EAQ Questions (Med-Surg)
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. Obtain the vital signs. 2.Auscultate lung sounds. 3.Hyperoxygenate for 30 seconds. 4.Suction for approximately 10 seconds. 5.Rotate the catheter during its withdrawal.
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? 1. Client no longer is infected. 2. Tuberculin skin test is negative. 3. Sputum is free of acid-fast bacteria. 4. Client's temperature has returned to normal.
3. Sputum is free of acid-fast bacteria. The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.
A client is started on a clear liquid diet after surgery. Which items should the nurse offer the client? Select all that apply. 1 Gelatin 2 Broth 3 Yogurt 4 Ice milk 5 Ginger ale
Gelatin Broth Ginger Ale
A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? Hypokalemia Hypocalcemia Hyponatremia Hypomagnesemia
Hypokalemia
A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. How is hemophilia inherited? X-linked recessive trait 2 Y-linked recessive trait 3 X-linked dominant trait 4 Y-linked dominant trait
X-linked recessive trait Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition. The trait is not carried on the Y chromosome.
A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse? "You should wait at least 6 weeks to allow enough time for your chest incision to heal." "You will need to talk that over with your surgeon before you leave." "You can resume sexual activity when you feel you have recovered enough and when your chest no longer hurts. "You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."
You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort.
A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? 1. Encourage range of motion to the client's arm on the affected side 2. Administer the prescribed cough suppressant at the prescribed times 3. Empty and measure the drainage in the collection chamber each shift 4. Apply clamps below the insertion site when getting the client out of bed
1. Encourage range of motion to the client's arm on the affected side promote maintenance of function in the arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. Drainage is marked with time taped on the side of the device. The closed system is not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be avoided because of the danger of precipitating a tension pneumothorax
The nurse is instructing a client with an eye disorder who is receiving prednisolone acetate eye drops regarding the precautions to be followed. Which statement made by the client indicates effective learning? 1. "I should check for bleeding in the eye." 2. "I should protect the drug from sunlight." 3. "I should refrain from wearing soft contact lenses." 4. "I should shake the bottle vigorously before I use the eye drops."
4. "I should shake the bottle vigorously before I use the eye drops." opical steroids such as prednisolone acetate are suspensions and hence shaking is required to distribute the drug evenly in the solution before use. Using nonsteroidal antiinflammatory (NSAIDs) drugs may cause bleeding in the eyes because these drugs disrupt platelet aggregation. Topical antiviral drugs should be protected from sunlight. Using NSAIDs may interact with contact lens materials and increase the risk for infection.
The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activity of the client might have led to this condition? 1. Using nasal saline sprays 2. Using drugs such as aspirin 3. Blowing the nose vigorously 4. Applying excess petroleum jelly to the nares
4. Applying excess petroleum jelly to the nares The sparing application of petroleum jelly to the nares helps to lubricate the area and provide comfort to the client. However, excess use may cause inhalation of the jelly into the lungs and may increase the risk of pneumonia. Nasal saline sprays are used to moisten the nares and prevent re-bleeding. Medications such as aspirin should be avoided after the placement of an epistaxis catheter to prevent bleeding. Vigorous nose blowing does not cause pneumonia.
The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? 1. Rhonchi 2. Wheezes 3. Fine crackles 4. Coarse crackle
4. Coarse crackle A series of long, discontinuous low-pitched sounds similar to blowing through straw under water indicates coarse crackles. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways. Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction. Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? 1. Place the client in the supine position 2. Spread a clamp in the insertion site to hold the site open 3. Obtain a sterile Vaseline gauze to cover the opening 4. Cover the opening with the cleanest material available
4. Cover the opening with the cleanest material available This emergency situation requires covering the opening with the cleanest material available to prevent atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential for infection. Placing the client in the supine position is useless and will impair further the client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is taken to obtain the occlusive dressing.
A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? 1. Sickle cell anemia is a random condition with no known cause. 2.If one parent is a carrier and one is negative for the gene, the child will get the disease. 3. If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. 4. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
4. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free. sickle cell autosomal recessive
A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 1. Rye 2. Oats 3. Rice 4. Corn 5. Wheat
1. Rye 2. Oats 3. Wheat
A healthcare provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. What should the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary? 1. Drain bile from the cystic duct 2. Keep the common bile duct patent 3. Prevent abscess formation at the surgical site 4. Provide a port for contrast dye in a cholangiogram
2. Keep the common bile duct patent Exploration of the common bile duct may cause edema; a T-tube prevents edema from obstructing the duct. The cystic duct is ligated when the gallbladder is removed. The T-tube will not prevent the formation of an abscess. A T-tube can be used to inject dye for a cholangiogram, but it is not inserted for that purpose.
The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect to observe if this occurs? 1 Slowed pulse rate 2 Pleural friction rub 3 Neck vein distention 4 Increasing hypotension
3. Neck vein distention Neck vein distention is caused by hypervolemia and pulmonary hypertension. The pulse is likely to be rapid and bounding. Pleural friction rub is present in pleurisy, not heart failure. Hypertension, not hypotension, will occur because of hypervolemia.
A nurse is caring for a client with heart failure. The health care provider prescribes a 2 gram sodium diet. What should the nurse include when explaining how a low salt diet helps achieve a therapeutic outcome? 1. Allows excess tissue fluid to be excreted 2. Helps to control food intake and thus weight 3. Aids the weakened heart muscle to contract and improves cardiac output 4. Helps reduce potassium accumulation that occurs when sodium intake is high
1 - Allows excess tissue fluid to be excretedA decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet, exercise (if permitted), and prevention of fluid retention. The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment? 1. A mediastinal shift may have occurred. 2. Subcutaneous emphysema may be present. 3. Tracheal edema may lead to an obstructed airway. 4. The cuff of the endotracheal tube may be underinflated.
1. A mediastinal shift may have occurred. After a pneumonectomy, the mediastinum may shift toward the remaining lung, or the remaining lung may shift toward the empty space, depending on the pressure within the empty space. Either of these shifts will cause the trachea to move from its usual midline position; this is known as a mediastinal shift. Subcutaneous emphysema is found by palpation over the lungs and chest areas. Tracheal edema cannot be assessed through palpation. The cuff of the endotracheal tube cannot be assessed through palpation of the trachea.
A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. 1. Ascites 2. Hunger 3. Pruritus 4. Jaundice 5. Headache
1. Ascites 3. Pruritus 4. Jaundice Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? 1. Cardiac problems 2. Joint inflammation 3. Kidney dysfunction 4. Peripheral neuropathy
1. Cardiac problems COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale) [1] [2], causing right ventricular heart failure. The skeletal system is not directly related to the pulmonary system; joint inflammation does not occur because of COPD. Kidney dysfunction is not as closely related to the pulmonary system as is the cardiac system; kidney problems usually do not occur because of COPD. Peripheral nerves are not as closely related to the pulmonary system as to the cardiac system; peripheral neuropathy does not occur because of COPD.
A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? 1. Check the IV access for a blood return 2. Apply warm compresses to the affected extremity 3. Slow the IV infusion until the burning sensation is gone 4. Request an oral supplement from the primary healthcare provider
1. Check the IV access for a blood return Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return. That finding determines the nurse's next intervention(s). If blood return is present, then it is appropriate to apply warm compresses. If there is not a blood return, the infusion needs to be stopped via that IV site, not slowed. If the potassium infusion cannot be administered, the primary healthcare provider must be notified so that other means of potassium replacement can be instituted.
The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a PO2 of 85 mm Hg, a PCO2of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply. 1. Coughing 2. Deep breathing 3. Bronchodilators 4. Humidified oxygen 5. Bronchial suctioning
1. Coughing 2. Deep breathing 4. Humidified oxygen Coughing moves secretions toward the mouth to be expectorated. Deep breathing expands the alveoli and increases the amount of oxygen being delivered to the alveolar capillary beds. Humidified oxygen increases the amount of oxygen that is being delivered to the alveolar capillary beds. Bronchodilators are not indicated at this time because the x-ray, PCO2, and pH are still within acceptable limits. Bronchial suctioning is not indicated at this time because the x-ray, PCO2, and pH results are still within acceptable limits.
The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first? 1. Draw peripheral blood cultures. 2. Administer levofloxacin 500 mg intravenously over 30 minutes. 3. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. 4. Take the client to x-ray for an abdominal computed tomography (CT) scan.
1. Draw peripheral blood cultures. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.
A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? 1. Palpate the area around the tubes for crepitus 2. Clamp the chest tubes when suctioning the client 3. Empty the drainage chamber at the end of the shift 4. Change the client's dressing daily using aseptic technique
1. Palpate the area around the tubes for crepitus Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is palpated gently; this is referred to as crepitus. Hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system; otherwise, clamping the tube is not necessary. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. To minimize the risk of a pneumothorax, the dressing is not changed routinely.
A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? 1. Peripherally inserted central catheter (PICC) line 2. #20 angiocatheter in either antecubital area 3. Large-gauge butterfly needle in hand 4. Femoral line
1. Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.
When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? 1. Remove secretions by suctioning. 2. Lower the setting of the tidal volume. 3. Check that tubing connections are secure. 4. Obtain a specimen for arterial blood gases (ABGs).
1. Remove secretions by suctioning. Secretions in the airway will increase pressure by blocking air flow and must be removed. The nurse must identify/correct the problem so that the set tidal volume can be delivered. Connections that are not intact would cause a low-pressure alarm. ABGs are used to assess client status, but they are not taken each time a pressure alarm is heard.
Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1. Syncope 2. Headache 3. Tachycardia 4. Hemiparesis
1. Syncope With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node. Hemiparesis is associated with a brain attack (cerebrovascular accident).
A nurse is teaching a newly admitted client who has acute pancreatitis about dietary restrictions. What should the education include? 1. Use of IV fluids 2. Season foods sparingly 3. Eat small frequent meals 4. Limit coffee to three cups/day
1. Use of IV fluids Acute pancreatitis requires an NPO status to allow the pancreas to rest. IV fluids are administered. Spicy, seasoned foods stimulate the pancreas and should be avoided, not just sparingly used. Small, frequent feedings place less demand on the pancreas to release digestive enzymes and are instituted when the acute phase is resolved. Fats stimulate the release of lipase from the pancreas, whether they are saturated or unsaturated fats, and should be avoided. Coffee stimulates pancreatic secretions and should be avoided.
A client is admitted with a diagnosis of torsion of the testes. How should the nurse respond when the client asks, "Why do I have to have surgery right now?" 1. "There's no other way to control the pain." 2. "Irreversible damage occurs after a few hours." 3. "The extreme swelling can cause the testicle to rupture." 4. "The reduction in testicular blood flow leads to rapid death of sperm."
2. "Irreversible damage occurs after a few hours." When a testis is twisted, its blood supply is decreased. This can result in gangrene. Medication can be given to relieve pain. The testes do not rupture if edema occurs. Sperm are continually produced, so their destruction is not the concern
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. What should the nurse do? 1. Notify the healthcare provider immediately of the findings. 2. Administer the prescribed oxygen. 3. Record the observations and continue to observe the client. 4. Administer the prescribed antianxiety medication.
2. Administer the prescribed oxygen. The cardiovascular and nervous systems of older adults are less flexible than those in a younger age group; postoperative hypoxia responds to oxygen. Notifying the healthcare provider is unnecessary because it is a common reaction of older adults to anesthesia, which may be alleviated by oxygen. Although necessary, recording the observations will not help the client adapt. An anxiolytic may increase agitation.
A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 2. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 3. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. 4. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.
2. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription.
A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply. 1. Raw carrots 2. Boiled spinach 3. Dried apricots 4. Brussels sprouts 5. Asparagus spears
2. Boiled spinach 3. Dried apricots According to the nutritional table, the food sources highest in iron are, "Liver and muscle meats, dried fruits (apricots), legumes, dark green leafy vegetables (spinach), whole-grain and enriched bread and cereals, and beans." Although carrots, Brussels sprouts, and asparagus spears contain some iron, they are not considered high sources of iron.
A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? 1. Acidosis 2. Calcium depletion 3. Potassium retention 4. Sodium chloride depletion
2. Calcium depletion In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.
Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. 1. Elevated levels of partial arterial oxygen 2. Elevated levels of eosinophils 3. Elevated levels of neutrophils 4. Elevated levels of red blood cells 5. Elevated levels of peripheral capillary oxygen saturation
2. Elevated levels of eosinophils 3. Elevated levels of neutrophils 4. Elevated levels of red blood cells Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease. Elevated levels of partial arterial oxygen and peripheral capillary oxygen saturation are not associated with chronic obstructive pulmonary disease. However, elevated levels of partial arterial oxygen indicate possible excessive oxygen administration. Decreased levels of peripheral capillary oxygen saturation indicate possible impaired ability of hemoglobin to release oxygen to tissues.
A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. What should the nurse be prepared to administer? 1. A low-residue diet 2. Intravenous therapy 3. Total parenteral nutrition 4. An oral electrolyte solution
2. Intravenous therapy IV therapy more controlled
What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy? 1. Limit the daily intake of fluids. 2. Keep the stoma covered with a scarf. 3. Only humidified air should be breathed. 4. Mucus plugs can be removed with cotton-tipped swabs.
2. Keep the stoma covered with a scarf. A stomal cover or scarf allows air to move into and out of the trachea but prevents particles of dirt and insects from entering the stoma. Fluids should not be limited; adequate fluids help to liquefy respiratory secretions. Humidified air is not necessary because maintenance of hydration keeps secretions liquefied and mobile, so they can be expelled. Cotton-tipped swabs should not be used because cotton threads may be inhaled.
A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises? 1. Spend more time inhaling than exhaling to blow off carbon dioxide 2. Perform diaphragmatic exercises to improve contraction of the diaphragm 3. Perform sit-ups to strengthen abdominal muscles to improve breathing 4. Use abdominal exercises to limit the use of accessory muscles of respiration
2. Perform diaphragmatic exercises to improve contraction of the diaphragm With emphysema, the diaphragm is flattened and weakened; strengthening the diaphragm is desirable. Longer expiration, not inhalation, facilitates removal of carbon dioxide. Sit-ups are too strenuous for clients with emphysema. The abdominal muscles are accessory muscles of respiration, and their contraction and relaxation are enhanced in diaphragmatic breathing.
The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? 1. Productive coughing 2. Return of breath sounds 3. Increased pleural drainage in the chamber 4. Constant bubbling in the water-seal chamber
2. Return of breath sounds The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase. Constant bubbling in the water-seal chamber indicates that there is a leak in the closed chest drainage system. Bubbling may occur in this chamber when air exits the pleural space with a cough or forceful expiration; the fluid will rise and fall in this chamber with pleural pressure changes associated with inspiration and expiration (tidaling).
The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? 1. Respiratory stridor 2. Subcutaneous emphysema 3. Bilateral 2+ pitting edema 4. Chest distention
2. Subcutaneous emphysema There is air in the tissues and palpation results in a crackling sound referred to as subcutaneous emphysema. Respiratory stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Bilateral 2+ pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.
A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? 1 Prevent dyspnea 2 Prevent cyanosis 3 Increase oxygen concentration to heart cells 4 Increase oxygen tension in the circulating blood
3 Increase oxygen concentration to heart cells Administration of oxygen increases the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although administering oxygen will increase oxygen tension in the circulating blood, it is not specific to heart cells, which are hypoxic when there is a myocardial infarction from a coronary occlusion.
Radium inserted in the vagina of a client now is being removed. Which safety precaution should the nurse employ when assisting with the radium removal? 1. Clean the radium in ether or alcohol. 2. Wear foil-lined rubber gloves while handling the radium. 3. Ensure that long forceps are available for removing the radium. 4. Document how long the radium was in place and when it was removed.
3. Ensure that long forceps are available for removing the radium. Radium must be handled with long forceps because distance helps limit exposure. A nurse does not clean radium implants. Foil-lined rubber gloves do not provide adequate shielding from the gamma rays emitted by radium. The amount and duration of exposure are important in assessing the effect on the client; however, documentation will not affect safety during removal.
During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? 1. Reinsert another tube immediately. 2. Notify the healthcare provider at once. 3. Keep calm because this is no immediate emergency. 4. Quickly take action to prevent the tracheal stoma from closing.
3. Keep calm because this is no immediate emergency. The client's concerns will be reduced if it is known that the stoma will stay open long enough so that another tube can be inserted easily. A permanent opening into the trachea is formed after two or three weeks, and a tube need not be reinserted promptly. The client is in no immediate danger, and it is not imperative to notify the healthcare provider at once. A permanent opening into the trachea is formed after two to three weeks and will not close quickly.
A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? 1. Raise the drainage system to bed level and check its patency 2. Clamp the tube when moving the client from the bed to a chair 3. Mark the time and fluid level on the side of the drainage chamber 4. Secure the chest catheter to the wound dressing with a sterile safety pin
3. Mark the time and fluid level on the side of the drainage chamber The fluid level and time must be marked so that the amount of drainage in the chest tube drainage system can be evaluated. The drainage system must be kept below chest level to promote drainage of the pleural space so the lungs can expand. Clamping the tube can produce backpressure, which may cause fluid to move into the pleural space from which it came, producing a tension pneumothorax. The catheter is secured by skin sutures, not to a dressing with a safety pin.
A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position? 1. Supine 2. Contour 3. Orthopneic 4. Semi-Fowler
3. Orthopneic he orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.
The treatment regimen for a female diagnosed with Hodgkin disease, stage III, will start with nodal irradiation. Because the client and her husband have been trying to conceive a child, the client becomes visibly anxious when she learns that the radiation therapy includes the pelvic nodal area. The nurse refers the client to the primary healthcare provider when the client starts to question the treatment. What is the rationale for the nurse's actions? 1. Radiation used is not radical enough to destroy ovarian function. 2. Intermittent radiation to the area does not cause permanent sterilization. 3. Reproductive ability may be preserved through a variety of interventions. 4. Ovarian function will be destroyed temporarily but will return in about six months.
3. Reproductive ability may be preserved through a variety of intervention Reproductive ability may be preserved through shielding the ovaries or harvesting ova. Radiation can influence or destroy ovarian functioning. Sterilization can occur. Women in the childbearing years should be informed of all options available to preserve ovarian function. Once ova are destroyed, they cannot regenerate.
A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response? 1 Blood loss 2 Tissue death 3 Vascular spasms 4 Electrolyte imbalance
3. Vascular spasms In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.
A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air 4 Taking medications as prescribed
4 Taking medications as prescribed Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish. Although a balance between activity and rest is desirable, it is not the priority. A change in lifestyle is not necessary. Although clean, fresh air is desirable, it is not the priority.
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response? 1. "I may have an elevated temperature." 2. "I may have paroxysmal hiccoughs." 3. "I may have transient headaches." 4. "I may have a sore throat."
4. "I may have a sore throat." A general anesthetic is delivered via an endotracheal tube that irritates the posterior pharynx and larynx, producing a sore throat. Elevated temperature, hiccoughs, and transient headaches are systemic effects and are not side effects of general anesthesia.
A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings? 1. Increased leukocyte development in response to infection 2. Decreased extracellular fluid volume secondary to infection 3. Decreased red blood cell proliferation because of hypercapnia 4. Increased erythrocyte production as a result of chronic hypoxia
4. Increased erythrocyte production as a result of chronic hypoxia Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1. Administer sedatives around the clock 2. Turn client every four hours 3. Increase ventilator settings as needed 4. Suction as needed
4. Suction as needed The nurse should observe the client's need for tracheal/oral/nasal suctioning every two hours and provide adequate suctioning as needed. The nurse should not administer sedatives around the clock, but administer sedatives as appropriate. The nurse should turn the client every two hours, not four hours. The nurse should not adjust vent settings as needed; however, the nurse should check ventilation settings at least once a shift.
A client who is negative for human immunodeficiency virus (HIV) but who has a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding? 1. The erythema does not meet the criterion for a diagnosis of tuberculosis; the results are negative. 2. The clinical manifestations indicate that the client has tuberculosis; the results are positive. 3. The results are indeterminate because of the client's history of COPD. 4. The client has been exposed to the pathogen that causes tuberculosis.
4. The client has been exposed to the pathogen that causes tuberculosis. The size of the induration determines the clinical significance of the reaction; an induration of 5 mm or more is considered positive in a client with HIV, indicating exposure to the tuberculosis bacillus or vaccination with bacillus Calmette-Guérin (BCG) vaccine, not the presence of active disease. The finding of an induration of 10 mm is a positive response. The size of the induration, not the amount of erythema, is used to determine the test result. Having COPD does not alter the reading; however, HIV does.
