MedSurg Assignment 3

A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client? 1 Exercise daily 2 Use disposable tissues 3 Avoid foods high in sodium 4 Monitor blood pressure weekly

2

Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? 1 Asthma 2 Emphysema 3 Chronic bronchitis 4 Centrilobular emphysema

2

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? 1 Lung biopsy 2 Thoracentesis 3 Mediastinoscopy 4 Ventilation-perfusion scan

2

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? 1 Report of pain when taking deep breaths 2 Client is observed splinting the fracture site 3 Diminished breath sounds on the affected side 4 Bowel sounds are auscultated in the lower chest

3

A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? 1 Change in level of consciousness 2 Increased pain 3 Increased respiration 4 Decreased heart rate

3

A client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is experiencing? Bargaining 2 Frustration 3 Depression 4 Rationalization

1

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? 1 Preoxygenate the client before suctioning. 2 Employ gentle suctioning as the catheter is being inserted. 3 Be sure the cuff of the tracheostomy is inflated during suctioning. 4 Loosen the client's secretions before suctioning by instilling saline.

1

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1 Pink 2 Clear 3 Green 4 Yellow

1

Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock

1

A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? 1 Keep collection device attached to mechanical suction 2 Keep chest tube clamped distal to the water-seal chamber 3 Keep collection device below the level of the client's chest 4 Keep chest tube end covered with sterile gauze pads taped to the client

3

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at bases of the lungs

4

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? 1 Remove the air that is present in the intrapleural space 2 Drain serosanguineous fluid from the intrapleural compartment 3 Permit the development of positive pressure between the layers of the pleura 4 Provide access for the instillation of medication into the pleural space

1

A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. Which is the most appropriate nursing action? 1 Instruct the client to cough 2 Clamp the tube immediately 3 Prepare for chest tube removal 4 Arrange for a stat chest x-ray film

1

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.

2

A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include? 1 Purpose of bronchodilators 2 Importance of meticulous oral hygiene 3 Technique used in pursed-lip breathing 4 Methods used to maintain a dust-free environment

2

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. 3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3

The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? 1 Careful monitoring for crepitus 2 Bed rest with range-of-motion exercises 3 Coughing and deep breathing every hour 4 Covering the chest tube site with a sterile dressing

3

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? 1 Initiate pulmonary hygiene to clear air passages of trapped mucus 2 Instruct to deep breathe slowly with inhalation longer than exhalation 3 Encourage continuous rapid panting to promote respiratory exchange 4 Administer oxygen at a low concentration to maintain respiratory drive

4

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? 1 Tremors 2 Anasarca 3 Bradypnea 4 Tachycardia

4

A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort? 1 Sims 2 Lateral 3 Orthopneic 4 Semi-Fowler

4

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. Auscultate lung sounds. 2. Obtain the vital signs. 3. Suction for approximately 10 seconds. 4. Rotate the catheter during its withdrawal. 5. Hyperoxygenate for 30 seconds.

obtain vitals, auscultate, hyper oxygenate, suction, rotate

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.

4

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation

4

Which client would have relatively smaller tidal volumes due to limited chest wall movement? 1 A client with asthma 2 A client with pneumonia 3 A client with pulmonary fibrosis 4 A client with phrenic nerve paralysis

4