MedSurg III: Exam 1

Narrowed airway, as in asthma attack

Musical, high-pitch squeak sound, most often heard on exhalation but can also be heard during inhalation

The nurse is monitoring a client's vital signs. Which of the following findings would be of greatest concern to the nurse? 1. Mild tachycardia in a febrile patient. 2. Mild bradycardia in a young, otherwise healthy male who is asleep. 3. Eighteen-month-old with a heart rate of 120 beats per minute. 4. Pulse deficit with an apical rate of 88 beats per minute and a peripheral pulse of 72.

Answer 4 Rationale: A pulse deficit of 16 beats less in peripheral pulses is indicative of ectopic beats and is of greatest concern. The RN &/or PHCP should be notified. Mild tachycardia is expected in febrile clients. Sleeping clients often have lower heart rates. A pulse of 120 is expected in an 18-month-old.

The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement? Scarring is not as severe in a child as in an adult. 1. Children are at a lower risk of infection than adults because of their strong immune systems. 2. Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. 3. Infants and children are at decreased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

Answer: 3 Rationale: Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. Scarring is more severe in a child; additionally, disturbed body image will be a distinct issue for a child or adolescent, especially as growth continues. An immature immune system presents an increased risk of infection for infants and young children. Infants and children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the health care provider for intervention? 1. 75 mg/dL 2. 92 mg/dL 3. 120 mg/dL 4. 240 mg/dL

Answer: 4 Rationale: The normal fasting blood glucose level is 70 to 100 mg/dL in an adult client without diabetes and 70 to 130 mg/dL in a client with diabetes. Values above the normal range should be evaluated to determine if further intervention is needed. The most critical value is 240 mg/dL.

Heard at end of inspiration with PNE, HF, asthma, restrictive airway diseases

High-pitch crackle and pop, on inhalation, not cleared by cough

Pulmonary edema or fibrosis, or in terminally ill patients

Low-pitch bubble/gurgle, early in inspiration through early expiration; not cleared by cough

Chronic obstruction in trachea or bronchus IE chronic bronchitis

Low-pitch, coarse, loud, low snoring/moaning; heard most in exhalation, may clear with cough

35 y.o. F with pleuritic chest pain and a pulmonary embolism. Respirations 35/min. pH = 7.6, pCO2 = 20, pO2 = 55.

Pt is hyperventilating, thus blowing off CO2. This lowers her pCO2 and increases blood pH. Increased pH = alkalosis. Decreased pCO2 defines respiratory alkalosis.

21 y.o. M, acute respiratory failure from narcotic intoxication. Respiratory rate = 4/min. pH = 7.20, pCO2 = 60, pO2 = 45.

Pt retaining CO2 d/t hypoventilation. pH is decreased indicating acidosis. pCO2 is increased, indicating respiratory acidosis.

Inflammation of the membrane that surrounds the lungs

Superficial, low-pitched, coarse rubbing/grating sound, not cleared by cough

Based on Mrs. Richardson's recent hx, what additional assessment takes priority? a. Blood pressure b. Pedal pulse volume c. Deep tendon reflexes d. Two-point discrimination

a. Blood Pressure

Ms. Carrie Richardson is an 85 y.o. African American female who has a hx of several TIAs. She is being admitted to a medical unit after an episode of weakness that caused her to "pass out" at home. The RN prepares to complete the admission assessment after receiving Ms. Richardson from the E.D. Ms. Richard is A&O to person, place, time, & situation. When assessing for neurological problems, which questions should the nurse ask? (Select all that apply) a. Do you have any numbness, tingling, or weakness in your arms or legs? b. When you passed out, did you hit your head? If so, where? c. Do you have any difficulty chewing or swallowing? d. Have you ever heard voices in your head nobody else hears?

a. Do you have any numbness, tingling, or weakness in your arms or legs? b. When you passed out, did you hit your head? If so, where? c. Do you have any difficulty chewing or swallowing?

60 y.o. M in acute renal failure after an IV pyelogram. pH = 7.25, pCO2 = 37, pO2 = 70

pH decreased = acidosis. pCO2 is normal indicating there is no respiratory component. This indicates pure metabolic acidosis.

45 y.o. F on NG suction x 36 hrs and inappropriate fluid-replacement. pH = 7.56, pCO2 = 35, pO2 = 80

pH increased indicating alkalosis. pCO2 is normal so there is no respiratory component. Pure metabolic alkalosis.

20 y.o. M with acute asthma attack. Despite nebs x3 lung sounds are tight. Respirations 40. pH = 7.30, pCO2 = 50, pO2 = 59.mn

pH is low indicating acidosis. pCO2 is elevated so it's a respiratory issue - respiratory acidosis with significant hypoxemia.