BH7 RESP

Physiological Integrity 10. Once a near-drowning victim is stabilized, the nurse would continue to assess the client for a. dyspnea. b. bronchospasm. c. electrolyte imbalances. d. shock.

a Clients are at high risk for pulmonary edema even several hours after a near-drowning incident. DIF: Cognitive Level: Comprehension REF: Text Reference: 1906 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 9. The nurse would record a Mantoux as "positive" when the induration at 48 hours is 5 cm in a client who is a. HIV positive. b. over 80 years of age. c. less than 120 pounds. d. allergic to eggs.

a A 5-cm Mantoux reading is considered positive in a client who is immuosuppressed. DIF: Cognitive Level: Assessment REF: Text Reference: 1846 TOP: Nursing Process Step: Application MSC:

Physiological Integrity 19. Before drawing blood for an arterial blood gases (ABGs), the nurse would perform a. Allen's test. b. a test for peripheral perfusion. c. an incentive spirometer assessment. d. pulse oximetry.

a Allen's test is a quick assessment of collateral circulation in the hand and is essential before performing a radial artery puncture (e.g., collecting ABG sample). DIF: Cognitive Level: Application REF: Text Reference: 1764 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 20. The nurse reviews the results of the arterial carbon dioxide tension (PaCO2) of a client with asthma to obtain information relative to the a. effectiveness of alveolar ventilation. b. evidence of atelectasis. c. presence of repiratory alkalosis. d. efficiency of gas exchange.

a Arterial oxygen tension (PaO2) reflects efficiency of gas exchange, whereas PaCO2 reflects effectiveness of alveolar ventilation. DIF: Cognitive Level: Analysis REF: Text Reference: 1764 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 8. A client tells the nurse that he read something about "dead space" in an article about emphysema and asks the nurse to explain it to him. The nurse's most accurate answer would be a. "Dead space is an area of your lung that does not participate in air exchange." b. "Dead space is a small area of necrotic tissue that can cause infection." c. "Dead space consists of parts of the lower airway that serve as a conduit for fresh air." d. "Any part of your lungs that contains mucous secretions is called dead space."

a As the alveoli and septa collapse, pockets of air form between the alveolar spaces (blebs) and within the lung parenchyma (bullae). This process leads to increased ventilatory dead space, resulting from areas that do not participate in gas or blood exchange. DIF: Cognitive Level: Application REF: Text Reference: 1818 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 9. A client being treated for emphysema has a chronic productive cough. The nurse would assess a characteristic feature of clients with long-term emphysema, which is a. barrel chest. b. broken vessels in the nose. c. pectus excavatum. d. erythematous ear lobes.

a Barrel chest occurs when the chest anteroposterior (AP) measurement is increased and equals the transverse measurement. It is a characteristic finding in clients with chronic disorders that interfere with ventilation (e.g., emphysema). DIF: Cognitive Level: Comprehension REF: Text Reference: 1750 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 14. When a client with a rapid, shallow breathing pattern is admitted to the nursing unit for treatment of COPD, the nurse would give the instruction a. "Try to maintain your breathing pattern." b. "Diaphragmatic breathing will be more effective." c. "Cough at least once every hour." d. "Slow your respiratory rate when exercising."

a Breathing re-training ensures maximal use of available respiratory function. Pursed-lip breathing and diaphragmatic breathing leave positive end-diastolic pressure in the lungs and help keep airways open. DIF: Cognitive Level: Comprehension REF: Text Reference: 1822 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 20. A client is being transported to the ED after sustaining carbon monoxide (CO) poisoning in a house fire. The nurse would prepare to administer a. 100% oxygen therapy. b. intermittent positive-pressure breathing. c. suctioning. d. ventilation with 50% oxygen by manual resuscitation bag.

a CO poisoning is treated by inhalation of 100% oxygen to shorten the half-life of CO to about an hour. Hyperbaric oxygen may be required to reduce the half-life of CO to minutes by forcing it off of the hemoglobin molecule. DIF: Cognitive Level: Comprehension REF: Text Reference: 1907 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 6. The nurse caring for a client recently diagnosed with active TB would include in the care plan the significant information regarding medications that a. TB is usually treated with three or more medications to prevent organism resistance. b. medications are generally given for 6 to 8 weeks. c. clients must report daily to the health department to receive their medication. d. clients are usually admitted to the hospital to initiate treatment for TB.

a Clients diagnosed with active TB are usually started on a minimum of two or three medications to ensure elimination of the resistant organisms. DIF: Cognitive Level: Application REF: Text Reference: 1847 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 17. On the seventh post-tonsillectomy day, a client begins to expectorate blood and calls the nurse at the clinic for advice. The most appropriate instruction by the nurse would be a. "Come to the emergency department at once." b. "Call your physician as soon as possible." c. "Lie on your side for the next 5 minutes." d. "Drink a very cold liquid."

a Clients should be encouraged to seek immediate medical attention if bleeding occurs after hospital dismissal. Delayed bleeding may occur once the healing membrane separates from the underlying tissue. DIF: Cognitive Level: Application REF: Text Reference: 1800 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 9. In assessing a client for emphysema, the nurse would know that the physical finding most often associated with this condition is a. barrel chest. b. bulbous nose. c. varicose veins. d. spider angiomas.

a Clients with emphysema develop barrel-shaped chests. The anteroposterior (AP) diameter of the chest is enlarged, and the chest has hyperresonant sounds during percussion. DIF: Cognitive Level: Comprehension REF: Text Reference: 1819 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 11. For a client who has a posterior nasal plug and anterior nasal packing in place to control an episode of severe epistaxis, the priority assessment for the nurse would be assessing for a. presence of hypoxia. b. swallowing of blood. c. appearance of nasal pain. d. presence of generalized discomfort.

a Clients with posterior plugs and anterior nasal packing are admitted to the hospital and monitored closely for hypoxia. DIF: Cognitive Level: Analysis REF: Text Reference: 1797 TOP: Nursing Process Step: Assessment MSC:

1. A client says to the nurse, "It's hard for me to breathe; I feel winded all the time." The nurse would record this subjective feeling on the chart as a. dyspnea. b. apnea. c. tachypnea. d. respiratory fatigue

a Dyspnea is one of the most common manifestations experienced by clients with pulmonary and cardiac disorders. It is a subjective manifestation and reflects the client's assessment of the degree of work of breathing for a given task or effort. DIF: Cognitive Level: Comprehension REF: Text Reference: 1743 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 13. For a client who has undergone functional endoscopic sinus surgery (FESS) as part of the surgical management of sinusitis, the nurse would instruct the client a. "Don't blow your nose for 1 week." b. "Eat only semi-solid foods." c. "Limit the amount of fluids you drink." d. "Lean forward when eating."

a FESS clients should avoid blowing the nose for 7 days after surgery. They should sniff backward or spit, not blow. DIF: Cognitive Level: Application REF: Text Reference: 1798 TOP: Nursing Process Step: Intervention MSC:

Psychosocial Integrity 19. A client experiencing a pulmonary embolus has pleuritic pain and hemoptysis. The nurse would assesses the presence of hemoptysis as an indication of 1. alveolar damage. 2. hemothorax. 3. ruptured vessels in the trachea. 4. hemorrhage in the sinuses.

a Hemoptysis is an indication that the atelectasis has caused alveolar damage. DIF: Cognitive Level: Analysis REF: Text Reference: 1831 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 4. A 44-year-old man with active pulmonary tuberculosis is experiencing hemoptysis, which describes a. bloody sputum. b. chest pain. c. constant cough. d. dyspnea.

a Hemoptysis is blood expectorated from the mouth in the form of gross blood, frankly bloody sputum, or blood-tinged sputum. DIF: Cognitive Level: Comprehension REF: Text Reference: 1743 TOP: Nursing Process Step: N/A MSC:

Physiological Integrity 14. A client who sustained a head injury is intubated and receiving volume-cycled mechanical ventilation via the controlled mechanical ventilation (CMV) mode. The nurse would explain that this means a. the ventilator delivers the preset volume regardless of the client's efforts. b. spontaneous inspiratory effort triggers the ventilator to deliver a preset tidal volume. c. the client's own breaths can become "stacked" with the ventilator breaths. d. a preset amount of pressure stays in the client's lungs at the end of exhalation.

a In the CMV mode the volume-cycled ventilator delivers a preset tidal volume. No allowance is made for spontaneous breaths. Because the ventilator is not responsive to the client's efforts, the CMV mode can lead to agitation and asynchrony. DIF: Cognitive Level: Comprehension REF: Text Reference: 1884 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 9. When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would a. report this to the physician immediately. b. continue observation of the drainage. c. clamp the tubing. d. monitor the client's vital signs.

a Large amounts of drainage (200 ml/hr or more) should be reported the physician immediately. DIF: Cognitive Level: Application REF: Text Reference: 1906 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 14. The nurse would explain to a client that laser surgery to remove laryngeal tumors has the major benefit of a. a usable voice. b. reduced edema. c. minimal blood loss. d. complete eradication of the cancer.

a Laser excision of laryngeal tumors usually results in a usable voice after surgery. DIF: Cognitive Level: Knowledge REF: Text Reference: 1788 TOP: Nursing Process Step: Intervention MSC:

Health Promotion and Maintenance 21. In making plans to enhance the nutrition of a client with cystic fibrosis, the nurse would explain that the client will be prescribed a. lipase capsules. b. large doses of vitamins A and C. c. tube feedings. d. a diet high in fiber and protein.

a Lipase capsules will provide the reduced enzymes from the pancreas. DIF: Cognitive Level: Analysis REF: Text Reference: 1870 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 7. The immediate nursing intervention for a client experiencing a laryngospasm would be a. administering 100% oxygen. b. calling the resuscitation team to the PACU. c. positioning the client in a high Fowler's position. d. immediately inserting a large-bore intravenous needle.

a Management is directed at reestablishing the airway as quickly and efficiently as possible. The nurse should administer 100% oxygen until the airway is fully reestablished, the larynx relaxes, and the spasms stop. DIF: Cognitive Level: Application REF: Text Reference: 1802 TOP: Nursing Process Step: Intervention MSC:

N/A 5. When a client is admitted to the ED with tension pneumothorax and mediastinal shift following an automobile accident, the nurse would know that the client will exhibit a. severe hypotension. b. bradycardia. c. a sucking chest wound. d. mediastinal flutter.

a Mediastinal shift may cause (a) compression of the lung in the direction of the shift and (b) compression, traction, torsion, or kinking of the great vessels; thus, blood return to the heart is dangerously impaired. The latter causes a subsequent decrease in cardiac output and blood pressure. DIF: Cognitive Level: Comprehension REF: Text Reference: 1905 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 15. In caring for a client who had surgery this morning and noting no fluctuation of fluid in the tube extending from the water-seal chamber of the client's closed-chest drainage system, the nurse would a. milk the chest tube. b. attach the system to suction. c. reposition the client. d. notify the physician immediately.

a Milking the tube may reestablish the flow from the chest to the collection bottle. The cessation of fluctuation means the system is clogged or that the lung has fully reexpanded. DIF: Cognitive Level: Application REF: Text Reference: 1863 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 10. A client has chronic obstructive pulmonary disease (COPD) caused by an enzyme deficiency. The nurse would explains that the enzyme most likely to be responsible for COPD is a. alpha1-antitrypsin (ATT). b. glutamic-oxaloacetic transaminase (GOT). c. trypsin. d. pepsin.

a Normally, ATT inhibits the action of enzymes that break down proteins. Clients without ATT have increased risk of COPD because the walls of the lung are at greater risk of destruction. DIF: Cognitive Level: Comprehension REF: Text Reference: 1818 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 13. A client with COPD has severe shortness of breath at rest and arterial oxygen tension (PaO2) of 35 mm Hg. When oxygen via nasal cannula is prescribed, the nurse would deliver the O2 at the flow rate of a. 2 L/min. b. 6 L/min. c. 10 L/min. d. 15 L/min.

a Oxygen is used when the client has severe exertional or resting hypoxemia (PaO2 below 40 mm Hg). Oxygen at 1 to 3 L/min by nasal cannula is required to raise PaO2 to 60 mm Hg. Oxygen is used cautiously in clients with emphysema. Because of long-standing hypercapnia, the respiratory drive in emphysematous clients is triggered by low oxygen levels. If high levels of oxygen are administered to these clients, their respiratory drive can be obliterated, and carbon dioxide retention can occur. DIF: Cognitive Level: Application REF: Text Reference: 1822 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 29. The nurse preparing a client for pulmonary angiography would include information about a. no exposure to radiation. b. the need to cough, deep-breathe, and hold the breath during the procedure. c. a sore throat and difficulty swallowing for a few days after the test. d. the expectation of blood in sputum and saliva after the test.

a Pulmonary angiography is painless and does not involve exposure to radiation. DIF: Cognitive Level: Application REF: Text Reference: 1771 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 7. The nurse would coach the asthmatic client in pursed-lip breathing because this technique a. increases pressure in the airway. b. decreases drying of the mucous membranes. c. increases oxygenation. d. decreases anxiety by distraction.

a Pursed-lip breathing increases the pressure in the airway, keeping it open to facilitate respiration. DIF: Cognitive Level: Application REF: Text Reference: 1812 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 12. The nurse would prepare a client with emphysema who has a ruptured emphysematous bleb for a. chest tube insertion. b. chest percussion and postural drainage. c. incentive spirometry. d. intubation.

a Spontaneous pneumothorax may develop from rupture of an emphysematous bleb. This results in a closed pneumothorax and requires chest tube insertion for reexpansion of the lung. DIF: Cognitive Level: Application REF: Text Reference: 1820 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 2. A client with pulmonary disease appears more comfortable after respiratory therapy but still feels short of breath. To measure the client's respiratory improvement, the nurse would use a. the Visual Analogue Scale. b. the Candle Scale. c. a treadmill test. d. a timed exercise test.

a The Visual Analogue Scale is used to quantify breathlessness in response to particular questions. It is easy to understand, and the amount of dyspnea during venous activities can be assessed. The modified Borg Category Ratio Scale is used to rate the intensity of dyspnea. DIF: Cognitive Level: Application REF: Text Reference: 1744 TOP: Nursing Process Step: Evaluation MSC:

Physiological Integrity 6. Before a laryngectomy the client asks how soon the artificial larynx can be employed for communication after surgery. The nurse's response would include the information that the artificial larynx can be employed a. 3 to 4 days after surgery. b. 1 week after surgery. c. 10 days after surgery. d. 2 weeks after surgery.

a The artificial larynx can be employed 3 to 4 days after surgery. DIF: Cognitive Level: Application REF: Text Reference: 1793 TOP: Nursing Process Step: Intervention MSC:

Health Promotion and Maintenance 2. In the preoperative teaching plan for a client scheduled for total laryngectomy and radical neck resection, the nurse would give highest priority to a. the client not being able to speak normally again. b. the endotracheal tube being in place for 2 to 3 days. c. the insertion of gastrostomy tube during surgery for feeding. d. the client not being able to perform deep-breathing exercises.

a The greatest problem for the client after laryngectomy is loss of voice. The client should be made aware that without surgery, the voice quality will worsen as the tumor enlarges. In any case, loss of voice constitutes a serious psychological issue. DIF: Cognitive Level: Application REF: Text Reference: 1789 TOP: Nursing Process Step: Intervention MSC:

Psychosocial Integrity 3. Auscultating the lungs of an asthmatic client, the nurse notes no inspiratory wheezing, which would suggest a. airway constriction requiring intensive interventions. b. an appropriate reaction to the medications used in the client's management. c. the need to assess further for manifestations of a pleural effusion. d. overuse of the intercostal muscles resulting in poor air exchange.

a The inability to auscultate wheezing in an asthmatic client with acute respiratory distress may be an ominous sign. It may indicate that the small airways are too constricted to allow any air flow. The client may require immediate, aggressive medical intervention. DIF: Cognitive Level: Application REF: Text Reference: 1809 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 11. The nurse has made the nursing diagnosis Ineffective Breathing Pattern related to tachypnea secondary to chest pain for a client with pneumonia. After administration of an analgesic, the nurse would a. auscultate the client's chest. b. reposition the client flat in bed. c. request that the client cough. d. encourage the use of an incentive spirometer.

a The nurse should administer prescribed cough suppressants and analgesics but should be cautious because narcotics may depress respirations more than desired. DIF: Cognitive Level: Application REF: Text Reference: 1843 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 7. When a 49-year-old client tells the nurse he has smoked half a pack of unfiltered cigarettes a day since he was 19 years old, the nurse would record the pack-years as a. 15. b. 20. c. 25. d. 30.

a The nurse should inquire about any history of smoking tobacco products, calculating the "pack-years," which helps to quantify the smoking history: years of smoking packs smoked per day = pack-years. DIF: Cognitive Level: Application REF: Text Reference: 1747 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 2. The nurse notes that a client in a long-term care facility has become increasingly confused in the last few days. The resident's vital signs are temperature 97.7° F, pulse 80, repirations 20, and blood pressure 90/62. The nurse would suspect a. pneumonia. b. tuberculosis (TB). c. plural effusion. d. cancer of the lung.

a The older adult with pneumonia may present not with fever or respiratory manifestations, but with altered mental status and volume depletion. DIF: Cognitive Level: Analysis REF: Text Reference: 1841 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 4. The nurse performing a brief physical assessment of an anxious client with asthma would carefully inspect the chest wall primarily to a. evaluate the client's use of the intercostal muscles. b. gain time to calm the client. c. observe the client for manifestations of diaphoresis. d. monitor the client for bilateral chest expansion.

a The ongoing assessment of an asthmatic client includes evaluation of the accessory muscles of respiration. The nurse should assess the client frequently, observing the respiratory rate and depth. The breathing pattern is assessed for shortness of breath, pursed-lips breathing, nasal flaring, sternal and intercostal retractions, and a prolonged expiratory phase. DIF: Cognitive Level: Application REF: Text Reference: 1813 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 35. The nurse requests the client to say "E" as the client's chest is auscultated. The nurse hears "A" as the stethoscope is placed over the left lower lobe. The nurse would record a. positive egophony over left lower lobe. b. atelectasis in the left lower lobe. c. positive whispered pectoriloquy over the left lower lobe. d. normal voice sounds assessment.

a The spoken "E" by the client sounds like "A" when the stethoscope is over an area of consolidation. DIF: Cognitive Level: Application REF: Text Reference: 1756 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 11. The nurse who is assessing several clients with respiratory problems would expect that increased tactile fremitus will most likely be demonstrated by the client with a. pneumonia. b. pneumothorax. c. pulmonary emboli. d. pleural effusion.

a The vibrations are transmitted from the larynx through the airways and can be palpated on the chest wall. The intensity of the vibrations on both sides is compared for symmetry. Stronger vibrations are felt over areas where there is consolidation of the underlying lung (e.g., pneumonia). DIF: Cognitive Level: Application REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 3. The nurse writing an infection control policy for a home health care agency would include the information that the rise in TB cases in recent years is related to a. the rise in HIV infection. b. the rise in illegal drug use. c. the rise in number of antibiotic-resistant bacteria. d. the aging of the U.S. population.

a This increase in TB has been attributed to the emergence of the human immunodeficiency virus (HIV) epidemic, recent influxes of immigrants from developing Third-World countries, and the deterioration of the U.S. health care infrastructure. DIF: Cognitive Level: Knowledge REF: Text Reference: 1844 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 23. The husband of a client with emphysema and pneumonia who is receiving mechanical ventilation via tracheostomy asks why his wife cannot have a tracheostomy button. The nurse's most informative response would be a. "Your wife needs suctioning, which cannot be done with a button." b. "A button cannot be used with a ventilator." c. "A button makes the work of breathing harder." d. "A button would decrease your wife's oxygenation."

b A button cannot be used with a ventilator. It replaces a standard tracheostomy tube for clients with retained secretions who do not require ventilatory assistance. DIF: Cognitive Level: Application REF: Text Reference: 1778 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 4. A client admitted to the emergency department (ED) with severe chest injuries and significant hypovolemia due to hemorrhage would be transfused to replace blood loss initially with a. type AB-negative blood. b. type O-negative blood. c. albumin. d. dextrose 5% in normal saline.

b A chest-injured client may require large quantities of blood replacement. Until the results of typing and crossmatching are available, the client is given O-negative blood. DIF: Cognitive Level: Knowledge REF: Text Reference: 1900 TOP: Nursing Process Step: N/A MSC:

Physiological Integrity 22. The nurse would assess a client with severe acute respiratory syndrome (SARS) for the major clinical manifestation indicating the onset of the lower respiratory phase, which is a. hempotysis. b. dry, nonproductive cough. c. rapid temperature elevation. d. pleuritic pain.

b A dry, nonproductive cough signals the onset of the lower respiratory phase of SARS. DIF: Cognitive Level: Analysis REF: Text Reference: 1850 TOP: Nursing Process Step: Assessment MSC:

Psychosocial Integrity 3. The observation that would require an immediate nursing intervention for a client recently returned to the unit following partial laryngectomy is a. blood-tinged sputum. b. pulsations of the tracheostomy tube. c. copious respiratory secretions. d. difficulty swallowing.

b A pulsating tracheostomy tube may indicate that the tip of the tube is resting on the innominate artery and may cause injury to the artery, resulting in hemorrhage. DIF: Cognitive Level: Analysis REF: Text Reference: 1789 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 16. At 9 AM a client is placed on a T-piece for weaning from the mechanical ventilator. The nurse arranges for follow-up arterial blood gases (ABGs) to be drawn at a. 9:15 AM. b. 9:30 AM. c. 10:30 AM. d. 12 noon.

b ABG values are obtained 30 minutes after a client has been placed on a weaning protocol. DIF: Cognitive Level: Application REF: Text Reference: 1893 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 18. In collecting a sputum specimen for acid-fast bacteria and culture, the nurse would be sure to a. collect the specimen after antibiotic therapy is initiated. b. provide an early-morning specimen. c. instruct the client to spit the specimen into a clean container. d. collect the specimen after any meal.

b Acid-fast smear and culture specimens are collected in the morning, when sputum is more plentiful and concentrated from pooling through the night. DIF: Cognitive Level: Application REF: Text Reference: 1771 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 23. To prevent leakage of blood into surrounding tissue after drawing blood for an ABG sample, the nurse would a. apply ice to the puncture site. b. maintain manual compression over the puncture site for 5 minutes. c. place a bandage over a sterile cotton swab on the puncture site for at least 1 minute. d. elevate the limb on several pillows.

b After the sample is drawn, continuous pressure should be applied to the site for 5 minutes for radial and brachial sites and 10 minutes for femoral sites. DIF: Cognitive Level: Application REF: Text Reference: 1764 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 15. A child has just returned to class after a 3-day absence for acute tonsillitis. When the child complains of an earache and sore throat and is drooling, the school nurse would suspect a. diphtheria. b. peritonsillar abscess. c. laryngospasm. d. chronic tonsillitis.

b As acute tonsillitis abates, the child may experience pain in the throat and ear and drooling. DIF: Cognitive Level: Analysis REF: Text Reference: 1800 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 24. After the physician tells a client that pneumonia has caused the client's bilateral lobar atelectasis, the client anxiously asks the nurse, "Does that mean my lungs have collapsed?" The most informative response by the nurse would be a. "Yes; both lungs have collapsed, but they are presently reinflating as your health improves." b. "No; only a lobe in each side has collapsed, but they will inflate as the pneumonia resolves." c. "Yes; large portions of your lungs have collapsed, but the unaffected portions of your lungs will accommodate your oxygen needs." d. "No, but your pneumonia has permanently damaged your lungs to the point they may never fully inflate."

b Atelectasis can occur throughout the lung or in portions of it (lobar). The lung reinflates after the condition that caused the obstruction has been treated. DIF: Cognitive Level: Application REF: Text Reference: 1837 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 16. The nurse auscultating over a client's trachea would expect to hear the breath sound characteristic of this location, which is a. adventitious. b. bronchial. c. bronchovesicular. d. vesicular.

b Bronchial breath sounds are heard over the manubrium in the large tracheal airways. DIF: Cognitive Level: Knowledge REF: Text Reference: 1755 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 16. The nurse notes intermittent bubbling in the water-seal chamber of a chest tube in place for a client with pneumothorax. The nurse's most appropriate action is to a. clamp the chest tube. b. encourage respiratory exercises. c. change the drainage unit. d. place petrolatum gauze around the chest tube.

b Bubbling in the water-seal compartment is caused by air passing out of the pleural space into the fluid in the bottle. Intermittent bubbling is normal when the lung is still expanding. Respiratory exercises will hasten the lung's reexpansion. DIF: Cognitive Level: Analysis REF: Text Reference: 1863 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 24. The group of medications that the nurse would instruct a client to withhold in the 6 hours before pulmonary function studies is a. antibiotics. b. bronchodilators. c. corticosteroids. d. diuretics.

b Clients should not smoke or use a bronchodilator 6 hours before undergoing a pulmonary function test. DIF: Cognitive Level: Comprehension REF: Text Reference: 1760 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 18. The nurse caring for a client who has the medical diagnosis of diphtheria would place the client in a a. semi-private room. b. room equipped for respiratory isolation. c. medical intensive care unit. d. room with a pleasant view.

b Diphtheria is spread by aerosolization of the organism (droplet infection) and when others use objects (e.g., eating utensils, towels) handled by diphtheria-infected people. DIF: Cognitive Level: Application REF: Text Reference: 1801 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 22. As part of the care of a mechanically ventilated client, the nursing action that would be inappropriate is a. providing oral care every 2 hours. b. draining water from the ventilator tubing back into the humidifier. c. using aseptic technique for suctioning. d. washing the hands before and after care.

b Drain water from ventilator tubing should not be drained back into the humidifier. Water may become a source of contamination, especially with Pseudomonas. DIF: Cognitive Level: Application REF: Text Reference: 1891 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 10. The nurse preparing to assess a client for the presence of clubbing would instruct the client to a. sit upright and lean over the bedside table. b. place the nails of the ring fingers together. c. walk 50 feet up the hall as quickly as possible. d. place both hands on a flat surface and splay the fingers.

b Early clubbing may be assessed by using the Schamroth technique. The client places the nails of the fourth (ring) fingers together while extending the other fingers together, then holds the hands up. A diamond-shaped space between the nails is a normal finding; that is, clubbing is absent. DIF: Cognitive Level: Application REF: Text Reference: 1750, 1752, Figure 61-5; TOP: Nursing Process Step: Assessment MSC:

Health Promotion and Maintenance 4. The nurse would know that the client most likely to exhibit a false-negative Mantoux reaction is a. a malnourished client. b. an HIV-infected client. c. a client previously diagnosed with TB. d. a client diagnosed with sickle cell disease.

b False-negative reactions are possible with the Mantoux test, especially in clients who are immunosuppressed or anergic. DIF: Cognitive Level: Analysis REF: Text Reference: 1846 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 17. A client has a three-bottle chest tube apparatus connected to suction. Noting that the suction control chamber is bubbling gently, the nurse would a. auscultate the lungs. b. record this as a normal finding. c. retape all the tubing connections. d. briefly clamp the chest tubing.

b Gentle bubbling in the suction chamber is normal. DIF: Cognitive Level: Application REF: Text Reference: 1864 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 8. When a friend comes to the nurse's apartment to seek help to stop the bleeding from a broken nose, the nurse would attempt to convince the friend to seek treatment in the emergency department primarily because a. it will be very difficult to stop the bleeding if the nose is fractured. b. the nose cannot be set for 2 to 3 days if edema develops. c. general anesthesia may be needed to locate the bleeding vessels. d. cosmetic results are poor when treatment is delayed.

b If a nasal fracture occurs, immediate medical management is advised. Within several hours of nasal injury, severe edema may occur, which causes difficulty in reducing the fracture. DIF: Cognitive Level: Application REF: Text Reference: 1804 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 21. When a client with a cuffed ET tube reports shortness of breath, the nurse would a. gives the ordered pain medication. b. assesses for a cuff leak. c. increase the level of O2 delivery. d. elevate the head of the bed.

b If the client can talk, the cuff is not inflated. The complaint of shortness of breath is also related to the ET tube not being tightly fitted. DIF: Cognitive Level: Analysis REF: Text Reference: 1884 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 20. The measure that would best aid the nurse in removing heavy, tenacious secretions during suctioning is a. hyperinflating the lungs before suctioning. b. instilling sterile saline directly into the trachea. c. encouraging frequent coughing and deep breathing. d. employing postural drainage before suctioning.

b If tracheal secretions are thick and not easily removed, the nurse should directly instill 3 ml of sterile normal saline into the trachea. The saline reduces the viscosity of secretions for easier removal and acts to stimulate the cough reflex mechanically. DIF: Cognitive Level: Application REF: Text Reference: 1783 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 22. The ambulatory care nurse would arrange for periodic monitoring of blood levels for a client with COPD who is beginning to use a. zafirlukast (Accolate). b. theophylline (Theo-Dur). c. ipratropium (Atrovent). d. beclomethasone (Vanceril).

b It is necessary to monitor blood levels in the client taking theophylline. DIF: Cognitive Level: Comprehension REF: Text Reference: 1814 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 27. The nurse would question the accuracy of a pulse oximetry evaluation in a client who is a. started on oxygen via a Venturi mask. b. experiencing hypotension. c. sitting in a chair after prolonged bed rest. d. on a ventilator.

b Limitations with pulse oximetry are still present despite advances in the technology. Hypotension, hypothermia, and vasoconstriction reduce arterial blood flow to the sensor. DIF: Cognitive Level: Analysis REF: Text Reference: 1761 TOP: Nursing Process Step: Evaluation MSC:

Physiological Integrity 25. To best prepare a client scheduled for measurement of lung volumes with body plethysmography, the nurse would a. practice walking up inclines with the client. b. note that the client will be placed in an airtight, box-like device. c. instruct the client to remove all metallic objects from the body and clothing. d. encourage the client to practice breath holding for sustained periods.

b Lung volumes are measured with a dilutional technique using helium or body plethysmography. The body plethysmograph, or the "body box," is a device used to measure lung volumes. While sitting in the airtight box, the client is instructed to perform a panting maneuver. DIF: Cognitive Level: Application REF: Text Reference: 1760 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 10. To prevent the complication of atelectasis in an 82-year-old woman with a hip fracture, the nurse would a. ambulate the client frequently. b. frequently reposition the client. c. suction the upper airway. d. supply oxygen.

b One of the primary goals of nursing intervention is to prevent atelectasis in the high-risk client. Frequent position changes and early ambulation help promote drainage of all lung segments. DIF: Cognitive Level: Application REF: Text Reference: 1838 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 11. The nurse would explain that the use of positive end-expiratory pressure (PEEP) assists the client on mechanical ventilation by a. gradually increasing the amount of oxygen delivered. b. keeping the alveoli open. c. increasing the amount of expired carbon dioxide. d. using a pressure of 30 cm H2O.

b PEEP keeps the alveoli open to offer more ventilation surface by using pressures of 5 to 20 cm H2O. DIF: Cognitive Level: Application REF: Text Reference: 1885 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 16. A client who has smoked for 10 years has developed acute tracheobronchitis. The nurse assisting the client to control the clinical manifestations of this disorder would instruct the client to a. cough vigorously and as frequently as possible. b. cover the mouth and nose before going outdoors when it is cold. c. drink only fruit juices. d. reduce the number of cigarettes smoked daily.

b Priority nursing goals include the relief of pain and elimination of tracheal irritation. The nurse should strongly advise the client to stop smoking and tell the client to avoid cold air and cover the mouth and nose before going outdoors. DIF: Cognitive Level: Application REF: Text Reference: 1829 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 18. In caring for a client scheduled to have chest tubes removed, the nurse's most appropriate action would be to a. assist the client to a prone position. b. medicate for pain ½ hour before removal. c. encourage deep breathing during removal. d. empty the collection chambers before removal.

b Removal of chest catheters can be moderately painful. The prescribed premedication should be administered about ½ hour before the procedure. DIF: Cognitive Level: Application REF: Text Reference: 1866 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 30. In the postprocedure care of a client who had a right thoracentesis, the nurse would a. turn the client to the right side. b. record the amount of fluid withdrawn. c. assist to ambulate and deep-breathe. d. administer oxygen at 2 L/min per nasal cannula.

b The amount of fluid withdrawn is counted as "output" and should be recorded as such. DIF: Cognitive Level: Application REF: Text Reference: 1772 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 23. After providing instructions to a client with newly diagnosed COPD who is learning to take a steroid medication by inhaler, the nurse would determine that proper technique has been learned when the client a. gently rolls the canister in the hands before use. b. holds breath for 5 to 10 seconds after inhalation. c. breathes out forcefully with an open mouth. d. starts to discontinue medication once clinical manifestations subside.

b The client should hold the aerosol vapor for 5 to 10 seconds after inhalation. DIF: Cognitive Level: Comprehension REF: Text Reference: 1816, Client Education Guide - Asthma; TOP: Nursing Process Step: Evaluation MSC:

Physiological Integrity 11. In developing a long-range plan for a client with chronic bronchitis, the nurse would consider the possibility that the client may develop the common cardiovascular change of a. aortic dissection. b. enlargement of the right ventricle. c. pulmonary hypertrophy. d. first-degree heart block.

b The client with chronic bronchitis may have an enlarged heart and right ventricular lift. DIF: Cognitive Level: Comprehension REF: Text Reference: 1819 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 12. To increase the level of comfort for a client with a lung abscess, the nurse would include in the care plan the intervention to a. encourage activity before meals. b. offer frequent oral hygiene. c. provide easy-to-eat milk products. d. restrict fluid intake.

b The client's sputum may have a foul taste. The nurse should rovide frequent opportunities for the client to use mouthwash and perform tooth brushing and flossing. DIF: Cognitive Level: Application REF: Text Reference: 1844 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 6. The nurse would explain that emergency treatment of a tension pneumothorax requires a. immediate tracheostomy. b. insertion of an 18-gauge needle into the pleural space. c. a small stab wound with a skin blade made into the pleural space. d. covering the chest wall wound with gauze.

b The immediate intervention is to convert tension pneumothorax into open pneumothorax (a less serious disorder). If a delay is anticipated (with chest tube insertion), a 14- to 18-gauge needle is inserted into the pleural space of the affected side at the level of the second intercostal space at the midclavicular line. DIF: Cognitive Level: Knowledge REF: Text Reference: 1904 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 9. After a posterior nasal pack is inserted by the physician, the client is very anxious and states, "I don't feel like I'm breathing right." The immediate intervention the nurse would initiate is a. monitor arterial blood gases (ABGs). b. direct a flashlight into the client's mouth and inspect the oral cavity. c. cut the pack strings and pull the packing out with a hemostat. d. reassure the client that this is normal discomfort.

b The nurse should inspect the oral cavity for the presence of blood, soft palate necrosis, and proper placement of the posterior plug. If the posterior plug is visible, the physician is notified for readjustment of the packing. DIF: Cognitive Level: Knowledge REF: Text Reference: 1797 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 12. As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would a. position the client's legs above heart level. b. administer oxygen as ordered using a high-flow rebreather bag. c. bring a tracheostomy set to the bedside. d. monitor vital signs every 30 to 45 minutes until stable.

b The nurse should monitor vital signs every 15 minutes initially until the client is stable and administer oxygen as ordered using a high-flow rebreather bag to maintain oxygenation (oxygen saturation above 90%). Mechanical ventilation and intubation equipment should be nearby. To reduce preload, the client should be positioned with the legs dependent. Raising edematous legs increases venous return and will stress the overtaxed left ventricle. DIF: Cognitive Level: Application REF: Text Reference: 1880 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 5. A client recently had a total laryngectomy and plans to use an artificial larynx for speech. The common problem that the nurse would address regarding the artificial larynx is a. neck discomfort. b. monotone speech quality. c. difficult-to-use device. d. masculine-sounding voice quality.

b The speech quality is monotone and mechanical sounding but intelligible. DIF: Cognitive Level: Application REF: Text Reference: 1793 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 28. When the nurse prepares to suction an unconscious client's tracheostomy, the initial action would be a. deflate the cuff. b. suction tracheostomy with the cuff inflated. c. turn the client to the side. d. use low suction pressure.

b The tracheostomy should be suctioned first with the cuff inflated to prevent aspiration of the secretions accumulated on top of the cuff. DIF: Cognitive Level: Application REF: Text Reference: 1783 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 27. When feeding a client with a tracheostomy, the nurse would a. thin the food to liquid consistency. b. tilt the client's chin toward the chest. c. inflate the cuff before the meal. d. follow each spoon of food with a small amount of liquid.

b Tilting the client's chin toward the chest closes the glottis. The feeding should be thick like pudding, and the cuff should be deflated. DIF: Cognitive Level: Application REF: Text Reference: 1785 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 7. When a client is admitted to the ED with a sucking chest wound, the nurse initially would a. leave the wound open. b. cover the wound with whatever is available. c. obtain a sterile gauze petroleum dressing to cover the wound. d. notify the physician.

b When an open sucking chest wound is detected, emergency intervention includes immediately covering the wound securely with anything available. The nurse should not waste time looking for a sterile gauze petroleum dressing if it is not immediately available. DIF: Cognitive Level: Application REF: Text Reference: 1904 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 29. Noting the need to use 8 ml rather than 5 ml to inflate the tracheostomy cuff sufficiently, the nurse would a. completely deflate the cuff to relieve the dilation. b. notify the physician to have an x-ray film obtained for tracheal dilation. c. replace the entire tracheostomy tube with a larger size. d. ask client to swallow, then cough.

b When the nurse notes the need for greater amount of air in the cuff to create an effective seal, the nurse should report this to the physician so that a confirming x-ray film for tracheal dilation can be obtained. DIF: Cognitive Level: Application REF: Text Reference: 1779 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 12. For client returning to the nursing unit after a Caldwell-Luc procedure, the nurse would plan care based on the knowledge that a. a tracheotomy will be present. b. chest tubes will drain excess fluid. c. the client will be unable to breathe through the nose. d. administering oxygen to the client may cause laryngospasm.

c After a Caldwell-Luc procedure, the maxillary sinus and anterior nasal cavity are packed with ½-inch gauze. Because of the packing, nasal breathing is obstructed. DIF: Cognitive Level: Application REF: Text Reference: 1798 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 23. The nurse would become concerned about the risk of hemorrhage if, in the first 2 hours after surgery, the thoracotomy client's drainage exceeded a. 50 ml. b. 100 ml. c. 300 ml. d. 750 ml.

c As much as 500 to 1000 ml of drainage may occur in the first 24 hours after chest surgery. Between 100 and 300 ml of drainage may accumulate during the first 2 hours; after this time, the drainage should lessen. DIF: Cognitive Level: Application REF: Text Reference: 1862 TOP: Nursing Process Step: Application MSC:

Physiological Integrity 24. In the event of deterioration in a client's respiratory status and a Jackson metal tracheostomy tube being used, the nurse would note the limitation that the tube a. has a high-pressure cuff. b. has no inner cannula. c. has is no respirator adapter. d. is very short.

c Because metal tubes do not have a standard 15-mm adapter, rapid adaptation to respiratory or anesthesia equipment is impossible unless a specific adapter is available. DIF: Cognitive Level: Knowledge REF: Text Reference: 1779 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th Edition Chapter 64: Management of Clients with Parenchymal and Pleural Disorders MULTIPLE CHOICE 1. The nurse administering influenza vaccinations to a group of office workers would not offer the vaccine to a client who a. is allergic to sulfa drugs. b. is taking amoxicillin for a bladder infection. c. is allergic to eggs. d. has a history of asthma.

c Clients allergic to eggs or who have a history of Guillain-Barré syndrome should not receive an influenza vaccine. DIF: Cognitive Level: Knowledge REF: Text Reference: 1839 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 19. On physical examination of a client with pneumonia, the nurse would expect a. vesicular breath sounds over the affected area. b. tympanic percussion notes over the affected area. c. increased tactile fremitus over the affected area. d. absence of whispered pectoriloquy over the affected area.

c Consolidated lung tissue transmits bronchial sound waves to outer lung fields. Crackling sounds and whispered pectoriloquy may be heard over the affected areas. Tactile fremitus is usually increased over areas of pneumonia, whereas percussion notes are dulled. DIF: Cognitive Level: Application REF: Text Reference: 1841 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 15. The nurse percusses an area of dullness on the anterior chest at the level of the tenth right rib on a client with chronic obstructive pulmonary disease (COPD). The most appropriate interpretation of this finding is that the percussion note was elicited over a. a pneumothorax. b. an area of pneumonia. c. the liver. d. the heart.

c Dull sounds are thud-like, medium pitched, and normally heard over the liver and heart. The location of the finding indicates liver tissue. DIF: Cognitive Level: Application REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Health Promotion and Maintenance 2. On entering the emergency department (ED), a client is short of breath and appears frightened. The nurse beginning the assessment of the client would be aware that an early clinical manifestation often associated with asthma is a. cyanosis. b. hypercapnia. c. anxiety. d. bradycardia.

c During asthma attacks, clients are dyspneic and have marked respiratory effort. At the beginning of an attack, the client generally appears anxious and has wheezing, cough, dyspnea, tachycardia, and difficulty with expiration. DIF: Cognitive Level: Knowledge REF: Text Reference: 1807-1808 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 32. The nurse would explain to a client that a contraindication for fluoroscopy is a. presence of a pacemaker. b. lupus erythematosus. c. pregnancy. d. liver disease.

c Exposure to radiation is minimal, but pregnant women should not be exposed to fluoroscopy. DIF: Cognitive Level: Application REF: Text Reference: 1767 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 19. The nurse would determine that a client with fractured ribs needs further self-care instructions when the client says a. "I'll be sure to take it really easy for the next several weeks." b. "That heating pad in the closet at home will come in handy now." c. "I'll strap the ribs snugly so they can't move around." d. "I can take pain medication every 4 hours if I need it."

c Fractured ribs are generally treated conservatively with rest, local heat, and analgesics. Strapping the ribs is no longer recommended because it restricts deep breathing and can increase the incidence of atelectasis and pneumonia. DIF: Cognitive Level: Application REF: Text Reference: 1901 TOP: Nursing Process Step: Evaluation MSC:

Physiological Integrity 15. The nurse would explain to a client with emphysema that the client's respiratory drive is triggered by a. increased oxygen levels. b. decreased carbon dioxide levels. c. decreased oxygen levels. d. equalized oxygen and carbon dioxide levels.

c In clients with emphysema, the drive to breathe is the opposite of normal. If high oxygen levels are administered, their respiratory drive can be obliterated. DIF: Cognitive Level: Application REF: Text Reference: 1822 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 25. The nurse would explain that the client's diagnosis of interstitial pneumonia means a. the alveoli are filled with fluid. b. the small bronchioles are inflamed. c. there is an inflammatory response in the tissue surrounding the air space. d. pus has accumulated in the major bronchi.

c Interstitial pneumonia occurrs when the parenchymal tissue surrounding the air space is inflamed. DIF: Cognitive Level: Analysis REF: Text Reference: 1841, 1842; TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 13. The nurse caring for a client who recently converted from a negative to a positive tuberculin skin test would anticipate as part of a prevention program a prescription for a. dexamethasone. b. gentamicin. c. isoniazid. d. penicillin.

c Isoniazid is one of the primary drugs used in the treatment of tuberculosis. DIF: Cognitive Level: Knowledge REF: Text Reference: 1847 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 21. A client who is being treated for pneumonia has a PaO2 of 75 mm Hg on room air. The most appropriate interpretation of these data by the nurse would be that the client a. is in severe respiratory distress and may need intubation. b. needs to be repositioned to improve ventilation. c. needs supplemental oxygen. d. is doing well, and no modifications are needed.

c Mild hypoxemia is a PaO2 less than 80 mm Hg on breathing room air. Results are evaluated in light of the oxygen needed. For example, if the PaO2 is 85 mm Hg with 50% oxygen, the client has a more significant problem with oxygen transport than a client whose PaO2 is 85 mm Hg on room air (21% oxygen). DIF: Cognitive Level: Analysis REF: Text Reference: 1765 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 10. A client with a posterior pack for severe epistaxis asks how long the packing must remain in place. The nurse's response would include the information that the packs stay in place for a. 24 hours. b. 2 to 3 days. c. 5 days. d. a period that depends on how long it takes to stop the bleeding.

c Nasal packing should remain in place for 5 days, during which time the client must be observed for additional bleeding, evidence of hypertension or hypotension, and infection. DIF: Cognitive Level: Application REF: Text Reference: 1797 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 36. The nurse preparing to perform a pulse oximetry is told by the client that her painted nails are artificial. Before the assessment, the nurse would a. remove the artificial nail. b. remove the polish if it is red or clear. c. attach the sensor to the toe. d. exert increased pressure on the sensor.

c Pulse oximetry readings can be taken in the fingers, ear lobes, or toes. Dark-red, blue, green, or black polish should be removed. Artificial nails do not interfere with the assessment. DIF: Cognitive Level: Application REF: Text Reference: 1763 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 12. The nurse clinician performing percussion of the chest on a client assesses a low-pitched, hollow sound over the middle lobe. The nurse would record this finding as a. dull sounds over middle lobe; reassess in 1 week. b. hyperresonance; refer to physician for work-up. c. normal resonance. d. tympany at middle lobe; refer to radiology.

c Resonant sounds are low-pitched, hollow sounds heard over normal lung tissue. DIF: Cognitive Level: Analysis REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 17. The nurse auscultating the chest of a client with chronic bronchitis would expect to hear the characteristic adventitious breath sound of a. bronchovesicular sounds in the bases. b. crackles throughout the lung fields. c. rhonchi on expiration. d. wheezes on inspiration.

c Rhonchi (gurgles) result when air passes through fluid-filled narrow passages. Diseases with excess mucus production (e.g., bronchitis) are associated with rhonchi on expiration. DIF: Cognitive Level: Analysis REF: Text Reference: 1756 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 26. The nurse is assessing breath sounds with the diaphragm of the stethoscope and hears rhonchi on expiration in both lower lobes. The nurse would reassess a. with the bell of the stethoscope. b. with the client leaning forward. c. after the client has coughed. d. after the client has taken a deep breath.

c Rhonchi are usually heard on expiration and may clear with a cough. DIF: Cognitive Level: Application REF: Text Reference: 1756 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 30. The wife of a client with a cuffed tracheostomy anxiously calls the nurse because her husband's face and neck are "puffing up like a balloon." The nurse would a. give 100% oxygen. b. inflate the cuff to 25 cm H2O to stop the air leak. c. offer reassurance that the emphysema will be absorbed. d. suction the tracheostomy thoroughly.

c Some clients with a tracheostomy experience subcutaneous emphysema when air escapes from the tracheostomy incision into the tissues and planes under the skin, causing a puffy appearance. The air is eventually absorbed. DIF: Cognitive Level: Comprehension REF: Text Reference: 1780 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 26. When the chest tube detaches from the closed-chest drainage system, and the client experiences sudden dyspnea, the nurse would a. clamp the chest tube. b. position the client in an upright position. c. reconnect the chest tube to the system. d. tell the client to perform Valsalva's maneuver.

c The atelectasis that occurred during the disconnection can be remedied by reattaching the chest tube to the system. Clamping the tube may cause a tension pneumothorax. DIF: Cognitive Level: Application REF: Text Reference: 1865 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 33. In teaching a client about a gallium scan, the nurse would include the instruction that a. the client will have to return in 24 hours for a serial scan. b. the throat may be sore for a few days after the test. c. the client will have brief discomfort at the injection site. d. the test takes about 2 hours to complete.

c The client may feel discomfort at the injection site; nothing is introduced to the throat. The test requires serial scans at 24, 48, and 72 hours after the initial scan, which takes about 45 to 60 minutes. DIF: Cognitive Level: Application REF: Text Reference: 1768 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 5. The nurse interprets a Mantoux reaction as "0 millimeters," a negative test. The client tells the nurse, "It's good to know that I definitely don't have TB." The correct response by the nurse would be a. "A negative Mantoux test means that you have not been exposed to TB." b. "This means that you do not have active TB at this time." c. "A negative test does not always mean that TB is not present." d. "A negative test simply means that you do not need treatment at this time."

c The client should understand that the absence of a positive test result does not always mean that TB is absent. DIF: Cognitive Level: Application REF: Text Reference: 1846 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 8. The nurse caring for a client with cystic fibrosis would select as high priority the nursing diagnosis of a. Activity Intolerance. b. Anxiety. c. Risk for Ineffective Airway Clearance. d. Risk for Deficient Fluid Volume.

c The disease process causes tracheobronchial secretions to become thick and viscous, leading to interference with normal ciliary action, plugging of airways, and creation of a reservoir for bacterial growth and infection. DIF: Cognitive Level: Application REF: Text Reference: 1869 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 34. The nurse would record the thoracic excursion as "normal" when the nurse's hands on the posterior chest wall a. move down and closer together on the client's expiration. b. exhibit spreading of the fingers. c. move up and out on the client's inspiration. d. do not move on inspiration or expiration.

c The examiner's hands should move up and out symmetrically on the client's inspiration. DIF: Cognitive Level: Application REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 31. The nurse would explain to a client that in a lateral decubitus view, the x-ray film will be made with the client a. standing and facing the x-ray machine. b. standing and facing away from the x-ray machine. c. lying on the side. d. lying on the back.

c The lateral decubitus (lying-down) position may be used when it is necessary to determine whether opaque areas on the pleura are caused by solid or liquid media. The client will be asked to lie on the right or left side, depending on which side of the chest is being assessed. DIF: Cognitive Level: Application REF: Text Reference: 1767 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th Edition Chapter 65: Management of Clients with Acute Pulmonary Disorders MULTIPLE CHOICE 1. In the nursing care of a client recently intubated and placed on mechanical ventilation, the nursing action that would take highest priority is a. monitoring temperature every 4 hours. b. turning the client every 3 hours. c. monitoring blood pressure frequently. d. assessing for pedal pulses regularly.

c The lowered cardiac output will be reflected in the hypotension that clients typically exhibit immediately after being placed on mechanical ventilation. It is imperative that blood pressure be monitored closely. DIF: Cognitive Level: Application REF: Text Reference: 1888 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 8. A client has just returned from China, where there is a high incidence of respiratory disorders. The nurse would advisethe client to have a screeming to assess for exposure to a. Valley fever. b. histoplasmosis. c. tuberculosis. d. adult respiratory distress syndrome (ARDS).

c The nurse should ask about recent travel to areas where respiratory diseases are prevalent, such as Asia (tuberculosis), the Ohio River Valley (histoplasmosis), and the San Joaquin Valley (Valley fever). Living in cities with polluted air has also been related to asthma. DIF: Cognitive Level: Application REF: Text Reference: 1747 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 6. An older adult client says, "I need to get a shot so that I'll never get pneumonia again." The most helpful response by the nurse would be a. "You cannot get a shot, or immunization, for pneumonia." b. "Most older people get flu shots, but they don't protect you from pneumonia." c. "There is an immunization called Pneumovax that provides protection against one type of pneumonia." d. "Immunization for pneumonia must be repeated every year in the fall to protect you from new strains of the disease."

c The nurse should ask older adults about immunization against pneumonia (polyvalent pneumococcal vaccine, Pneumovax) and influenza. Ask the client to list the dates of these immunizations. Pneumovax provides lifelong immunity against pneumococcal pneumonia, whereas "flu shots" must be received annually in the fall. DIF: Cognitive Level: Application REF: Text Reference: 1746 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 6. The nurse caring for a client with asthma would place the client in the a. supine position. b. side-lying position. c. Fowler's position. d. lithotomy position.

c The nurse should place the client in the Fowler's position and give oxygen as ordered. DIF: Cognitive Level: Comprehension REF: Text Reference: 1813 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 21. The nurse is assessing the partial thromboplastin time (PTT) for a client taking heparin for the resolution of a pulmary embolus. If the INR of the client is 1.2, the nurse would be a. alarmed as the clotting time is dangerously long. b. satisfied that the clotting time is withing the therapeutic range. c. aware that the physician will need to be notified to increase the heparin. d. confused as a report of 1.2 does not relate to INR standards.

c The optimal INR ratio for heparin therapy is 2.5 to 3. A reading of 1.2 indicates that the clotting time is still too fast for effective anticoagulant therapy. DIF: Cognitive Level: Analysis REF: Text Reference: 1832 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th Edition Chapter 62: Management of Clients with Upper Airway Disorders MULTIPLE CHOICE 1. The nurse would identify that the client at highest risk for development of laryngeal cancer is a. a 30-year-old man who smokes one pack of cigarettes per day. b. a 60-year-old woman who smokes occasionally and is easily fatigued. c. a 70-year-old man with a 40-year history of alcohol use and heavy smoking. d. an 80-year-old man who has a very high intake of caffeinated beverages.

c The primary etiologic agent in laryngeal cancer is cigarette smoking. Three of four clients who develop laryngeal cancer have smoked or currently smoke. Alcohol appears to act synergistically with tobacco, increasing the risk of developing a malignant tumor in the upper airway. DIF: Cognitive Level: Application REF: Text Reference: 1786 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 3. Evaluating the respiratory status of a 59-year-old man with vague complaints of respiratory problems, the nurse would know the assessment that is normal is a. dyspnea with mild exertion. b. an inspiratory wheeze heard only with a stethoscope. c. the absence of sputum production after coughing. d. reports of loud snoring by the client's spouse.

c The tracheobronchial tree normally produces about 3 ounces of mucus a day as part of the normal cleansing mechanism. However, sputum production with coughing is not normal. DIF: Cognitive Level: Application REF: Text Reference: 1744 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 20. After administering a Mantoux test to a client on Monday, the nurse would request that the client return for an evaluation of the results on a. Monday evening. b. Tuesday during the day. c. Wednesday or Thursday. d. late Friday.

c The wheal must be examined (read) in 48 to 72 hours by a trained professional. DIF: Cognitive Level: Comprehension REF: Text Reference: 1846 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 18. When the ED nurse receives a radio call from an ambulance transporting a client who sustained chest trauma and has a severe flail chest, the nurse would set up the treatment area with a. rib spreaders. b. pulse oximeter. c. intubation tray. d. petroleum jelly gauze.

c Treatment is usually with intubation and mechanical ventilation, which can (a) restore adequate ventilation, thus reducing hypoxia and hypercapnea; (b) decrease paradoxical motion by using positive pressure to stabilize the chest wall internally; (c) relieve pain by decreasing movement of the fractured ribs; and (d) provide an avenue for removal of secretions. DIF: Cognitive Level: Comprehension REF: Text Reference: 1902 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 26. A client is trying unsuccessfully to clear the airway with a cough. The measure the nurse would suggest to help the client cough more effectively is a. cough while leaning forward. b. drink milk to coat the throat. c. place a clean finger over the tracheostomy tube and cough. d. insert a large-lumen suction catheter before coughing.

c When the client's condition is stabilized sufficiently, coughing may be enhanced by having the client place a finger over the tracheostomy tube opening while attempting to cough. DIF: Cognitive Level: Application REF: Text Reference: 1783 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 22. A client has a fenestrated tracheostomy tube in place. A tracheostomy plug will be used to allow the client to talk. The intervention by the nurse that would be essential before inserting the plug is a. alerting the client to a new system of communication. b. positioning the client to facilitate air flow. c. evaluating the client's tidal volume. d. deflating the cuff on the tracheostomy tube.

d A cuffed tracheostomy tube is always deflated before using a talking tracheostomy adapter. Cuff inflation prevents exhalation, causing suffocation. DIF: Cognitive Level: Analysis REF: Text Reference: 1778 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 20. A client who experienced pulmonary embolus and was receiving heparin therapy will now start receiving sodium warfarin (Coumadin). When the client asks the nurse when the heparin infusion will be removed, the nurse's most appropriate response would be a. "It will be taken away 6 hours after the first dose of warfarin." b. "It is uncertain because it is an individual physician's preference." c. "It will be discontinued just before you leave the hospital to go home." d. "It will be discontinued in 3 to 5 days, once the warfarin takes effect."

d Administration of sodium warfarin is begun about 3 to 5 days before heparin is stopped to provide a transition to oral anticoagulants. DIF: Cognitive Level: Comprehension REF: Text Reference: 1832 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th Edition Chapter 63: Management of Clients with Lower Airway and Pulmonary Vessel Disorders MULTIPLE CHOICE 1. The nurse is working on a respiratory care unit where many of the clients are affected by asthma. The action by the nurse that would most likely increase the respiratory difficulty of the clients is a. allowing the clients to eat leafy vegetables. b. encouraging the clients to ambulate. c. withholding antibiotic therapy until cultures are obtained. d. wearing perfume to work.

d Apparently, environmental factors (e.g., viral infection, allergens, pollutants) interact with inherited factors to produce asthma. Other inciting factors include excitatory states (e.g., stress, laughing, crying), exercise, changes in temperature, and strong odors (e.g., perfume). DIF: Cognitive Level: Comprehension REF: Text Reference: 1808 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 15. A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator. The appropriate approach by the nurse to the client's postoperative pain control would be a. the neuromuscular blocking agent will prevent pain impulse transmission, so the prn analgesic order is unnecessary. b. a sedative should be given with the neuromuscular blocking agent, and together these will control pain. c. a sedative should be given with an anxiolytic and the neuromuscular blocker to control pain. d. an analgesic is needed specifically for pain control and must be given as needed along with the neuromuscular blocker and a sedative or anxiolytic.

d Because the neuromuscular blocking agent does not inhibit pain or awareness, it is combined with a sedative or an anti-anxiety agent (anxiolytic). Pain medication may also be required if the client has pain. DIF: Cognitive Level: Comprehension REF: Text Reference: 1888 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 5. A client receives a beta-adrenergic bronchodilator and supplemental oxygen when entering the ED for treatment of asthma, but the client's condition remains unchanged. The nurse would anticipate that the client a. will be coached immediately in biofeedback techniques. b. will increase the amount of oral fluids taken. c. will undergo "stat" pulmonary function tests. d. will receive intravenous (IV) steroids.

d Emergency management of the asthmatic client begins with inhaled beta-adrenergic drugs. If the asthma does not abate, nebulized atropine sulfate or IV steroids may be given. DIF: Cognitive Level: Comprehension REF: Text Reference: 1812 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 18. A client experiencing severe chest pain from a pulmonary emboli has been medicated for pain but appears anxious and restless. The additional nursing measure that most likely would assist the client in dealing with fear is a. reassuring the client that the pain medication will be effective in 30 minutes. b. asking the client not to focus on the pain. c. explaining the monitoring devices to the client. d. remaining at the bedside with the client.

d Emotional support can reduce anxiety and lessen dyspnea. The nurse should stay with the client and provide calm, efficient nursing care. DIF: Cognitive Level: Comprehension REF: Text Reference: 1832-1833 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 14. The nurse performing a physical examination on a 25-year-old, 90-pound, anorexic client notes hyperresonance during percussion of the chest. The nurse would anticipate that the client will need a. aggressive respiratory therapy. b. immediate assessment by the physician. c. monitoring of the lung status for progression to tympany. d. routine respiratory care for this normal finding.

d Hyperresonant sounds are normally heard in children and very thin adults. DIF: Cognitive Level: Application REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 8. After dressing a sucking chest wound, the nurse notes that the client is developing severe dyspnea, tachypnea, cyanosis, tachycardia, and asymmetrical chest movements. The nurse would a. notify the physician. b. check the chest dressing for any air leakage. c. insert an 18-gauge needle into the pleural space. d. remove the chest dressing.

d If a tension pneumothorax appears to be developing after the wound is sealed, the nurse should immediately unplug the seal to allow the air to escape. DIF: Cognitive Level: Application REF: Text Reference: 1905 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 25. When a client coughs violently and the tracheostomy tube falls out and the client becomes dyspneic, the nurse attempts to reinsert the tracheostomy tube over the next 60 seconds but is unable to do so. The nurse's next action would be a. start high-flow oxygen via nasal prongs. b. place a finger in the stoma. c. perform a cricoidectomy. d. call a code.

d If the tracheostomy tube cannot be reinserted in 1 minute, the nurse should call a code for respiratory arrest. Unless the client is breathing adequately, an emergency cricoidectomy will be necessary. DIF: Cognitive Level: Analysis REF: Text Reference: 1780 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 17. The nurse would determine that a client is having a dysfunctional ventilatory weaning response if the client's respiratory rate rises to a. 20 breaths per minute. b. 25 breaths per minute. c. 30 breaths per minute. d. 35 breaths per minute.

d Manifestations of respiratory muscle fatigue include a respiratory rate of more than 30 breaths per minute or higher increased PaCO2, abnormal patterns of breathing, hemodynamic changes (e.g., dysrhythmias), diaphoresis, anxiety, and dyspnea. DIF: Cognitive Level: Comprehension REF: Text Reference: 1894 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 19. The nurse caring a client with diphtheria would prominently place at the bedside a. an intermittent positive-pressure breathing (IPPB) machine. b. a syringe with epinephrine (Adrenalin). c. a sphygmomanometer. d. an emergency tracheostomy set.

d Nursing management focuses on management of the airway obstruction. Suction equipment and a tracheostomy tray should be kept at the bedside. DIF: Cognitive Level: Application REF: Text Reference: 1802 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 16. The nurse is caring for an older client who states in her medical history that she has had "quinsy" in the past. The nurse would recognize that this term can be used interchangeably with a. "strep throat." b. crypt infection. c. stridor. d. peritonsillar abscess.

d Peritonsillar abscess ("quinsy") may arise from acute streptococcal or staphylococcal tonsillitis. DIF: Cognitive Level: Knowledge REF: Text Reference: 1800 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 23. A client's ventilator alarm begins to ring. The nurse enters the room and notes that the "low expired minute volume" alarm is sounding. After quickly determining that the client is in no acute distress, the nurse would a. suction the client. b. look for a kink in the tubing. c. add more water to the humidifier. d. look for a leak or disconnection in the system.

d Possible causes of low expired minute volume include low spontaneous client breathing activity, leakage in the cuff, leakage in the client circuit, and improper alarm limit setting. The nurse should check cuff pressure and the client circuit, performing a leakage test if necessary, and check pause time and graphics to verify, while considering more ventilatory support for the client. DIF: Cognitive Level: Application REF: Text Reference: 1892 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 7. In planning for a client diagnosed with TB who is being admitted to the nursing unit, the nurse would place the client in a room a. with two windows. b. near the elevator. c. near the nurses' station. d. with negative air flow.

d Private respiratory rooms should be available and maintained at negative pressure relative to the hallway. These rooms should send room air directly to the outside and have at least six air exchanges per hour. DIF: Cognitive Level: Application REF: Text Reference: 1849 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 4. In planning postoperative nursing care for a client who has undergone radical neck dissection and total laryngectomy, the nurse would give priority to the fact that a. prognosis after treatment is excellent. b. esophageal speech is relatively easy to learn with practice. c. the stoma should never be covered after this type of surgery. d. there is a radical change in appearance as a result of this type of surgery.

d Surgical management of laryngeal tumors often includes neck dissection. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal assessory nerve, jugular vein, and submandibular area. DIF: Cognitive Level: Application REF: Text Reference: 1789 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 14. The nurse would know that a client who has just begun treatment for pulmonary TB with rifampin has a good understanding of this medication with the statement that a. "I won't go to any family gatherings for 6 months." b. "I told my wife to throw away all our spoons and forks before I come home." c. "It's going to be important to remember to cover my nose when I sneeze." d. "My urine will look orange because of the medication."

d The client should understand that orange urine, feces, saliva, sputum, sweat, and tears may occur when taking rifampin. DIF: Cognitive Level: Knowledge REF: Text Reference: 1847, Integrating Pharmacology Box; TOP: Nursing Process Step: Evaluation MSC:

Physiological Integrity 3. The nurse monitoring a client with adult respiratory distress syndrome (ARDS) would closely assess for a. atelectasis. b. cor pulmonale. c. pneumonia. d. pulmonary edema.

d The hallmark of ARDS is increased permeability of the pulmonary endothelium and alveolar epithelium, with resultant movement of fluid into the interstitial and alveolar spaces. This leads to the development of pulmonary edema, which decreases lung compliance and impairs oxygen transport. DIF: Cognitive Level: Application REF: Text Reference: 1895 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 13. A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position since insertion, the nurse would assess the a. results of the chest x-ray film taken 2 hours earlier. b. current oxygen saturation readings. c. status of the client's breath sounds. d. position of the numbers on the ET tube at the lip line.

d The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tube's side. If the tube slips, its correct position can be quickly established. DIF: Cognitive Level: Comprehension REF: Text Reference: 1883 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 2. A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88, respirations 18, blood pressure 138/78, and PaCO2 45 mm Hg. Current vital signs include pulse 104, respirations 26, blood pressure 140/80, and PaCO2 62 mm Hg. The nurse would a. obtain a complete blood count (CBC). b. assist in tracheostomy. c. administer a nebulized bronchodilator. d. assist with reintubation.

d The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO2 or increased PaCO2. If these manifestations are noted, the nurse should notify the physician and prepare for reintubation. DIF: Cognitive Level: Analysis REF: Text Reference: 1894 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 21. The nurse explaining the pieces of a tracheostomy to a client would note that the portion of the tracheostomy apparatus used to round the end of the tube for insertion is the a. flange. b. inner cannula. c. pilot tube. d. obturator.

d The obturator is placed into the outer tube before insertion. Its rounded tip smoothes the end of the cannula and facilitates nontraumatic insertion of the tube into the stoma. DIF: Cognitive Level: Knowledge REF: Text Reference: 1777 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 22. A client recuperating from a lung resection is encouraged to deep-breathe and cough several times a day and has not needed supplemental oxygen. ABG results are PaO2 95 mm Hg, PaCO2 40 mm Hg, and pH 7.35. The course of treatment that the nurse would anticipate is a. high-flow oxygen therapy. b. assisted ventilation. c. intermittent positive-pressure breathing. d. maintenance of the present course of treatment.

d These findings are normal. Mild hypoxemia is a PaO2 less than 80 mm Hg on breathing room air. Results are evaluated in light of the oxygen needed. For example, if the PaO2 is 85 mm Hg with 50% oxygen, the client has a more significant problem with oxygen transport than a client whose PaO2 is 85 mm Hg with room air (21% oxygen). DIF: Cognitive Level: Application REF: Text Reference: 1764 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 13. When the nurse hears a high, hollow, drum-like sound while percussing the right chest of a young man with a right pneumothorax; the nurse would record this finding as a. dullness. b. flatness. c. resonance. d. tympany.

d Tympanic notes are high, hollow, drum-like sounds heard with percussion over the stomach, a large tension pneumothorax, or a large air-filled chamber. DIF: Cognitive Level: Comprehension REF: Text Reference: 1753 TOP: Nursing Process Step: Assessment MSC:

Physiological Integrity 28. The nurse would explain to a client that the most helpful test in the evaluation of a possible pulmonary embolus is a. alveolar lavage. b. bronchoscopy. c. gallium scan. d. ventilation-perfusion scan.

d Ventilation-perfusion scanning is used to assess lung ventilation and lung perfusion. These scans are valuable in diagnosing pulmonary embolism, pulmonary infarction, emphysema, fibrosis, and bronchiectasis. DIF: Cognitive Level: Application REF: Text Reference: 1765 TOP: Nursing Process Step: Intervention MSC:

N/A 5. The nurse would explain to a client with complaints of wheezing and chest tightness that wheezing occurs when a. sputum production is increased. b. an allergic reaction is taking place. c. air is trapped in the alveoli. d. air is passing through a narrowed airway.

d Wheezing sounds are produced when air passes through partially obstructed or narrowed airways on inspiration or expiration. DIF: Cognitive Level: Application REF: Text Reference: 1745 TOP: Nursing Process Step: Intervention MSC:

Physiological Integrity 17. The nurse is caring for a young woman with a pulmonary emboli who is receiving heparin and must have an arterial blood gas (ABG) sample drawn. The nurse would arrange to remain in the room to be available to hold pressure on the puncture site for at least a. 1 minute. b. 2 minutes. c. 5 minutes. d. 10 minutes.

d When invasive studies such as ABGs are necessary, pressure is applied to the site for at least 10 minutes. DIF: Cognitive Level: Comprehension REF: Text Reference: 1833 TOP: Nursing Process Step: Intervention MSC: