Complex Exam 1
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi
A. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. Incorrect Answers: B. A client who has asthma experiences expiratory wheezing during an acute asthma attack. C. A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound that is often heard without a stethoscope. D. A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snoring-like noises produced in the throat.
A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma
A. Aspiration of water The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway. Incorrect Answers: B. Exposure to water alone does not cause infection; infectious microorganisms cause infection. The nurse should instruct the client to examine the stoma every day for any signs of infection. C. After initial healing, bathing should not cause bleeding around the stoma. Even in the immediate postoperative period, hemorrhage is unlikely. D. Breakdown of the wound is possible in the postoperative period due to many factors such as poor nutrition. However, brief contact with water during bathing does not cause this complication.
A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum
A. Discuss ways the client can reduce the number of cigarettes smoked per day The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually. Incorrect Answers: B. Pipe smoking still exposes the client to harmful smoke. C. The client will benefit from treatment even if smoking continues; however, treatment is more effective if the client stops smoking cigarettes. D. The nurse should encourage the use of nicotine gum to assist the client in smoking cessation.
A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia
A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid. Incorrect Answers: B. A low sodium level is not a manifestation of respiratory acidosis. Causes of hyponatremia include diuretics, kidney disease, vomiting, and burn injuries. C. A high calcium level is not a manifestation of respiratory acidosis. Causes of hypercalcemia include kidney failure and hyperparathyroidism. D. A low magnesium level is not a manifestation of respiratory acidosis. Causes of hypomagnesemia include malnutrition, alcohol use disorder, and diarrhea.
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings
A. Initiate bag-valve-mask ventilation
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings
A. Initiate bag-valve-mask ventilation The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first provide ventilations with a bag-valve-mask device. Incorrect Answers: B. The nurse should provide a communication board due to the client's inability to speak; however, there is another action the nurse should take first. C. The nurse should obtain a blood sample for ABG analysis to help determine the status of the client's respiratory system; however, there is another action the nurse should take first. D. The nurse should routinely document the client's ventilator settings; however, there is another action that the nurse should take first.
A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis
A. Respiratory alkalosis
A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia
A. Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom. Incorrect Answers: B. This finding is a manifestation of a blood clot in the leg, which can lead to a pulmonary embolism. C. This finding is a manifestation of an infection. D. Tachycardia, not bradycardia, is a manifestation of a pulmonary embolism.
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease ]C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm
A. client who has a chest tube following a pneumothorax Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider. Incorrect Answers: B. A client who has Crohn's disease is not at risk for crepitus. Crohn's disease is an inflammatory disorder of the small intestines. C. A client who is postoperative following a laparoscopic appendectomy is not at risk for crepitus because the surgery is minimally invasive. D. A client who is recovering from thyroid storm is not at risk for crepitus. Thyroid storm results in a fever, tachycardia, and hypertension from the excessive release of thyroid hormone.
A nurse is providing teaching about exercise to a client who has type 1 diabetes mellitus. Which of the following statements should the nurse include? A. "You should exercise during a peak insulin time." B. "Wear a medical alert identification tag when you exercise." C. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase." D. "You will get the most benefit from exercise when your glucose levels are higher than normal."
B. "Wear a medical alert identification tag when you exercise." The client should wear a medical alert identification tag in the event of a hypoglycemic response because exercise can potentiate the effects of insulin and cause blood glucose levels to decrease. Incorrect Answers: A. The client should avoid exercising within 1 hour of receiving insulin or at the peak time of insulin. This is because exercise can increase the absorption of insulin at the injection site and cause a marked drop in blood sugar at the insulin peak time. The client should plan to eat at least 1 hour before exercise and drink a carbohydrate liquid to decrease the risk of a hypoglycemic response. C. A client who exercises can potentiate the effects of insulin and cause the blood glucose levels to decrease. D. A client who has poorly controlled insulin-dependent diabetes mellitus should not exercise when blood glucose levels are >250 mg/dL or if ketones are noted in the urine; this is because there is an inadequate amount of insulin for transporting glucose. Peer Comparison A 5% B 82% C 6% D 7%
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk
B. A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. Incorrect Answers: A. The activation of a high-pressure alarm indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions could generate a high-pressure alarm, not a low-pressure alarm. C. Resistance during the delivery of a specific volume of oxygen to the client triggers the ventilator's high-pressure alarm, not a low-pressure alarm. A possible cause is decreased lung compliance due to disorders such as COPD. D. When a client is coughing or trying to talk, the ventilator must exert greater force to deliver the preset volume of oxygen. This increased resistance of the airway against the machine can trigger a high-pressure alarm, not a low-pressure alarm.
A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? A. Hunger B. Increased urination C. Cold, clammy skin D. Tremors
B. Increased urination Increased urination is a manifestation of hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis. Incorrect Answers: A. Increased hunger is a manifestation of hypoglycemia due to a cholinergic response to central glucose deprivation. C. Cold, clammy skin is a manifestation of hypoglycemia due to a cholinergic response to central glucose deprivation. D. Tremulousness is a manifestation of hypoglycemia due to an adrenergic response to central glucose deprivation.
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss
B. Involuntary muscle spasms The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency. Incorrect Answers: A. Hypertension is an indication of thyroid storm, which is a potential complication following a thyroidectomy. C. Cold intolerance is an indication of hypothyroidism. D. Weight loss is an indication of hyperthyroidism.
A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following clients should the nurse include in the screening? A. Men who smoke B. Men and women who are obese C. Women who have hepatitis D. Men and women who consume high-protein and low-carbohydrate foods
B. Men and women who are obese There is a high correlation between obesity and type 2 diabetes mellitus. Obesity plays a major role in the development of type 2 diabetes mellitus by decreasing the number of available insulin receptors in skeletal muscles and fat cells, which is referred to as peripheral insulin resistance. A reduced-calorie diet for obese clients tends to reverse the phenomenon of peripheral insulin resistance. Incorrect Answers: A. Smoking can produce cardiovascular and pulmonary complications, but no studies have found that smoking leads to type 2 diabetes mellitus. C. Women who have hepatitis are at risk of developing cirrhosis but not type 2 diabetes mellitus. D. There is no correlation between a high-protein and low-carbohydrate diet and a risk of developing type 2 diabetes mellitus.
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm
B. Promotes carbon dioxide elimination A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. Incorrect Answers: A. Pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. The nurse should increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. C. A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using chest-wall muscles. D. A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using the diaphragm.
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
B. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. Incorrect Answers: A. Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. C. Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk of developing metabolic alkalosis. Excessive vomiting also places a client at risk of developing metabolic alkalosis. D. Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk of developing metabolic acidosis.
A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. To encourage deep breaths B. To mobilize secretions in the airways C. To dilate the bronchioles D. To stimulate the cough reflex
B. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen and promote the drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity. Incorrect Answers: A. Chest physiotherapy does not encourage deep breaths. However, once airway secretions are mobilized and expectorated, the client might be able to breathe more deeply. C. Chest physiotherapy does not dilate the bronchioles; however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways. D. Chest physiotherapy does not stimulate the cough reflex; however, the mobilization of secretions can increase the client's ability to cough up secretions.
A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. "I can keep my dentures in during the procedure." B. "I am allowed only clear liquids prior to the procedure." C. "A tissue sample might be obtained during the procedure." D. "A signed consent form is not required for this procedure."
C. "A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing. Incorrect Answers: A. The client needs to remove dentures, glasses, or contacts so they can be stored safely until after the procedure is completed. B. The client should ingest nothing by mouth for 6 hours prior to the procedure to reduce the risk of aspiration. D. A signed consent form is required prior to a bronchoscopy because it requires sedation, and risk is involved. By signing the consent form, the client is demonstrating an understanding of the procedure and the risks.
A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."
C. "When I breathe out through pursed lips, my airways don't collapse between breaths." Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for clients who have emphysema. The client should use this technique during physical activity and episodes of dyspnea. Incorrect Answers: A. The client should first inhale slowly through the nose, then exhale slowly through pursed lips. B. The client should practice pursed-lip breathing while sitting upright or walking. D. The client should tighten the abdominal muscles when using the pursed-lip breathing technique.
A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep-breathing and coughing D. Assist the client with ambulation
C. Encourage deep-breathing and coughing The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway. Incorrect Answers: A. The nurse should provide chest physiotherapy to help the client clear secretions; however, there is another action the nurse should take first. B. Oropharyngeal suction might be necessary if this client is unable to expectorate secretions from the throat or mouth; however, there is another action the nurse should take first. D. The nurse should assist the client with ambulation to help clear secretions; however, there is another action the nurse should take first. Peer Comparison A 6% B 18% C 74% D
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position
C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation. Incorrect Answers: A. The nurse should instruct the client to cough immediately to help dislodge and remove the oral secretions that commonly accumulate; however, there is another action the nurse should take first. B. The nurse should give the client oxygen via face mask or nasal cannula to help maintain oxygen saturation; however, there is another action the nurse should take first. D. The nurse should keep the client upright to help improve gas exchange and reduce edema of the larynx; however, there is another action the nurse should take first.
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication
C. Increase the oxygen flow and request an arterial blood gas determination The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements. Incorrect Answers: A. Clients who have COPD typically require a nasal cannula with an oxygen flow of 2 to 4 L/min or a Venturi mask delivering up to 40% oxygen. B. Although the client might require intubation and mechanical ventilation at some point, it is premature to anticipate this measure before trying other therapeutic interventions to help relieve the client's dyspnea. D. The nurse should assist the client into a high-Fowler's position. Upright positioning allows maximal chest expansion and can help relieve dyspnea. First-line medications for managing dyspnea due to COPD are bronchodilators, cholinergic antagonists, xanthines, and corticosteroids.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul respirations D. Elevated blood pressure
C. Kussmaul respirations The nurse should expect this client with DKA to experience Kussmaul respirations. These deep and rapid respirations are the body's attempt to exhale carbon dioxide to reverse the metabolic acidosis that occurs with DKA. Incorrect Answers: A. The nurse should expect ketones to be present in the urine and blood of a client who has DKA due to excessive glucose production. B. Distended neck veins are not an expected finding of DKA. Signs of dehydration (e.g. flattened neck veins, hypotension, dry skin, and sunken eyeballs) are common. D. A client with DKA is more likely to have orthostatic hypotension due to the dehydration caused by the excessive blood glucose and osmotic diuresis.
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips
C. Night sweats Night sweats and fevers are clinical manifestations of tuberculosis. Incorrect Answers: A. A pericardial friction rub is a clinical manifestation of rheumatic carditis. B. Anorexia and weight loss are clinical manifestations of tuberculosis. D. Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease. Peer Comparison A 8% B 1% C 87% D 4% Difficulty level: Easy
A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn
C. Perform an Allen's test prior to obtaining the specimen The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. Incorrect Answers: A. The nurse should not administer oxygen prior to the blood draw because the test measures the client's arterial blood gases when breathing room air. B. The nurse should use ice to preserve the arterial blood gas specimen during transportation to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site. D. The nurse should apply pressure to the puncture site for 5 to 10 minutes after the needle is withdrawn. The high pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
C. Respiratory alkalosis Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis. Incorrect Answers: A. Respiratory acidosis reflects an increase in carbon dioxide resulting from inadequate excretion and an increase in the hydrogen ion level (i.e. decreased pH) of the blood. Common causes of this acid-base imbalance are airway obstruction and respiratory depression. B. Metabolic acidosis results from a metabolic disturbance such as diabetic ketoacidosis or excessive ingestion of alcohol or salicylates, not a respiratory problem. D. Metabolic alkalosis results from a metabolic disturbance such as prolonged vomiting or excessive nasogastric suctioning, not a respiratory problem.
A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis
C. Tachycardia Tachycardia, dyspnea, restlessness, headaches, and increased blood pressure are indications of impending respiratory failure. Incorrect Answers: A. Wheezing indicates asthma, not respiratory failure. B. Bradypnea is an indication of respiratory depression. Tachypnea is an indication of respiratory failure. D. Diaphoresis develops as hypoxemia worsens; therefore, it is a manifestation of worsening, not impending, respiratory failure.
A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching? A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt with peaches
C. Turkey and cheese sandwich A turkey and cheese sandwich is high in protein, carbohydrates, and sodium. A client who has Addison's disease requires a diet low in potassium and high in sodium, carbohydrates, and protein. Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). Addison's disease occurs when the adrenal glands do not produce enough cortisol and, in some cases, aldosterone. Incorrect Answers: A. B. D. Bananas, baked potatoes, and plain yogurt with peaches are high in potassium. A client who has Addison's disease requires a diet low in potassium because this condition causes hyperkalemia.
A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? A. "After the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." D. "I will show you how to splint your incision while coughing."
D. "I will show you how to splint your incision while coughing." A client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint the incision to reduce pain when coughing. Incorrect Answers: A. B. A client who had a pneumonectomy should cough to clear secretions from the remaining lung. C. Pain medication reduces pain to a tolerable level. However, it does not necessarily keep the client pain-free. Additionally, telling the client not to worry is a barrier to communication and provides false reassurance.
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion
D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. Incorrect Answers: A. The client might require mechanical ventilation to stabilize the respiratory status; however, there is no indication at this time for a tracheostomy. B. A thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, or tuberculosis or for a client who requires microscopic examination of the pleural fluid. C. While the client will require several portable chest X-rays, there is no immediate indication for a CT scan of the chest.
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
D. Metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic. Therefore, the nurse should report to the provider that the client has metabolic acidosis. Incorrect Answers: A. With respiratory alkalosis, the pH is elevated. B. With metabolic alkalosis, the pH is elevated. C. With respiratory acidosis, the PaCO2 is elevated.
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula
D. Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen. Incorrect Answers: A. simple face mask provides oxygen at flow rates that can reduce the respiratory drive of a client who has COPD. B. A nonrebreather mask provides oxygen at flow rates that can reduce the respiratory drive of a client who has COPD. C. A bag-valve-mask (a manual resuscitation bag) is a handheld device that provides ventilation to a client who is not breathing or who is breathing inadequately.
A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table
D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air. Incorrect Answers: A. Lying flat on the affected side does not allow access for draining the accumulated fluid and air. B. A prone position does not allow access for draining the accumulated fluid and air. C. A supine position does not allow access for draining the accumulated fluid and air.
A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg The nurse should identify that these laboratory values reflect metabolic alkalosis. The pH and bicarbonate values are greater than the expected reference range, and the PaCO2 is within the expected reference range.
