Oxygenation
To detect cyanosis in clients with dark skin, the nurse should assess which area? Oral mucosa Nose Sclera Fingernails
Oral mucosa - In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjuctivae, oral mucosa, and nail beds.
A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.50 7.35 7.45 7.30
7.50 - The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.
A patient has an autosomal recessive inherited condition. For what type of disorder does the nurse anticipate the patient will be treated? Hereditary breast cancer Huntington disease Familial hypercholesterolemia Cystic fibrosis
Cystic fibrosis - Gaucher's disease, cystic fibrosis, sickle cell anemia, and PKU are examples of autosomal recessive conditions (National Human Genome Research Institute, 2011d). The other conditions listed are all autosomal dominant inherited conditions.
In which position should the client be placed for a thoracentesis? Lateral recumbent Prone Sitting on the edge of the bed Supine
Sitting on the edge of the bed - If possible place the patient upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the patient could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position.
The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? administer sublingual nitroglycerin enhance myocardial oxygenation educate the client about his symptoms decrease anxiety
enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.
A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of myocardial infarction. pulmonary embolism. pulmonary edema. pneumonia.
pulmonary embolism. - Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach." "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation."
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording? Deceleration followed by acceleration of 15 bpm Increase in variability by 27 bpm Decrease in variability for 15 seconds Acceleration of at least 15 bpm for 15 seconds
Acceleration of at least 15 bpm for 15 seconds - A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.
The client with airway obstruction may experience perfusion of the lungs without ventilation due to what disorder? Abdominal aneurysm Cardiogenic shock Atelectasis Pulmonary embolism
Atelectasis - Perfusion without ventilation is defined as a shunt. It occurs in conditions such as atelectasis in which there is airway obstruction. With dead air space there is ventilation without perfusion that occurs with conditions such as pulmonary embolism, which impairs blood flow to a part of the lung.
Bronchiectasis is considered a secondary COPD, and with the advent of antibiotics, it is not a common disease entity. In the past, bronchiectasis often followed specific diseases. Which disease did it not follow? Necrotizing bacterial pneumonia Influenza Complicated measles Chickenpox
Chickenpox In the past, bronchiectasis often followed a necrotizing bacterial pneumonia that frequently complicated measles, pertussis, or influenza. Chickenpox has never been linked to bronchiectasis.
A client is diagnosed with atherosclerosis. What would the nurse say is the most likely cause of his angina? Decreased musculature of the myocardium related to plaque Hypertension of the myocardium Decreased oxygenation to the myocardium A reduction in plaque secondary to atherosclerosis
Decreased oxygenation to the myocardium - Angina pectoris results from deficit in myocardial oxygen supply (myocardial ischemia) in relation to myocardial oxygen demand, most often caused by atherosclerotic plaque in the coronary arteries.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? use of a cooling blanket endotracheal suctioning encouragement of coughing incentive spirometry
Endotracheal suctioning - Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? Acute pain related to surgery Ineffective airway clearance related to anaesthesia Impaired physical mobility related to surgery Deficient fluid volume related to blood and fluid loss from surgery
Ineffective airway clearance related to anaesthesia - Ineffective airway clearance related to anaesthesia takes priority for this client because general anaesthesia may impair a client's ability to clear secretions from his airway. Acute pain related to surgery, Deficient fluid volume related to blood and fluid loss from surgery, Impaired physical mobility related to surgery, although important, are secondary.
A child is being discharged after being diagnosed with an asthma attack. What information regarding the rescue inhaler is most important for the nurse to include in discharge teaching? Monitor heart rate. Watch for hyperactivity. Record changes in taste. Report nausea and vomiting.
Monitor heart rate. - Albuterol (salbutamol) is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases as a rescue inhaler. Signs and symptoms of albuterol toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, dizziness, and a bad taste in the mouth. While all of these are potential side effects, tachycardia and heart palpitations are the most serious, so monitoring the heart rate is most important to include in discharge teaching.
The balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured. What is the term for the measurement obtained? cardiac output pulmonary artery pressure pulmonary artery wedge pressure central venous pressure
Pulmonary Artery Wedge Pressure - When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded, reflecting left-atrial pressure and left-ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution, which involves injection of fluid into the pulmonary artery catheter.
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis - Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had normal lung function
Sudden onset of lung impairment in a client who had normal lung function In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.
A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse? The wires are measuring the fluid level in the heart. The wires will administer ongoing electrical shocks to the heart to maintain rhythm. The wires are left in the heart for 1 month after surgery in case needed for potential arrhythmias. These wires are connected to the heart and will detect if your infant's heart gets out of rhythm.
These wires are connected to the heart and will detect if your child's heart gets out of rhythm. - Following cardiac repair there is always a possibility of arrhythmias. The wires are placed and connected to an external pacemaker. This is done as a preventative measure and can be used if an arrhythmia occurs. Once it is felt the child is in no danger of an arrhythmia the wires are removed. There is not set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative pressure Time cycled Volume cycled Pressure cycled
Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
Which of the following medications would the nurse expect to be used to facilitate intubation of the client? attacurium (Tracrium) diazepam (Valium) pancuronium (Pavulon) fentanyl (Sublimaze)
attacurium (Tracrium) Attacurium (Tracrium) is commonly used to facilitate intubation of the surgical client.
A group of nursing students are preparing a presentation for a health fair illustrating the structures found during a pregnancy. Which structures should the students point out form a protective barrier around the developing fetus? ectoderm and amnion chorion and endoderm chorion and amnion amnion and mesoderm
chorion and amnion - The chorion and amnion are the two fetal membranes. The ectoderm, mesoderm, and endoderm are layers in the developing blastocyst.
Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child? Diarrhea Vomiting Fever Nasal congestion
Nasal congestion The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? tap water normal saline distilled water mineral oil
distilled water
A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings? Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her. "Your daughter has an innocent heart murmur, which is nothing to worry about." "Your daughter has an organic heart murmur, which indicates that she has some degree of heart disease. The doctor will provide a referral to a good cardiologist." "Your daughter has a functional heart murmur; I recommend that you limit her physical activity so that her heart rate is not elevated for long periods of time."
"Your daughter has an innocent heart murmur, which is nothing to worry about." The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response? "They won't cause any major defects." "I'll let your primary care provider know how you feel about it." "Your primary care provider will order safe doses of your medication." "It's OK to not use them if you would feel more comfortable."
"Your primary care provider will order safe doses of your medication." Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis
Acute respiratory distress syndrome - Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Prepare for gastric lavage. Monitor the client's heart rhythm. Obtain a urine specimen for drug screening.
Ans: Prepare to assist with ventilation. - Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests the intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition? Observing for excessive crying Assessing for the presence of femoral pulses Auscultating for a cardiac murmur Recording an upper extremity blood pressure
Assessing for the presence of femoral pulses
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? Increase in arterial oxygenation Decreased white blood cell count Regulation of sodium and potassium Decreased depressive symptoms
Increase in arterial oxygenation - Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse? It will show if blood is being shunted. It will determine disturbances in heart conduction. It will determine if the heart is enlarged. This image will clarify the structures within the heart.
It will determine if the heart is enlarged. - Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? Nitroglycerin transdermal patch Meperidine hydrochloride (Demerol) Isosorbide mononitrate (Isordil) Morphine sulfate (Morphine)
Morphine sulfate (Morphine) - Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina-type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize? Increase fluids and take more vitamins. Bed rest and bathroom privileges only until birth. Discuss induction of labor with the primary care provider. Decrease activity and rest more often.
Decrease activity and rest more often. - If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. Anteroposterior rib diameter decreases. Lungs are pulled up and pushed back against the thoracic cage. Intercostals muscles relax to allow for expansion. Diaphragm contracts and elongates the chest cavity.
Diaphragm contracts and elongates the chest cavity. The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.
In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted? I II III IV
Grade I - COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.
The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? High pitched breath sounds over the trachea Minimal air movement through the lungs Lower pitched breath sound over the peripheral Resonance over the lungs on percussion
Minimal air movement through the lungs - Minimal or no air movement requires immediate intervention because this child's status is severely compromised. Breath sounds over the trachea typically are high pitched. Breath sounds over the peripheral lung fields are lower-pitched. Normally percussion over air-filled lungs reveals resonant sounds.
A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Observe respiratory status frequently. Massage the newborn's back. Ensure the newborn's warmth. Provide warm water to drink. Provide oxygen supplementation.
Observe respiratory status frequently. Ensure the newborn's warmth. Provide oxygen supplementation.
The most common cause of cholinergic crisis includes which of the following? Overmedication Compliance with medication Undermedication Infection
Overmedication - A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.
A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition? Place the client in the left lateral position. Keep the head of the client's bed slightly elevated. Keep the client's legs slightly elevated. Place the client in an orthopneic position.
Place the client in the left lateral position. - The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion. Elevating the client's legs, placing the client in an orthopneic position, or keeping the head of the bed elevated will not help alleviate the client's condition.
A client has been admitted with bacterial pneumonia and is complaining of difficulty breathing. The nurse would explain the most likely reason for the dyspnea is that pneumonia interferes with lung compliance due to: Destruction of alveoli Scar tissue Pulmonary congestion Pulmonary fibrosis
Pulmonary congestion - Pulmonary congestion results from the accumulation of fluid in the alveoli and is closely related to pulmonary edema. Pneumonia can cause inflammation in the involved lung tissue, causing the alveoli to fill with fluid and pus, which then decreases pulmonary compliance and also the gas exchange between the pulmonary capillaries and inspired air.
The client's ultrasound shows a thrombus in the venous sinus in the soleus muscle. The nurse explains that early treatment is important to prevent: Cerebrovascular accident Loss of pulses in the limb Acute myocardial infarction Pulmonary embolism
Pulmonary embolism - The most common site of a deep vein thrombosis (DVT) is in the venous sinuses in the soleus muscle and posterior tibial and peroneal veins. The risk of pulmonary embolism emphasizes the need for early detection and treatment of DVT. The other options are caused by occlusions in the arterial system.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Respiratory alkalosis — elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis. pH: 7.35-7.45. PaO2: 75 to 100 mmHg. PaCO2: 35-45 mmHg. HCO3: 22-26 mEq/L. O2 Sat: 94-100%
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain R/T surgery' B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Risk for aspiration R/T anesthesia
Risk for aspiration R/T anesthesia - Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.
Which sign appears early in a neonate with respiratory distress syndrome? Tachypnea more than 60 breaths/minute Poor capillary filling time (3 to 4 seconds) Pale gray skin color Bilateral crackles
Tachypnea more than 60 breaths/minute Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. Crackles occur as the respiratory distress progressively worsens. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen.
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? Aortic stenosis Coarctation of aorta Tetralogy of Fallot Pulmonary stenosis
Tetralogy of Fallot - Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.
The nurse sees a 3-year-old child in the ambulatory setting for localized wheezing on auscultation. Which statement by the parent would be most important to report to the health care provider? The parent likes the child to play by himself for 15 minutes every afternoon. The child was eating peanuts yesterday. The parent gives the child hard candy as an afternoon treat. The child has two cousins who have many allergies.
The child was eating peanuts Aspiration can cause airway mucosal inflammation. When aspiration from a small object occurs, the child may cough and gasp for a few seconds to a few minutes. Following that, the child may not be symptomatic for a day or longer. The aspiration of a foreign body may mimic an asthma attack, but an asthma attack would have generalized wheezing. Localized wheezing suggests only a small portion of a lung is involved, such as occurs following aspiration. Allergic situations cause early symptoms such as rash development and are generally not genetic or inherited in nature. The child playing by himself would have no effect on allergies or aspiration.
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse? The client makes noises when he breathes. The client reports thirst. The client is sleepy from the anesthesia. The client reports pain at the surgical site.
The client makes noises when he breathes. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.
The nurse is assisting a pregnant client who has just underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results? The fetus is developing at a fast rate but doing fine. The fetal heart rate increases with activity and indicates fetal well-being. The results indicate a stress test is needed for further evaluation. There is no evidence of congenital anomalies or deformities.
The fetal heart rate increases with activity and indicates fetal well-being.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that: the main focus is on monitoring the body's pathophysiologic response. the problem's existence requires validation by the physician. the interventions planned must be within the nurse's scope of practice. the signs and symptoms of the disease are part of the information conveyed.
the interventions planned must be within the nurse's scope of practice. - A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focussed on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? Macrophages Type II Type IV Type I
Type II There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.
A child with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. Which is the priority intervention for this child? check vital signs encourage increased fluid intake weigh the client measure urine output
check vital signs - Central diabetes insipidous is a disorder of the posterior pituitary. The fluid status of the child can be assessed first by assessing the vital signs. The large amounts of fluid loss can cause fluid and electrolyte imbalance that should be corrected. Urine output is important but not the priority. Encouraging fluids will not correct the problem and weighing the client is not necessary at this time. Diabetes insipidous is managed by decreasing the protein and sodium in the diet and daily replacement of the antidiuretic hormone.
A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure acute respiratory distress syndrome GERD disseminated intravascular coagulation hypoglycemia
kidney failure acute respiratory distress syndrome disseminated intravascular coagulation - When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.
