Gas exchange mastery Q's

Nurse is caring for patient on a medical surgical unit which client had the highest rate for developing a pulmonary embolism 1) obese pt w/ leg trauma 2) pregnant client w/ acute asthma 3) client w/ diabetes who has cholecystitis 4) client w/ pneumonia who is immunocompromised

1 obese pt w/ leg trauma

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first ? 1) supine 2) high Fowler 3) left lateral 4) trendelenberg

2 High Fowler Gives the lungs more room to expand thereby promoting respiration and affording more comfort. Trandelenberg , supine & left lateral will increase dyspnea & do not permit chest expansion

nurse is caring for a 4 year old child whi has been hospitalized with an acute asthma exacerbation which assessment finding requires action by the nurse 1) diminished breath sounds 2) pulse rate of 110 beats/min 3) pulse ox reading 95% 4) respiratory rate 24 breaths per min

1) Diminished breath sounds

Nurse caring for client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve?

1) curing condition permanetly 2) raising mucous secretions from the chest 3) limiting pulmonary secretions by decreasibt fluid intake 4) convincing the cliebt that the conditionbis emotionally based 2

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first ? 1) do you have chest pain 2) are you feeling anxious 3) do you have any palpitations 4) are you feeling short of breath

1- do you have chest pain

Nurse caring for patient with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions ? 1) client is no longer infected 2) tb skin test is negative 3) sputum is free of acid fast bacteria 4) clients temperature has returned to normal

3- sputum free of acid fast bacteria Once pt tests positive, they will always show as positive but w/ absence I'd bacteria in sputum - indicates disease can no longer be spread by airborne route. Treatment is over an extended period: eventually client may not have active disease but still remains infected.

Nurse assesses the lungs of a client & auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documents as what? 1) vesicular 2) Bronchial 3) crackles 4) rhonchi

3. Crackles

which client would have relatively smaller tidal volumes due to linited chest wall movement 1) client with asthma 2) client w/ pneumonia 3) client w: pulmonary fibrosis 4) pt w/ phrenic nerve paralysis

4 client w/ Phrenic nerve paralysis

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first ? 1) notify PCP immediately 2) apply warm moist compress to incision site 3) increase the intravenous fluid rate by 20 mL/hr 4) monitor vital signs more frequently

1 notify PCP Immediately

RN Caring for client w/ respiratory tract infection that started with common cold but has progressed to whooping cough. client also has coughing fits that last for several minutes. Which organism is responsible for the clients condition ? 1) Bacillus anthracis 2) Bordetella pertussis 3) streptococcus pneumoniae 4) mycobacterium tuberculosis

2

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first ? 1) interview the client for a health history 2) assess the clients heart and lung sounds 3 monitor the clients pulse & temp 4) obtain clients BLood specimen for electrolytes

2 assess clients heart & lung sounds

Client who just returned from surgery reports SOB & chest pain which should the nurse initially administer? 1) supplemental O2 2) intravenous morphine 3) endotracheal intubation 4) sublingual nitroglycerin

Supplemental O2