA) to a client. Which parameters should the nurse assess before and during therapy? 1.Nausea and vomiting 2.Headache and level of consciousness 3.Lung sounds and presence of dyspnea 4.Urine output and blood urea nitrogen level

3 Rationale: Albuterol is an adrenergic bronchodilator. The nurse assesses respiratory pattern, lung sounds, pulse, and blood pressure before and during therapy. The nurse also notes the color, character, and amount of sputum.

The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3 Rationale: In respiratory acidosis the pH is decreased and the Pco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Pco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.

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 bilaterally

3 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 with 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.

The nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? 1.Holding a warm compress over the puncture site for 5 minutes 2.Encouraging the client to open and close the hand rapidly for 2 minutes 3.Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes 4.Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

3 Rationale: Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

A 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

3 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.

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis (CF). What instruction should the nurse include in the client's teaching plan? 1.Schedule the procedures so they are 4 hours apart. 2.Perform the breathing exercises and then the postural drainage. 3.Perform the postural drainage first and then the breathing exercises. 4.Perform postural drainage in the morning and breathing exercises in the evening.

3 Rationale: Breathing exercises are recommended for a majority of children with CF, even those with minimal pulmonary involvement. The exercises usually are performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility, such as swinging the arms and bending and twisting the trunk, are included. The ultimate aim of these exercises is to establish a good habitual breathing pattern.

During clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about cystic fibrosis? 1.CF causes mucus that is formed to be abnormally thick. 2.It is a condition transmitted as an autosomal recessive trait. 3.This disease causes dilation of the passageways of many organs. 4.It is a chronic multisystem disorder affecting the exocrine glands.

3 Rationale: CF is a chronic multisystem disorder affecting the exocrine gland. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction (not dilation) of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

The nurse is caring for a client who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

3 Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1. A 25-year-old woman with diabetic ketoacidosis 2. A 65-year-old man out of bed 1 day after prostate resection 3. A 73-year-old woman who has just had pinning of a hip fracture 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash

3 Rationale: Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding? 1.Extreme fatigue 2.The presence of pain 3.An airway obstruction 4. The presence of dehydration

3 Rationale: Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. Options 1, 2, and 4 are inaccurate interpretations of the position that the child assumed.

The health care provider (HCP) prescribes cromolyn (Intal) for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect? 1.Promote bronchodilation. 2.Decrease the risk of infection. 3.Suppress an allergic response. 4.Eliminate the need for a rescue inhaler.

3 Rationale: Cromolyn is a first-line therapy for prophylactic treatment of asthma; it is a mast-cell stabilizer, antiasthmatic, and antiallergic. The medication acts in part by stabilizing the cytoplasmic membrane of mast cells, thereby preventing release of histamine and other mediators. It is not a bronchodilator. It does not decrease the risk of infection. It does not eliminate the need for the rescue inhaler.

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1."The child may be allergic to antibiotics." 2."The child is too young to receive antibiotics." 3."Antibiotics are not indicated unless a bacterial infection is present." 4."The child still has the maternal antibodies from birth and does not need antibiotics."

3 Rationale: Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. It can be viral or bacterial. Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, no supporting data in the question indicate that the child may be allergic to antibiotics.

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3. Respiratory acidosis 4.Respiratory alkalosis

3 Rationale: Respiratory acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base disturbances can occur in a client with COPD during exacerbation of the disease, but the most likely imbalance is respiratory acidosis. The remaining options are incorrect. COPD is a respiratory condition, not a metabolic one. Respiratory alkalosis is associated with hyperventilation.

terbutaline is prescribed for a client with bronchitis. The nurse understands that this medication should be used with caution if which medical condition is present in the client? 1.Osteoarthritis 2.Hypothyroidism 3.Diabetes mellitus 4.Polycystic disease

3 Rationale: Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

A nurse is providing care to a client with the following arterial blood gas (ABG) results: pH 7.50; Pao2 90 mm Hg; Paco2 40 mm Hg; and bicarbonate 35 mEq/L. When the nurse notifies the health care provider (HCP) about these levels, the nurse should anticipate receiving which prescription for this client from the HCP? 1. Obtain a serum alcohol level. 2.Obtain a serum salicylate level. 3.Discontinue nasogastric suctioning. 4.Discontinue the client's Fentanyl patch

3 Rationale: The ABG results indicate metabolic alkalosis as the pH and bicarbonate are elevated. Nasogastric suctioning may cause metabolic alkalosis by decreasing the acid components in the stomach. Excess alcohol ingestion and salicylate toxicity may cause metabolic acidosis. Fentanyl (an opioid) may cause respiratory acidosis.

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms, indicating the acid-base disturbance that could occur in the client? 1.Bradypnea, dizziness, and paresthesias 2.Bradycardia, listlessness, and hyperactivity 3.Headache, nausea, vomiting, and diarrhea 4.Restlessness, confusion, and a positive Trousseau's sign

3 Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours post-overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? 1. Increased oxygen saturation with ambulation 2. A widened diaphragm documented by chest x-ray 3. Hyperinflation of lungs documented by chest x-ray 4. A shortened expiratory phase of the respiratory cycle

3 Rationale: The clinical manifestations of COPD are several, including hypoxemia; hypercapnia; dyspnea on exertion and at rest; oxygen desaturation with exercise; use of accessory respiratory muscles; and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3 Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Pco2 of 58 mm Hg, Po2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3 Rationale: The normal pH is 7.35 to 7.45. Normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Pco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

A nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.34 and the Pco2 is 50 mm Hg. Which acid-base imbalance should the nurse interpret that this client is experiencing? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3 Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is low and the Pco2 is elevated. This is an expected finding in a client with a neuromuscular disorder such as Guillain-Barré syndrome because the client may retain carbon dioxide as a result of ventilatory failure as paralysis ensues.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias

3 Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client who has been receiving theophylline by the intravenous (IV) route has the medication prescription changed to an immediate-release oral form of the medication. After discontinuing the IV medication, when should the nurse schedule the first dose of the oral medication? 1.Just after the next meal 2.Just before the next meal 3.4 hours after discontinuing the IV form 4.Immediately on discontinuing the IV form

3 Rationale: With immediate-release preparations, oral theophylline should be administered 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose should be administered immediately on discontinuation of the IV infusion. Therefore the remaining options are incorrect.

Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? 1.Platelet count 2.Neutrophil count 3.Liver function tests 4.Complete blood count

3 Rationale: Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.

A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least how many minute(s)? 1.1 minute 2.2 minutes 3.5 minutes 4.10 minutes

3Rationale: After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of pressure for a longer period may be needed.

The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, a Pco2 of 58 mm Hg, a Po2 of 80 mm Hg, and an Hco3 of 27 mEq/L. The nurse should interpret this to mean that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

3Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco2 is elevated. In respiratory alkalosis, an opposite effect occurs; the pH is elevated and the Pco2 is low. In metabolic acidosis, the pH is low and the bicarbonate is low; in metabolic alkalosis, the opposite effect occurs.

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias

3Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid irregular pulse, and dysrhythmias.

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate? 1."The child probably has an infection." 2."Have the child gargle with mouthwash every 4 hours." 3."You need to contact the health care provider immediately." 4."Bad mouth odor is normal and may be relieved by drinking more liquids."

4 Rationale: A tonsillectomy is the surgical removal of the tonsils. Bad mouth odor is normal after tonsillectomy and may be relieved by drinking more liquids. There is no more information that would indicate an infection. Mouthwash gargles will irritate the throat. There is no need to contact the health care provider immediately because bad mouth odor is common and expected after tonsillectomy.

The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child? 1.Cola with ice 2.A glass of milk 3.Cool cherry Kool-Aid 4.Yellow noncitrus Jell-O

4 Rationale: After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Milk and milk products, including pudding, are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. Red liquids should be avoided because they giv

A mother calls the pediatrician's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother? 1."Is your child crying and irritable?" 2."Does your child have a productive cough?" 3."Did he have a temperature last night of greater than 100° F?" 4."Is your child telling you at this time he is having trouble breathing?"

4 Rationale: Airway is always the most important indicator to determine if the child can be seen in the health care provider's office or needs to be taken to the emergency department. Although all the assessment questions address manifestations of asthma, option 4 specifically addresses airway.

A client suffering from prolonged vomiting has developed metabolic alkalosis. The nurse plans care, knowing that this imbalance will be corrected primarily when the kidneys do which function? 1.Secrete sufficient water. 2.Retain sufficient chloride. 3.Secrete sufficient potassium. 4.Retain sufficient hydrogen ions.

4 Rationale: Because hydrogen ions contribute to acidosis in the body, the kidneys retain hydrogen ions in alkalosis to restore acid-base balance. Chloride is an anion that will contribute to alkalosis if it is retained because anions combine with cations and neutralize them. Secretion of potassium also will increase the level of anions in the bloodstream. Secretion of water affects fluid balance.

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 is 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

4 Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All 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 owing to the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support lo

A nurse has provided instructions to the mother of a child with cystic fibrosis (CF) about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures? 1."The diet needs to be low in fat." 2."The diet needs to be low in protein." 3."The diet needs to be low in calories." 4."The diet needs to be high in calories."

4 Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and water-soluble vitamin supplements (A, D, E, and K) are administered. If nutritional problems are severe, supplemental tube feedings or parenteral nutrition is administered. Fats are not restricted unless steatorrhea cannot be controlled by administration of increased pancreatic enzymes.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1.A decreased pH and an increased CO2 2.An increased pH and a decreased CO2 3.A decreased pH and a decreased HCO3 4.An increased pH with an increased HCO3

4 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamental Skills: Acid-Base Strategy(s): Subject Priority Concepts: Acid-Base Balance, Clinical Judgment

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Headache and tachypnea 2.Hyperactivity and dyspnea 3.Muscle twitches and cyanosis 4.Lightheadedness and paresthesias

4 Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. Options 1, 2, and 3 are not clinical manifestations of respiratory alkalosis.

Cromolyn sodium is prescribed for the client with allergic asthma. The nurse should plan care understanding that which is an action of this medication? 1.Dilate the bronchi. 2.Increase the number of eosinophils. 3.Promote the migration of eosinophils into the inflammatory site. 4.Inhibit the release of mediators from mast cells after exposure to an antigen.

4 Rationale: Cromolyn sodium is an antiasthmatic, antiallergic, and mast cell stabilizer that inhibits the release of mediators from mast cells after exposure to an antigen. It can also interrupt the migration of eosinophils into the inflammatory site and decrease the number of eosinophils. These actions decrease airway hyperresponsiveness in some clients with asthma. It has no bronchodilating action.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the side and adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication? 1.Insomnia 2.Constipation 3.Hypotension 4.Bronchospasm

4 Rationale: Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1."The immunization schedule will need to be altered." 2."The child should not receive any hepatitis vaccines." 3."The child will receive all the immunizations except for the polio series." 4."The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4 Rationale: Cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for children with cystic fibrosis. Options 1, 2, and 3 are incorrect.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1.Tell the mother that the child must stay in the tent. 2.Place a toy in the tent to make the child feel more comfortable. 3.Call the health care provider and obtain a prescription for a mild sedative. 4.Let the mother hold the child and direct the cool mist over the child's face.

4 Rationale: Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face (blow-by). A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 2 would not alleviate the child's fear.

Which of the following statements by a client taking montelukast (Singulair) should indicate the need for further teaching? 1."I will need to have my liver function checked." 2."I can take the medication with food or without." 3."I may be able to decrease the use of my metered-dose inhaler." 4."I will take the medication when I first notice I am having trouble breathing."

4 Rationale: Montelukast cannot be used for quick relief of an asthma attack because effects of the medication develop too slowly. For prophylaxis and maintenance therapy of asthma, maximal effects develop within 24 hours of the first dose and are maintained with once-daily dosing in the evening. Options 1, 2, and 3 are correct statements.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1. Ask a family member to stay with the client at all times. 2. Ask the health care provider for a prescription for succinylcholine. 3. Encourage the client to sleep until arterial blood gas results improve. 4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4 Rationale: Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

The nurse has just administered the first dose of omalizumab (Xolair) to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect? 1."I have a severe headache." 2."My feet are quite swollen." 3."I am nauseated and may vomit." 4."My lips and tongue are swollen."

4 Rationale: Omalizumab is an antiinflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an adverse reaction. The client statements in options 1, 2, and 3 are not indicative of an adverse reaction.

The nurse is administering a dose of pirbuterol (Maxair Autohaler) to a client. The nurse should monitor for which side/adverse effect of this medication? 1.Drowsiness 2.Hypokalemia 3.Hyperglycemia 4.Increased pulse and blood pressure

4 Rationale: Pirbuterol is an adrenergic bronchodilator. Side/adverse effects can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy. All other options are not side/adverse effects of this medication.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed and leaning on an overbed table .

4 Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4 Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1.Side or prone 2.Back or prone 3.Stomach with the face turned 4.Back rather than on the stomach

4 Rationale: Sudden infant death syndrome (SIDS) is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition? 1.Metabolic acidosis with compensation 2.Respiratory acidosis with compensation 3.Metabolic acidosis without compensation 4.Respiratory acidosis without compensation

4 Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore the condition is without compensation. The remaining options are incorrect interpretations. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamental Skills: Acid-Base Strategy(s): Subject Priority Concepts: Acid-Base Balance, Clinical Judgment

pulmonary disease has been on oral glucocorticoids and is currently being weaned to triamcinolone (Azmacort) by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms? 1.Chills, fever, and generalized rash 2.Vomiting, diarrhea, and increased thirst 3.Blurred vision, headache, and insomnia 4.Anorexia, nausea, weakness, and fatigue

4 Rationale: The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other signs that can be detected and are objective include hypotension and hypoglycemia

A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence? 1.Insufficient dosage of the medication, which needs to be increased 2.Probable interaction of this medication with an over-the-counter cold remedy 3.Tolerance to the medication, indicating a need for a stronger type of bronchodilator 4.Paradoxical bronchospasm, which must be reported to the health care provider (HCP)

4 Rationale: The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication should be withheld and the HCP should be notified. Options 1, 2, and 3 are incorrect interpretations.

A client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. A nurse who is trying to enhance the client's respiratory status should avoid which action? 1.Keeping the head of the bed elevated 2.Monitoring the flow rate of supplemental oxygen 3.Assisting the client to turn, cough, and breathe deeply 4.Encouraging the client to breathe slowly and shallowly

4 Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

n a client seen in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, Pco2 32 mm Hg, Po2 94 mm Hg, HCO3 level 24 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

4 Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg, and the normal HCO3 concentration is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.

A client taking theophylline has a serum theophylline level of 15 mcg/mL. How does the nurse interpret this laboratory value? 1.Below therapeutic range 2.In excess of the therapeutic range 3.Near the top of the therapeutic range 4.In the middle of the therapeutic range

4 Rationale: The normal therapeutic range for the theophylline level is 10 to 20 mcg/mL. A level above 20 mcg/mL is considered toxic. The value of 15 mcg/mL places the client in the middle of the therapeutic range.

A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant? 1.Supine, side-lying position with the arms elevated 2.Prone with the head of the bed elevated 15 degrees 3.Trendelenburg, at a 60-degree angle with pelvis higher than head 4.Head and chest at a 30-degree angle with the neck slightly extended

4 Rationale: The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure of the diaphragm. Options 1, 2, and 3 do not achieve these goals.

A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone (Azmacort) by inhalation. The nurse plans to monitor the client for which signs/symptoms during the change? 1.Chills, fever, generalized rash 2.Vomiting and diarrhea, increased thirst 3.Blurred vision, headache, and insomnia 4.Anorexia, nausea, weakness, and fatigue

4 Rationale: Triamcinolone (Azmacort) is an adrenocorticosteroid. The client who is being changed from an oral to an inhalation glucocorticoid could experience signs of adrenal insufficiency. The nurse should monitor the client for anorexia, nausea, weakness, and fatigue. The nurse should also monitor for hypotension and hypoglycemia. The signs/symptoms in options 1, 2, and 3 are not associated with adrenal insufficiency.