Ch 23 NCLEX
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Apply a compression dressing to the area. b) Report the finding to the physician immediately. c) Measure the patient's pulse oximetry. d) Record the observation.
a) Apply a compression dressing to the area. Explanation: Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. During surgery the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted.
The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma b) Squamous cell carcinoma c) Adenocarcinoma d) Bronchoalveolar carcinoma
a) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? a) Negative b) Positive c) Borderline d) Uncertain
a) Negative Explanation: The size of the induration determines the significance of the reaction. A reaction of 0-4 mm is not considered to be significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.
A patient suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which of the following interventions to improve oxygenation and provide comfort for the patient? a) Position the patient in the prone position b) Force fluids for the next 24 hours c) Administer small doses of pancuronium (Pavulon) d) Assist the patient up to a chair
a) Position the patient in the prone position Explanation: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs.
A mechanically ventilated patient is receiving a combination of atracurium (Tracrium) and an opioid analgesic morphine. The nurse monitors the patient for which potential complication? a) Venous thromboemboli b) Pulmonary hypertension c) Pneumothorax d) Cor pulmonale
a) Venous thromboemboli Explanation: Neuromuscular blockers predispose the patient to venous thromboemboli (VTE), muscle atrophy, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The patient may have discomfort or pain but be unable to communicate these sensations.
A nurse is caring for a patient after a thoracentesis. Which of the following signs if noted in the patient should be reported to the physician immediately? a) "Patient is drowsy and complains of headache." b) "Patient is becoming agitated and complains of pleuritic pain." c) "Patient has subcutaneous emphysema around needle insertion site." d) "Patient has an oxygen saturation level of 93%."
b) "Patient is becoming agitated and complains of pleuritic pain." Explanation: After a thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the patient may become anxious and develop dyspnea with increased use of the accessory muscles.
An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Mottling of the skin upon inspection b) Decreased chest wall excursion upon palpation c) Resonance upon percussion d) Wheezing upon auscultation
b) Decreased chest wall excursion upon palpation Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area.
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Intubate the patient and control breathing with mechanical ventilation c) Increase oxygen administration d) Schedule the patient for pulmonary surgery
b) Intubate the patient and control breathing with mechanical ventilation Explanation: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate.
During a community health fair, a nurse is teaching a group of seniors about health promotion and infection prevention. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? a) Exercise daily b) Receive vaccinations c) Drink six glasses of water daily d) Take all prescribed medications
b) Receive vaccinations Explanation: Identifying the patients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages patients at risk of pneumococcal and influenza infections to receive vaccinations against these infections.
The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Headache b) Shortness of breath c) Weight loss d) Fever
b) Shortness of breath Explanation: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.
The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin D b) Vitamin B6 c) Vitamin E d) Vitamin C
b) Vitamin B6 Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.46, PaO2 80 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.36, PaCO2 32 mm Hg d) pH 7.35, PaCO2 48 mm Hg
b) pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.
A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." b) "You must consume a diet low in fat by limiting dairy products and concentrated sweets." c) "You must consume a diet rich in protein, such as chicken, fish, and beans." d) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta."
c) "You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess.
A patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest? a) Cyanosis b) Hypertension c) Paradoxical chest movement d) Wheezing
c) Paradoxical chest movement Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows which of the following signs? a) Tissue sloughing b) Bruising c) Redness and induration d) Drainage
c) Redness and induration Explanation: A reaction occurs when both induration and erythema (redness) are present
Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Use a heat application b) Use a prescribed analgesic c) Turn onto the affected side d) Elevate the head of the bed
c) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain.
The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? a) pH 7.87, Paco2 38, HCO3 28 b) pH 7.47, Paco2 28, HCO3 30 c) pH 7.25, Paco2 48, HCO3 24 d) pH 7.49, Paco2 34, HCO3 25
c) pH 7.25, Paco2 48, HCO3 24 Explanation: pH 7.25, Paco2 48, HCO3 24 = respiratory acidosis pH 7.87, Paco2 38, HCO3 28 = metabolic alkalosis pH 7.47, Paco2 28, HCO3 30 = respiratory alkalosis pH 7.49, Paco2 34, HCO3 25 = respiratory alkalosis
Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions b) Do not allow visitors with respiratory infections c) Place suspected patients together d) Encourage breathing exercises
d) Encourage breathing exercises Explanation: The nurse instructs the patient in lung-expanding breathing exercises to restore normal respiratory function.
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Cyanosis b) Bilateral wheezing c) Inspiratory crackles d) Rapid onset of severe dyspnea
d) Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event
A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Diminished breath sounds b) Decreased respiratory rate c) Bloody, productive cough d) Sucking sound at the site of injury
d) Sucking sound at the site of injury Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds