Med- Surg 1 Final
You have determined a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements. List at least five nursing interventions appropriate for this diagnosis.
Assess nutritional status Observe, document food intake Monitor lab values Consult with dietitian Provide frequent, small feedings, snacks Client in seated or high-Fowler for meals Assist to choose preferred foods Snacks at the bedside Mouth care before meals Consult with physician if intake poor
The nurse is teaching a patient with cerebral atherosclerosis about their newly prescribed medication, clopidogrel (Plavix). Which statement by the patient indicates that teaching has been effective?
"I will call my health care provider if my stools are tarry."
Dehydration
0.9% Normal Saline
Adult RR
10-20
Adolescence RR
12-20
Older Adult RR
12-24
10 year old RR
16-20
6 year old RR
16-22
Preschooler RR
20-30
Infant RR
20-40
Newborn RR
30-60
The mother of a 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse addresses this mother's concern?
A. "Your baby should be able to control defecation by now." B. "Feces containing less water may be difficult for infants to expel." C. "Frequent bowel movements can occur with breastfeeding." D. "The increased frequency in defecation means your baby is at risk of weight loss." C Rationale: Frequent bowel movements often occur with breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to pass, the infant is not experiencing hard stools.
Which client is at the highest risk for developing fluid volume deficit?
A. A 76-year-old who has an NG tube to low suction following colon cancer surgery? B. A thin 55-year-old who smokes and takes glucocorticoids for chronic lung disease? C. A 1-year old child being treated in the clinic for a runny nose and ear infection? D. A 30-year-old jogging in 50-degree weather? A
The nurse is caring for a client in a long-term care facility who has not had a bowel movement in 5 days. The unlicensed assistive personnel report that the client is passing a very small amount of liquid stool. What action should the nurse take initially?
A. Administer a laxative B. Advise the healthcare provider of the situation C. Check the client for an impaction D. Document the findings C Rationale: The nurse needs to check the client for an impaction because liquid stool is likely to seep around the impaction. Smearing of liquid stool is a common symptom of an impaction. The question asks what the nurse should do initially. Although the nurse may report the findings to the health care provider, this should not be the initial action. The nurse must first ascertain whether the client is impacted. An impaction must be removed digitally. A laxative may be appropriate in the future but not initially. The nurse needs to record the findings, but only after adequately assessing the client for impaction.
A client is experiencing increased urinary urgency and incontinence. Which medication does the nurse anticipate will be prescribed for this client?
A. Antiflatulent B. Cholingergic agent C. Anticholinergic agent D. Diuretic C Rationale: Anticholinergics are used to relieve symptoms associated with voiding in clients who have urge incontinence. Cholinergic agents, diuretics, and antiflatulents are not appropriate for this client.
What is an example of an IV solution that would be appropriate to treat an extracellular fluid volume deficit?
A. D5W B. 3% saline C. Lactated Ringer's solution D. D5W in ½ normal saline (0.45%) C
A client complains to the nurse,"I feel that there is nothing that I can control about my health." The empathetic nurse realizes that the client is totally focused on internal variables. For which factors is the client's complaint correct? (Select all that apply)
A. Genes B. Nutrition C. Culture D. Age E. Sex A, C, D, E Rationale: The client is correct that some health-related factors cannot be controlled: genes, age, sex, and culture. However, nutrition is an external variable, and the client can control that factor.
An older male client is experiencing dysuria and urinary retention. Which condition in the client's history may be causing these clinical manifestations?
A. Polyuria B. Anuria C. Prostatic hyperplasia D. Renal failure C Rationale: Prostatic hyperplasia (enlargement of the prostate) can cause urinary retention, dribbling at the end of urination, incontinence, and nocturnal enuresis. Renal failure does not cause dysuria or retention. Polyuria is a term that describes an increase in urination. Anuria is the absence of urination.
Which finding would indicate to the nurse that fluid volume balance in a client with fluid volume excess has not yet been achieved?
A. S3 heart sounds and moist lung crackles resolving. B. Return to coherent conversation and appropriate behavior. C. Urine output increasing and specific gravity decreasing. D. Skin tenting decreasing and conjunctiva of eyes moist. A
A client was recently diagnosed with type 2 diabetes. This diagnosis led to changes in diet, recommended activity level, and frequent glucose monitoring during waking hours. What kind of changes is the client experiencing?
A. Self-concept changes B. Body image changes C. Lifestyle changes D. Emotional changes Rationale: The client's disease requires lifestyle changes: altered diet and activity level, and frequent testing. It is not a matter of emotional, body image, or self-concept changes.
A geriatric nurse is explaining the concept of the illness-wellness continuum to an older couple who have become homebound. Which of the following could the nurse tell them is true about their situation? (Select all that apply)
A. Their perception of their own health is important B. Their perception of each other's health is important C. They can expect to die prematurely D. They can expect to fully recover mobility E. They will have "good" days and "bad" days A, B, E Rationale: In their situation, the couple will have both"good" and "bad" days. Their perception of their own and each other's health is important. They can neither expect to die prematurely nor expect to fully recover mobility.
The nurse is reviewing the urinalysis test results conducted on Shanice Evans, a 29-year-old female. The report states that Shanice's urine appeared cloudy or hazy. Based on theurinalysis, which diagnosis does the nurse anticipate?
A. Urinary tract infection B. Cirrhosis of the liver C. Elevated glucose levels D. Fever and dehydration A. Rationale: Hazy or cloudy urine indicates the presence of bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid, spermatozoa, or urates, which can indicate a urinary tract infection. Concentrated or dark urine is found with dehydration and fever. Cirrhosis of the liver and hyperglycemia do not cause the urine to appear cloudy or hazy
Movement of ions across cell membranes causes an electrical impulse that stimulates muscle contraction. This electrical activity, called the ____________ _____________ produces the waveforms represented on an ECG.
Action Potential
Inotropes: Dopamine (Intropin) MOA
Activates beta and alpha- adrenergic receptors. Increases BP by causing vasoconstriction and increasing the force of myocardial contraction.
____________ is the force the ventricles must overcome to eject their blood volume. The right ventricle must generate enough tension to open the pulmonary valve and eject its volume into the low-pressure pulmonary arteries.
Afterload
CCBs
Amlodipine (Norvasc) Diltiazem (Cardisem)
Ciprofloxacin(Cipro)
Antibacterial Tlreatment of UTI
The nurse will assess the ___________ ____________ for a patient whose peripheral pulse is irregular or unavailable. This pulse is auscultated in the lower left side, below the 4th rib.
Apical Pulse
____________ __________ ____________ is a measure of the pressure exerted by the blood as it flows through the arteries.
Arterial Blood Pressure
The nurse is about to assist a patient who will attempt oral feedings for the first time after having a stroke. What action should the nurse take after assessing the gag reflex?
Assist the patient into a chair.
A sound heard before S1 and is termed an ___________ ___________.
Atrial Gallop
This lab value is normally 8-21
BUN
The nurse is providing care to a client diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client?
Barrel chest
ACE
Benzapril (Lotensin) enalapril (Vasotec)
Internal Variable Influencing Health
Biological: Genes Psychological: Presence of mental illness Cognitive: Disorders of Cognition ssuch as ASD.
A heart rate in an adult less than 60 bpm is called _____________.
Bradycardia
A client with a history of mild heart failure (HF) is receiving metoprolol (Lopressor), a beta blocker, for hypertension. The nurse should give priority to which assessment finding?
Bradycardia and peripheral edema
The contraction and relaxation of the heart constitute one heartbeat, and this process is called the _________?
Cardiac Cycle
The ________ __________ is the cardiac output adjusted for the clients body size or body surface area. It provides very beneficial data regarding the heart's ability to perfuse the tissues.
Cardiac Index
__________ ____________ is referred to as the amount of blood pumped by the ventricles into the pulmonary and systemic circulations in 1 minute. Multiplying the stroke volume (SV) by the heart rate (HR) determines __________ ___________.
Cardiac Output
The heart's ability to respond to an increase in strenuous activity and adjust its cardiac output is called _________ __________.
Cardiac Reserve
Located at the end of the bones, provide support
Cartilage
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations indicate the client's perfusion is affected?
Central cyanosis
Disorders of ____________ (the process of coagulation where blood is converted from a liquid to a gel), can result in impairments of excessive bleeding.
Clotting
_________ refers to the ability of the arteries to contract and expand.
Compliance
___________ is the inherent capability of the cardiac muscle fibers to shorten.
Contractility
The _________ ____________ is a network of vessels that supply the heart muscle. The left and right coronary arteries originate at the base of the aorta and branch out to encircle the myocardium.
Coronary Circulation
An adverse reaction associated with the use of ACE inhibitors is:
Cough
Vasodilators: Nitroprusside (Nitropress) MOA
Create vasodilation by directly acting on the smooth muscle, affecting both arterioles and veins
Vasodilators: Nitroglycerin (Tridil) MOA
Create vasodilation by directly acting on the smooth muscle, affecting both arterioles and veins.
This lab value is normally 0.6-1.2
Creatinine
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the client's history support the current diagnosis?
Current cigarette smoking
_____________ is the phase when the heart contracts, resulting from ion channel functions. Two types of ion channels function to produce the electrical changes that occur during the depolarization phase: the fast sodium channels and the slow calcium channels.
Depolarization
What muscles does BPH affect?
Detrusor
_____________ refers to the phase of ventricular relaxation. In this phase, the ventricles relax and are filled during atrial contraction.
Diastole
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
Difficulty comprehending instructions
Which diagnostic study can estimate the size, symmetry, and consistency of prostate gland?
Digital Rectal Exam
The nurse is caring for a child who has had several repeated admissions for respiratory syncytial virus (RSV) bronchiolitis. Which interventions would be the most beneficial for the nurse to discuss with the parents?
Do not smoke, and avoid all secondhand smoke around the child.
A pulse with an irregular rhythm is referred to as a ___________ or arrhythmia.
Dysrhythmia
Inotropes: Dopamine (Intropin) side effects
Dysrhythmias, tingling or coldness of extremities, nervousness, change in BP. Tachycardia or bradycardia, HTN, necrosis at injection site, severe HTN.
Painful urination
Dysuria
Most common cause of UTI
E.Coli
This diagnostic test captures the action potential of cardiac function
ECG
The _________ is the stroke volume divided by the end-diastolic volume and represents the fraction or percent of the diastolic volume that is ejected from the heart during systole.
Ejection Fraction
A mass or collection of hardened feces in folds of the rectum
Fecal impaction
CCB side effects
Flushed skin, HA, dizziness, peripheral edema, light-headedness, N, C, fatigue, and sexual dysfunction
Estimates how much blood passes through the glomeruli each minute
GFR
Excretion of carbohydrates in the urine
Glycouria
ARBs side effects
HA, dizziness, orthostatic hypertension, diarrhea, URI
a) ACE side effects
HA, dizziness, orthostatic hypotension, rash, cough
Thiazide diuretics
HCTZ (Microzide) Chlorothiazide (Diuril)
The nurse is assessing the patient's lab values prior to administering a medication. He notices that the _________ which indicates the percentage of red blood cells to blood plasma is elevated.
Hct
Blood in urine
Hematuria
Nonpharmacological treatment for bowel incontinence
High Fiber diet Adequate fluid Intake Regular Exercise Kegel Exercises Behavior Modifications
A client taking medication for treatment of essential hypertension has a serum potassium level of 3.2 mEq/L. Which medication should the nurse conclude to be the causative factor for this serum potassium level?
Hydrochlorothiazide (Hydrodiuril)
What is the term for when urine is obstructed and is building pressure?
Hydronephrosis
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program?
Hypertension
_______________ is a below normal blood pressure reading- one that is consistently between 85 and 110 mmHg in an individual whose baseline blood pressure is typically higher.
Hypotension
Cyanosis, which indicates this condition ____________ (lower-than-normal amounts of oxygen in the blood).
Hypoxemia
What is Health Promotion?
Improvement of health and prevention Complex Requires adoption of healthy living
The nurse working on a medical surgical unit is caring for a client newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention?
Increased respiratory rate
Inotropes: Dobutamine (Dobutrex) MOA
Increases myocardial contractility and cardiac output = tissue receives O2 quickly.
Vasodilators: Nitroprusside (Nitropress) nursing interventions
Interventions Monitor mental status, dizziness, hypotension, and adventitious lung sounds; also signs of nausea and disorientation, muscle spasms, and decreased or absent reflexes
ARBs
Irbesartan (Avapro) Losartan (Cozaar)
Ventilation
Is the actual exchange of oxygen/carbon dioxide, the actual air that reaches the alveoli
Body tissues that do not receive enough blood and oxygen become ________. If the tissues do not receive enough blood flow to maintain the functions of the cells, the cells die.
Ischemic
Absence of electrical activity is represented by a straight line, referred to as the _____________ ____________.
Isoelectric Line
When teaching a client about their new diagnosis of asthma, the nurse understands that which statement is most descriptive of asthma?
It is a chronic disorder characterized by heightened airway reactivity
Prevention of bowel incontinence
Kegel Exercise Avoid Straining Treating/Eliminating cause of diarrhea
When taking a blood pressure using a stethoscope, the nurse identifies phases in the series of sounds called ___________ ________.
Korotkoff Sounds
Severe Burns
Lactated Ringers
External Variable Influencing Health
Lifestyle Choices Healthy or Unhealthy Activities
Connect bone to bone
Ligaments
The nurse is providing home care instructions to parents for a child recently diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which symptoms would the nurse include in the instructions to ensure that the parents understand when to call EMS?
Listlessness and retractions with apneic episodes
Oliguria
Low output of urine
First line medication to treat UTI
Macrobid
Rectal Pain, frequent but non productive desire to defecate
Manifestation for Fecal Impaction
The client has a prescription to take a daily dose of metoprolol. Before this medicine is prescribed, the client should be questioned if he has a history of asthma. What is the best rationale given by the nurse?
Metoprolol may cause bronchial constriction.
Thiazide diuretics side effects
Minor hypokalemia, fatigue
Inotropes: Dobutamine (Dobutrex) nursing interventions
Monitor VS before drug admin, record I&Os, monitor IV site for infiltration. May cause anxiety feeling due to mimicking stress.
Inotropes: Dopamine (Intropin) nursing interventions
Monitor VS before drug admin, record I&Os, monitor IV site for infiltration. May cause anxiety feeling due to mimicking stress.
Vasodilators: Nitroglycerin (Tridil) nursing interventions
Monitor mental status, dizziness, hypotension, and adventitious lung sounds.
Inotropes: Dobutamine (Dobutrex) side effect
N/V/ HA, visual disturbances; halos, yellow/green tinge or blurring. AV Block
Stones that from in kidney
Nephrolithiasis
Voiding two or more times at night
Nocturia
Treatments for Constipation
Oil retention enema or manual removal
Low amount of urine output
Oliguria
A patient with chronic bronchitis who has a new prescription for a combined fluticasone and salmeterol inhaler (Advair) asks the nurse the purpose of using two drugs. What is the best explanation that the nurse will provide to the client?
One drug decreases inflammation, and the other is a bronchodilator.
What are anticholinergics used for in concept of elimination?
Overactive bladder Irritable bowel syndrome Incontinence
The nurse is providing care to a client newly diagnosed with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote airway clearance?
Place in Fowler position.
Located at the apex of the heart and is referred to as the _______ __ ___________ _________ (PMI).
Point of Maximum Impulse
Excessive amounts of urine
Polyuria
Muscle cramps/weakness
Potassium Chloride
___________ is the amount of cardiac muscle fiber tension, or stretch, that exists at the end of diastole, just before contraction of the ventricles.
Preload
Impaired function of the anal sphincter or nerve supply
Primary Cause of Bowel Incontinence
Polyuria
Production of abnormally large amounts of urine
The ________ is a wave of blood created by contraction of the left ventricle of the heart. Generally it represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction.
Pulse
If the radial pulse falls behind the apical rate, the client has a ________ ________, indicating weak, ineffective contractions of the left ventricle.
Pulse Deficit
The difference between the diastolic and the systolic pressures is called the ________ ___________.
Pulse Pressure
The _________ _________ is the pattern of the beats and the intervals between the beats. (Equal time elapses between beats of a normal pulse).
Pulse Rhythm
What is the priority nursing assessment in the first 24 hours after admission for the client with a thrombotic stroke?
Pupil size and pupillary response
Medication used for pain control with kidney stones
Pyridium
What can the nurse educate about preventing stones
Reducing sodium and animal intake
Vasodilators: Nitroglycerin (Tridil) side effects
Reflex tachycardia, Orthostatic hypotension, fluid retention, HA, and palpitations. Sodium and water retention.
Vasodilators: Nitroprusside (Nitropress) Side effects
Reflex tachycardia, Orthostatic hypotension, fluid retention, HA, and palpitations. Sodium and water retention.
The heart has a protective mechanism called __________where the myocardial cells resist stimulation.
Refractory Peroid
Nocturia
Regularly voiding two or more times a night
Anticholinergic Meds for asthma
Relax smooth muscle of airway Decrease mucus secretions Ipratropium bromide inhaler
______________ is the process that returns the cell to its resting, polarized state.
Repolarization
Gender, age, obesity, smoking, family history, diabetes
Risk Factors of Urinary Incontinence
Closure of the AV valve produces the _______, which is characterized by the syllable "lub". The AV valves close when the ventricles fill.
S1
This sound is produced by the closure of the semilunar valves?
S2
The nurse can auscultate this sound in most children, young adults, and in pregnancy during the 3rd trimester. ______________ Also called a ventricular gallop.
S3
The nurse can hear the _________ during auscultation of the heart of a child, well-trained athlete, and even a healthy older adult. This sound is caused by an atrial contraction and ejection of blood into the ventricles in late diastole.
S4
Urine leakage when cough, sneeze, laugh, exercise, or lift heavy objects
Stress Incontinence
The difference between the end-diastolic volume and the end- systolic volume is called the _________ __________. It ranges from 60-100 mL/ beat and averages approximately 70 mL /beat in an adult.
Stroke Volume
A client has been brought to the emergency department complaining of the most severe headache of their life. Which type of stroke should the nurse anticipate?
Subarachnoid Stroke
___________ refers to the phase of ventricular contraction. During this phase, the ventricles are filled and then contract to expel blood into the aorta and pulmonary arteries.
Systole
An invasive procedure used to treat BPH
TURP
While assessing the patient, the nurse notices that the patient's pulse is excessively high and identifies it as ______________.
Tachycardia
What drug is used for BPH?
Tamsulosin(Flomax)
Connect muscle to bone
Tendons
Perfusion
The actual blood that reaches the alveoli
Explain the use of mucolytics and expectorants for the treatment of COPD. List at least one example
They are sometimes used to reduce the viscosity of the bronchial mucus and to aid in its removal. medications that promote the discharge or expulsion of mucus from the respiratory tract. They can change the physical properties of the mucus by thinning it. These medications also increase the ability of cilia to clear and drain mucus. Expectorants increase hydration of the mucus whereas mucolytics work to break up mucus. Guaifenesin (Mucinex)
During an assessment the nurse discovers a palpable vibration called a _______ over the precordium or an artery.
Thrill
Stones form somewhere besides kidneys
Urolithiasis
The nurse instructs the client on the use of a metered-dose inhaler (MDI) containing a short acting beta agonist (SABA). Which statement is most important for the nurse to include?
Use the bronchodilator drug as needed to treat acute episodes of wheezing.
Diabetes Insipidus
Vasopressin
It is S3 and also called a ________ __________.
Ventricular Gallop
Blood pressure is higher when the blood is __________, meaning thick.
Viscous
Health
a state of physical, mental, and social functioning that realizes a person's potential.
The nurse who is assisting a client with chronic obstructive pulmonary disease to learn effective breathing techniques would use which of the following statements to explain why dyspnea occurs?
a. "Decreased surfactant causes many of your alveoli to collapse." b. "You have difficulty breathing in enough air." c. "Your airways open wider on inspiration and trap air on expiration." d. "Your lung compliance is decreased." C Rationale: The primary physiological alteration occurring with COPD is alveolar air trapping and alveolar hyperinflation, which lead to alveolar rupture and loss of area available for gas exchange. Decreased surfactant production is associated with ARDS and is not a primary alteration of COPD. Lung compliance is decreased, but this is a result of alveolar trapping and hyperinflation.
A client who had a hip fracture is in the clinic for evaluation a month after surgery. The nurse determines that the client has met outcome goals when the client states which of the following?
a. "I need help getting out of bed." b. "I am eating and drinking well." c. "I am having problems with constipation." d. "I went to the grocery store yesterday." D
A child is hospitalized after an acute asthmatic episode. The nurse determines that the parents need further instruction if which of the following statements is made?
a. "Next time, we'll be sure to give cromolyn before soccer." b. "After discharge, our child will quit the swim team." c. "We think this is an exercise-induced episode." d. "We need to make sure the inhaler is with our child at all times." B
The nurse should counsel the parents of a child with asthma that, before performing postural drainage exercises, the parents should:
a. Administer the bronchodilator. b. Change the child's clothing. c. Administer an antibiotic. d. Suction the child. A
The nurse would anticipate administering respiratory medications to a child hospitalized with asthma by which of the following most frequently used routes?
a. Aerosol b. Intravenous c. Subcutaneous d. Oral A
Which of the following would be an expected assessment finding in a client with chronic obstructive pulmonary disease (COPD)?
a. Anteroposterior (AP) chest diameter equal to or greater than lateral chest diameter b. Mental confusion and lethargy c. Pitting edema of ankles and lower legs d. Oxygen saturation of 85% or less A Rationale: Development of a barrel chest due to air trapping is an expected finding of COPD. Confusion, lethargy, and low oxygen saturation levels indicate respiratory failure. Pitting edema occurs with heart failure.
A client diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this client?
a. Antibiotic therapy b. Nonsteroidal anti-inflammatory agents c. Oxygen by nasal cannula at 4-6 liters/minute d. Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents C Rationale: The nurse should be concerned about the order for oxygen to be provided at 4-6 liters/minute. This amount of oxygen is too much for a client with COPD because the client's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this client should be at a lower rate, such as 1-2 liters/minute, with close assessments of the client's breathing status. The order for antibiotic therapy is expected, as the client is febrile with an increase in white blood cells. Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this client. Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this client.
Which assessment finding by the nurse indicates the client is experiencing a neurovascular complication after recent treatment of an open fracture?
a. Bruising at the affected area b. Paresthesia distal to the fracture c. Small amount of purulent drainage d. Pain level of 4/10 with active ROM B
Which assessment finding supports the nurse's suspicion that a client is experiencing symptoms associated with early onset chronic obstructive pulmonary disease (COPD)?
a. Dysrhythmias b. Cyanotic nail beds c. Clubbing of the fingers d. Cough in the morning producing clear sputum D Rationale: The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the client develops an infection, in which case the sputum would become yellow or green in color. With the progression of COPD, the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading to the development of cyanotic nail beds and clubbing of the fingertips. Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this client is Imbalanced Nutrition: Less than Body Requirements. Which interventions are appropriate for this nursing diagnosis? Select all that apply.
a. Encourage a diet high in protein and fats. b. Keep snacks to a minimum. c. Provide frequent small meals with between meal supplements. d. Encourage carbohydrate-rich foods to provide needed calories for energy. e. Suggest the client eat 3 meals per day to maintain energy needs. A, C Rationale: A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Frequent small meals help maintain intake and reduce fatigue associated with eating. Carbohydrate-rich foods would increase the client's carbon dioxide production and worsen the symptoms of the disease. The client should be encouraged to eat frequent small meals, not 3 meals a day. The client should be encouraged to eat frequent snacks, not limit snacks.
The nursing student is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
a. Excessive rapid breathing b. Chest pain c. Rapid breathing at rest d. Shallow breathing e. Cyanosis A, C, D
A Chamber of Commerce wants to partner their business members with local government to produce visible efforts to improve health. At a Chamber meeting, what kind of health promotion activities could the members propose? (Select all that apply)
a. Immunization awareness b. Fitness programs c. Recycling efforts d. Health fairs e. Methadone clinics A, B, C, D Health promotion activities could include health fairs, fitness programs, recycling efforts, and immunization awareness efforts. Methadone clinics are a form oftreatment, not health promotion.
The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minutes, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this client?
a. Ineffective Coping b. Ineffective Airway Clearance c. Anxiety d. Ineffective Breathing Pattern D Rationale: The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
1. The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions are appropriate in order to control the client's breathing pattern? Select all that apply.
a. Instruct in pursed-lip breathing. b. Teach visualization and meditation. c. Deep breathing and coughing every hour. d. Instruct in abdominal breathing. e. Provide oxygen 2 liters nasal cannula. A, B, D Rationale: Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.
The nurse teaches the parent how to attach a spacer to the metered-dose inhaler for a young child, explaining that the spacer:
a. Makes the device look less intimidating to the child. b. Makes it unnecessary to shake the inhaler prior to administration. c. Decreases the chances of undesired side effects. d. Reduces the risk for oral yeast. D
When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse?
a. Narrow bronchi b. Narrow trachea passages c. Blocked large airway passages d. Inflamed pleural surfaces C Rationale: The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
The nurse is providing care to a client with respiratory syncytial virus (RSV). The client's condition is not severe and there is no history of immune compromise. Which pharmacologic therapies does the nurse anticipate based on this data? Select all that apply.
a. Nebulized epinephrine b. Ribavirin c. Systemic corticosteroids d. Antibiotics A, C
The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?
a. Notify the healthcare provider of this assessment finding. b. Obtain an arterial blood gas for further respiratory assessment. c. Begin monitoring the respiratory rate every 5 minutes. d. Continue to monitor the newborn per facility policy. D
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the client's breathing pattern? Select all that apply.
a. Provide adequate rest periods. b. Assist with ADLs. c. Educate on relaxation techniques. d. Educate on pursed-lip breathing. e. Administer a cough suppressant. A, B, C, D Rationale: Providing adequate rest periods prevents fatigue and reduces oxygen demands. Assisting with ADLs conserves energy and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucous to maintain adequate oxygenation.
The nurse is caring for a 65-year-old who fell and is in skeletal traction for a right femur fracture. The client is complaining of pain in the leg. The nurse determines that the right foot is pale and without a pedal pulse. The nurse takes which of the following actions?
a. Reassures the client that the finding is normal for older adults b. Administers half of the pain medication ordered as pain perception may be lower in older adults c. Releases the traction d. Notifies the physician D
The nurse working in the emergency department (ED) is assessing an infant client. Which findings support the diagnosis of respiratory syncytial virus (RSV)? Select all that apply.
a. Rhinorrhea b. Irritability c. Grunting d. Bradypnea e. Tachypnea A, B, C, E
When teaching use of a metered-dose inhaler (MDI), the nurse instructs the client to
a. Take quick, shallow breaths in rapid succession while holding the canister down. b. Use the inhaler containing the anti-inflammatory drug first, then the bronchodilator. c. Use the anti-inflammatory drug as needed to treat acute episodes of wheezing. d. Rinse the mouth after using the inhaler to reduce systemic absorption of the drug. C
Apnea
absence of breathing
LABA Meds
albuterol, formoterol, and salmeterol
SABA meds
albuterol, levalbuterol, metaprotereol, and subcutaneous terbutaline
bradypnea
an abnormally slow rate of respiration usually of less than 10 breaths per minute
Illness
an individual finds themselves in an imbalanced, unsustainable relationship with their environment and are failing in their ability to survive and create a higher quality of life A state of being...
LABA are used in
conjunction with anti-inflammatory drugs to control symptoms and are not recommended to treat acute attacks and are used for prophylactic treatment.
Hypoxemia
decreased level of oxygen s/s- chest wall indrawing, cyanosis is late Interventions- O2, treat underlying cause
Orthopnea
difficulty breathing when lying down s/s- dyspnea when laying down Interventions- reposition to fowlers or semi-fowlers, elevate HOB when sleeping
Disease
failure of a person's adaptive mechanisms to counteract stimuli and stresses adequately, resulting in functional or structural disturbances
Dyspnea
labored breathing or shortness of breath s/s- labored breathing, audible labored breathing, anxiety, distressed facial expression, nasal flaring Interventions- O2, semi fowlers, treat underlying cause, rest, frequent breaks, fluid overload?, breathing treatments, etc
Dysuria
painful or difficult urination
SABA is recommended
quick relief and acute symptoms, up to 3 treatments at 20-minute intervals or a single nebulizer treatment can be used as needed.
Tachypnea
respiratory rate greater than 20 breaths for children and adults, greater than 60 for newborns s/s- excessive rapid breathing, rapid breathing at rest, shallow respirations Interventions- depends on underlying cause, suction, O2, bronchodilator, semi-fowlers or high fowlers, suctioning