CAQs medsurg assn #3, MedSurg Assignment 3
A client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is experiencing? Bargaining 2 Frustration 3 Depression 4 Rationalization
1
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? 1 Provide a means for the client to write 2 Allow the client more time for articulation 3 Use visual clues, such as gestures and objects 4 Face the client and speak slowly and distinctly
1
A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? 1 Preoxygenate the client before suctioning. 2 Employ gentle suctioning as the catheter is being inserted. 3 Be sure the cuff of the tracheostomy is inflated during suctioning. 4 Loosen the client's secretions before suctioning by instilling saline.
1
A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? 1 Ammonia level 2 Culture and sensitivity 3 White blood cell count 4 Alanine aminotransferase (ALT) level
1
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1 Pink 2 Clear 3 Green 4 Yellow
1
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? 1 Arterial oxygen saturation 2 Partial pressure of oxygen in arterial blood 3 Partial pressure of arterial carbon dioxide 4 Partial pressure of oxygen in venous blood
1
Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock
1
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1 Initiate oxygen via a nasal cannula 2 Administer the prescribed morphine 3 Prepare the client for endotracheal intubation 4 Place a nitroglycerin tablet under the client's tongue
1
A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? 1 Keep collection device attached to mechanical suction 2 Keep chest tube clamped distal to the water-seal chamber 3 Keep collection device below the level of the client's chest 4 Keep chest tube end covered with sterile gauze pads taped to the client
3
A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? 1 Change in level of consciousness 2 Increased pain 3 Increased respiration 4 Decreased heart rate
3
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions
3
A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort? 1 Sims 2 Lateral 3 Orthopneic 4 Semi-Fowler
4
A client who recently immigrated to the United States (Canada) has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1 Vitamin A is an integral part of the retina's pigment called melanin. 2 It is a component of the rods and cones, which control color visualization. 3 Vitamin A is the material in the cornea that prevents the formation of cataracts. 4 It is a necessary element of rhodopsin, which controls responses to light and dark environments.
4
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis
4
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions
4
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.
4
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation
4
A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? 1 "Cover your cough with your forearm." 2 "Dispose of used paper tissues in a paper bag." 3 "Encourage your roommate to get the flu vaccine." 4 "Move out of your apartment until you are over the cold."
1
A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage? 1 Refer to the date and time markings on the outside of the collection chamber. 2 Aspirate the drainage from the collection chamber. 3 Replace the existing system with a new one to access the drainage in the existing system. 4 Clamp the chest tube and empty the fluid from the collection chamber.
1
A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? 1 Remove the air that is present in the intrapleural space 2 Drain serosanguineous fluid from the intrapleural compartment 3 Permit the development of positive pressure between the layers of the pleura 4 Provide access for the instillation of medication into the pleural space
1
A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. Which is the most appropriate nursing action? 1 Instruct the client to cough 2 Clamp the tube immediately 3 Prepare for chest tube removal 4 Arrange for a stat chest x-ray film
1
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.
2
A registered nurse is teaching the student nurse the precautions to follow when blood samples are collected. Which statement made by the student nurse indicates effective learning? 1 "I can place the specimen with other samples." 2 "I can use a single-lumen line to obtain samples." 3 "I should not reveal the test procedure to the client." 4 "I should not place the blood samples collected for adrenaline on ice."
2
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? 1 Report of pain when taking deep breaths 2 Client is observed splinting the fracture site 3 Diminished breath sounds on the affected side 4 Bowel sounds are auscultated in the lower chest
3
After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? 1 Postural drainage 2 Pursed-lip breathing 3 Incentive spirometry 4 Sustained exhalation
3
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area
4
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1 Peak expiratory flow rate 2 Forced vital capacity 3 Forced mid-expiratory flow rate 4 Forced expiratory volume/forced vital capacity ratio
4
What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder?
The assessment of the pharynx begins with an inspection of the mouth. By using a tongue depressor, the posterior pharynx and the rise and fall of the soft palate are observed. The next step is to assess for edema or ulceration and the symmetry of the enlarged tonsils. The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. The last step is to palpate the lymph nodes for size, shape, mobility with palpation, consistency, and tenderness.
A client has a surgical creation of a colostomy for cancer of the rectum. The client asks, "What's the difference between irrigating a colostomy and having an enema?" Which information should the nurse share with the client? 1 Colostomy irrigation instillation uses a cone-shaped tip catheter. 2 Colostomy irrigation lubricates the catheter tip with a water-soluble jelly. 3 Colostomy irrigation clears the tubing of air before insertion of the solution. 4 Colostomy irrigation instillation will not cause cramping in the client's abdomen.
a
A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. Place the steps in the order that they should be performed. 1. Auscultate lung sounds. 2. Obtain the vital signs. 3. Suction for approximately 10 seconds. 4. Rotate the catheter during its withdrawal. 5. Hyperoxygenate for 30 seconds.
obtain vitals, auscultate, hyper oxygenate, suction, rotate
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers
2
A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client? 1 Exercise daily 2 Use disposable tissues 3 Avoid foods high in sodium 4 Monitor blood pressure weekly
2
Which parameter describes the maximum volume of air that the lungs can contain? 1 Vital capacity 2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity
2
While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? 1 Lung biopsy 2 Thoracentesis 3 Mediastinoscopy 4 Ventilation-perfusion scan
2
A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. 3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.
3
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? 1 Decrease in red cell formation 2 Rupture of emphysematous bullae 3 Depression in the respiratory center 4 Excessive drying of the respiratory mucosa
3
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? 1 Careful monitoring for crepitus 2 Bed rest with range-of-motion exercises 3 Coughing and deep breathing every hour 4 Covering the chest tube site with a sterile dressing
3
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement? 1 Auscultate the lungs. 2 Obtain arterial blood gases. 3 Notify the healthcare provider. 4 Apply pressure to the abdomen.
1
Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? 1 Pulmonary angiography 2 Helical computed tomography (CT) 3 Ventilation-perfusion (V/Q) scans 4 Computed tomography pulmonary angiography (CT-PA)
1
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? 1 Put on a gown when entering the room 2 Place the client with another client who has TB 3 Wear a particulate respirator when caring for the client 4 Don a surgical mask with a face shield when entering the room
3
Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? 1 PaO2-72, SpO2- 96 2 PaO2-60, SpO2- 90 3 PaO2-55, SpO2- 88 4 PaO2-40, SpO2- 75
3
Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? 1 Kinking of the bowel onto itself 2 A band of connective tissue compressing the bowel 3 Telescoping of a proximal loop of bowel into a distal loop 4 A protrusion of an organ or part of an organ through the wall that contains it
3
Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs? 1 Vesicular 2 Bronchial 3 Adventitious 4 Bronchovesicular
3
Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate 3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli
3
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? 1 Initiate pulmonary hygiene to clear air passages of trapped mucus 2 Instruct to deep breathe slowly with inhalation longer than exhalation 3 Encourage continuous rapid panting to promote respiratory exchange 4 Administer oxygen at a low concentration to maintain respiratory drive
4
A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at bases of the lungs
4
A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1 Slow, deep respirations 2 Normal oral temperature 3 Dry, unproductive cough 4 Diminished breath sounds
4
A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? 1 Tremors 2 Anasarca 3 Bradypnea 4 Tachycardia
4
A client with hyperthyroidism refuses radioactive iodine therapy, and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription? 1 High-protein, high-carbohydrate diet 2 Iodine preparations 3 Antithyroid drugs 4 Drugs to increase the blood pressure
4
A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation? 1 "The alveoli need oxygen to live." 2 "The alveoli have no direct effect on oxygenation." 3 "Collapsed alveoli increase oxygen demands." 4 "Oxygen is exchanged for carbon dioxide in the alveolar membrane."
4
A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease? 1 Estrogens 2 Androgens 3 Glucocorticoids 4 Mineralocorticoids
4
A nurse is eliciting a health history from a client with ulcerative colitis. Which factor does the nurse consider to be most likely associated with the client's colitis? 1 Food allergy 2 Infectious agent 3 Dietary components 4 Genetic predisposition
4
Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO2
4
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? 1 Dull 2 Flat 3 Tympany 4 Resonance
4
Which client would have relatively smaller tidal volumes due to limited chest wall movement? 1 A client with asthma 2 A client with pneumonia 3 A client with pulmonary fibrosis 4 A client with phrenic nerve paralysis
4
Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest X-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging
4
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? 1 Forced vital capacity 2 Functional residual capacity 3 Forced expiratory volume in 1 second 4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
4
A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Absence of the gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea
4
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based
2
A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? 1 "I'll just finish the carton that I have at home." 2 "I'll cut back to a half pack a day." 3 "I find that smoking is the only way I can relax." 4 "I should find this easy because I don't smoke when I drink."
2
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include? 1 Purpose of bronchodilators 2 Importance of meticulous oral hygiene 3 Technique used in pursed-lip breathing 4 Methods used to maintain a dust-free environment
2
Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? 1 Asthma 2 Emphysema 3 Chronic bronchitis 4 Centrilobular emphysema
2
