Perfusion & Gas Exchange
A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. Which is the best response by the nurse? A: "Your father may be having mini-strokes; I will notify his physician." B: "Your father is just confused about some things since he is in the hospital." C: "The confusion will pass. Your father just has to get up and move around." D: "Talk with your father about past events, and that will help with the confusion."
A: "Your father may be having mini-strokes; I will notify his physician."
Which manifestation is an adverse effect of intravenous Lorazepam? (Select all that apply) A: Amnesia B: Drowsiness C: Sleep driving E: Blurred vision F: Respiratory depression
A: Amnesia B: Drowsiness C: Sleep driving E: Blurred vision F: Respiratory depression
Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? A: Duration of cry B: Respiratory distress C: Frequency of voiding D: Poor nutritional intake
B: Respiratory distress
Which clinical findings indicate compromised circulation for a client with a long leg cast? (Select all that apply) A: Foul odor B: Swelling of the toes C: Drainage on the cast D: Increased temperature E: Prolonged capillary refill
B: Swelling of the toes E: Prolonged capillary refill
The nurse assesses a client who has an intravenous (IV) infusion of normal saline. Which assessment finding is the nurse's priority concern? A: There is bleeding at the infusion site. B: The client feels short of breath and is orthopneic. C: The IV limits client mobility. D: Infiltration has occurred at the catheter insertion site.
B: The client feels short of breath and is orthopneic.
What is the most significant modifiable risk factor for the development of impaired gas exchange? A: Age B: Tobacco use C: Drug overdose D: Prolonged immobility
B: Tobacco use
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? A: It relieves bronchial spasms. B: It increases the depth of respiration's. C: It loosens pulmonary secretions. D: It expels carbon dioxide from the lungs.
C: It loosens pulmonary secretions.
The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. Which sounds would the nurse document in the client's assessment record? A: Rhonchi B: Wheezes C: Fine crackles D: Coarse crackles
D: Coarse crackles
The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? A: The alveoli need oxygen to live. B: The alveoli have no direct effect on oxygenation. C: Collapsed alveoli increase oxygen demand. D: Oxygen is exchanged for carbon dioxide in the alveolar membrane.
D: Oxygen is exchanged for carbon dioxide in the alveolar membrane.
Which is the priority nursing intervention for a 3.5-year-old child after a cardiac catheterization? A: Encouraging early ambulation B: Monitoring the insertion site for bleeding C: Comparing the blood pressures in the extremities D: Restricting fluids until the blood pressure stabilizes
B: Monitoring the insertion site for bleeding
The nurse assesses the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? A: Client with shock B: Client with anemia C: Client with epilepsy D: Client with peripheral vascular disease
C: Client with epilepsy
The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? A: Vesicular B: Bronchial C: Crackles D: Rhonchi
C: Crackles
Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy? A: Urinary retention B: Signs of restlessness C: Decreased blood pressure D: Signs of respiratory obstruction
D: Signs of respiratory obstruction
Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? A: Good cry B: Grimace C: Absent respiration D: Slow, weak cry
D: Slow, weak cry
A 4-month-old infant with severe tachypnea, flaring of the nares, wheezing, and irritability is admitted to the pediatric unit with bronchiolitis. Which clinical finding is associated with possible respiratory failure? A: Expiratory wheezing B: Intercostal retractions C: Fine crackles on deep inspiration D: Sudden absence of breath sounds
D: Sudden absence of breath sounds
Which risk associated with estrogen therapy would the nurse include in the teaching plan for a client who smokes? A: Hypocalcemia B: Vaginal bleeding C: Multiple pregnancies D: Thromboembolic disorders
D: Thromboembolic disorders
The nurse is assessing the sleep patterns of a patient when the patient reports he has trouble sleeping when lying flat. Which is the best response by the nurse? A: Open a window to let fresh air into the room. B: Use nasal strips to assist with breathing. C: Sleep in a side-lying position. D: Use pillows to prop yourself up while sleeping.
D: Use pillows to prop yourself up while sleeping
A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? A: Tissue ischemia B: Brain malformations C: Intestinal blockage D: Cardiac dysrhythmia
D: Cardiac dysrhythmia
Which disorder would the nurse suspect in the client who has blue nail beds? A: Thrombocytopenia B: Polycythemia vera C: Iron-deficiency anemia D: Cardiopulmonary disease
D: Cardiopulmonary disease
At which interval are humidified oxygen systems replaced to prevent infection? A: 1 day B: 3 days C: 5 days D: 7 days
A: 1 day
The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client? A: Apnea B: Bradypnea C: Tachypnea D: Hyperpnea
B: Bradypnea
The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? A: Mental alertness B: Perfusion C: Pain D: Reaction to medications
B: Perfusion
When teaching about prevention of coronary artery disease (CAD) for a 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg), smokes 1 pack a day of cigarettes, and has siblings with CAD, which topics are most important for the nurse to include? (Select all that apply) A: Age B: Height C: Weight D: Tobacco use E: Family history
C: Weight D: Tobacco use
A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? A: "Hypertension happens to everyone sooner or later. Don't be concerned about it." B: "Hypertension can happen from eating a poor diet, so change what you are eating." C: "Hypertension can happen from arterial changes that block the blood flow." D: "Hypertension happens when people do not exercise, so you should walk every day."
C: "Hypertension can happen from arterial changes that block the blood flow."
A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? A: "Perfusion is a normal function of the body, and I don't have to be concerned about it." B: "Perfusion is monitored by the physician." C: "Perfusion is monitored by vital signs and capillary refill." D: "Perfusion varies as a person ages, so I would expect changes in the body."
C: "Perfusion is monitored by vital signs and capillary refill."
Which finding would be consistent with a client's long-standing hypoxemia? A: Scoliosis B: Kyphosis C: Clubbing D: Kyphoscoliosis
C: Clubbing
The nurse is assessing a female patient at the neighborhood clinic. The patient reports "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A: Ischemia B: Pneumonia C: Myocardial infarction D: Peptic ulcer disease
C: Myocardial infarction
The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-g sodium diet. Which statement from the client indicates that further teaching is needed? A: "I must check my pulse every day." B: "I can gradually increase my exercise as long as I take rest periods." C: "I should call my health care provider if I have difficulty breathing when I am lying flat." D: "I can use a little table salt on my food as long as I do not use it when cooking food."
D: "I can use a little table salt on my food as long as I do not use it when cooking food."
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? A: The infant is becoming more active. B: There is an increase in intake of breast milk or formula. C: The infant is unable to maintain an adequate iron intake. D: A depletion of fetal hemoglobin occurs.
D: A depletion of fetal hemoglobin occurs
The nurse should anticipate that which patient will need to be treated with insertion of a chest tube? A: A patient with asthma and severe shortness of breath B: A patient undergoing a bronchoscopy for a biopsy C: A patient with a pleural effusion requiring fluid removal D: A patient experiencing a problem with a pneumothorax
D: A patient experiencing a problem with a pneumothorax
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO 2 intoxication (CO 2 narcosis), which would the nurse do? A: Initiate pulmonary hygiene to clear air passages of trapped mucus. B: Instruct to deep-breathe slowly with inhalation longer than exhalation. C: Encourage continuous rapid panting to promote respiratory exchange. D: Administer oxygen at a low concentration to maintain respiratory drive.
D: Administer oxygen at a low concentration to maintain respiratory drive.
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? A: Elevated blood pressure B: Bounding pedal pulses C: Night blindness D: Reflux disease
A: Elevated blood pressure
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? A: Red blood cell count B: Sputum culture C: Arterial blood gas D: Total hemoglobin
C: Arterial blood gas
A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. Which actions would the client's postoperative plan of care include? A: Encouraging the client to ambulate in the hallway B: Placing the bed in the Trendelenburg position C: Helping the client dangle her legs over the side of the bed D: Maintaining the client on bed rest until the dressings have been removed
A: Encouraging the client to ambulate in the hallway
The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining? A: Fluid retention B: Kidney function C: Nutritional status D: Medication dosage
A: Fluid retention
Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? A: Hemoglobin level of 8.0 B: Bronchoconstriction and mucus C: Peripheral arterial disease D: Decreased thoracic expansion
A: Hemoglobin level of 8.0
Which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction? A: Identify the learning needs of the client. B: Determine the nursing goals for the client. C: Explore the use of group teaching for the client. D: Evaluate the community resources available to the client.
A: Identify the learning needs of the client
What is the purpose of including exercise and activity in a cardiac rehabilitation program? (Select all that apply.) A: Increase cardiac output B: Increase serum lipids C: Increase blood pressure D: Increase blood flow through the arteries E: Increase muscle mass F: Increase flexibility
A: Increase cardiac output D: Increase blood flow through the arteries E: Increase muscle mass
Which nursing intervention promotes perfusion and healing of the surgical wound for an older adult? A: Minimize the use of tape on the skin. B: Keep the client adequately hydrated. C: Change the dressings as soon as they get wet. D: Provide rest for the client throughout the day.
B: Keep the client adequately hydrated.
After the nurse has completed discharge teaching for a client who has had a myocardial infarction, which client statement indicates that more teaching is needed? A: "I will avoid physical activity." B: "I will take 1 baby aspirin every day." C: "I will continue my smoking cessation program." D: "I will try to lose the extra weight I'm carrying."
A: "I will avoid physical activity."
The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? A: "It stimulates the heart to beat in a normal rhythm." B: "It protects the heart from atherosclerotic changes." C: "It provides the heart with oxygenated blood." D: "It protects the heart from infection."
A: "It stimulates the heart to beat in a normal rhythm."
A child in respiratory distress is admitted to the hospital and diagnosed with acute spasmodic laryngitis (spasmodic croup). At the time of discharge, the mother asks how to handle another attack at home. Which would the nurse recommend? A: "Place him near a cool-mist humidifier." B: "Bring him to the emergency department." C: "Give him an over-the-counter cough syrup." D: "Offer him warm tea sweetened with honey."
A: "Place him near a cool-mist humidifier."
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. Which action would the nurse take? A: Administer the prescribed oxygen. B: Administer the prescribed antianxiety medication. C: Notify the health care provider immediately of the findings. D: Record the observations and continue to observe the client.
A: Administer the prescribed oxygen.
The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? A: An elevation of the total white cell count indicates generalized inflammation. B: Eosinophil count will assist to identify the presence of a respiratory infection. C: White cell count will differentiate types of respiratory bacteria. D: Level of neutrophils provides guidelines to monitor a chronic infection.
A: An elevation of the total white cell count indicates generalized inflammation.
Which action would be the nurse's first priority when receiving a client with major burns? A: Assessing airway patency B: Checking the client from head to toe C: Administering oxygen as needed D: Elevating the extremities if no fractures are noticed
A: Assessing airway patency
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement? A: Auscultate the lungs. B: Obtain arterial blood gases. C: Notify the health care provider. D: Apply pressure to the abdomen.
A: Auscultate the lungs.
A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? A: Black, tarry stools B: Frequent nausea C: Joining Alcoholics Anonymous D: Pain that increases after meals
A: Black, tarry stools
Which life-threatening wounds are treated with hyperbaric oxygen therapy? (Select all that apply) A: Burns B: Skin cancer C: Osteomyelitis D: Diabetic ulcers E: Myocardial infarction
A: Burns C: Osteomyelitis D: Diabetic ulcers
When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next? A: Check the pulses with a Doppler device. B: Notify the primary health care provider. C: Notify the staff in the catheterization laboratory. D: Document the findings in the client's medical record.
A: Check the pulses with a Doppler device.
Which child is the best roommate option for child admitted in a vasoocclusive sickle cell crisis? A: Child with thalassemia B: Child with osteomyelitis C: Child with viral pneumonia D: Child with acute pharyngitis
A: Child with thalassemia
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A: Chronic lung disease with increased carbon dioxide retention B: Acute anxiety, hyperventilation, and decreased carbon dioxide retention C: Decreased cardiac output with increased serum lactic acid production D: Gastric drainage with increased removal of gastric acid
A: Chronic lung disease with increased carbon dioxide retention
Which action by the nurse will be most effective when teaching a client about exercises to prevent venous stasis? A: Demonstrate specific exercises. B: Suggest frequent moving of the legs. C: Advise against sitting for prolonged periods. D: Suggest that the client change positions frequently
A: Demonstrate specific exercises.
The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? A: Disorientation and tremors B: Tachycardia and decreased blood pressure C: Increased anxiety and irritability D: Hyperventilation and lethargy
A: Disorientation and tremors
The nurse teaches a postoperative client how to use an incentive spirometer. Which client behavior indicates to the nurse that the spirometer is being used correctly? A: Inhales deeply through the mouthpiece, relaxes, and then exhales B: Inhales deeply, seals the lips around the mouthpiece, and exhales C: Uses the incentive spirometer for 10 consecutive breaths per hour D: Coughs several times before inhaling deeply through the mouthpiece
A: Inhales deeply through the mouthpiece, relaxes, and then exhales
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? A: Initiate oxygen via a nasal cannula B: Administer the prescribed morphine C: Prepare the client for endotracheal intubation D: Place a nitroglycerin tablet under the client's tongue
A: Initiate oxygen via a nasal cannula
For clients experiencing an anaphylactic attack, which medication would the nurse initiate immediately? A: Isoproterenol B: Diphenhydramine HCl C: Hydrocortisone sodium succinate D: Methylprednisolone sodium succinate
A: Isoproterenol
Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? A: It helps prevent drying of membranes. B: It provides a mode of giving inhalant medications. C: It increases the surface tension of the respiratory tract. D: It provides an environment free of pathogenic organisms.
A: It helps prevent drying of membranes.
Which assessment is priority after checking airway for a client with a cervical spinal cord injury? A: Level of consciousness B: Sensory perception in all extremities C: Presence and location of diaphoresis D: Vital sign assessment and oxygen assessment
A: Level of consciousness
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply) A: Neurologic system B: Endocrine system C: Pulmonary system D: Immune system E: Cardiovascular system F: Hepatic system
A: Neurologic system C: Pulmonary system E: Cardiovascular system
The nurse is administering oral glucocorticoids to a patient with asthma. What finding indicates a therapeutic response to the medication? A: No observable respiratory difficulty or shortness of breath over the last 24 hours B: A decrease in the amount of nasal drainage and sneezing C: No sputum production, and a decrease in coughing episodes D: Relief of an acute asthmatic attack
A: No observable respiratory difficulty or shortness of breath over the last 24 hours
The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? A: Peripheral arterial disease of the lower extremities B: Chronic obstructive pulmonary disease (COPD) C: Chronic asthma D: Severe anemia secondary to chemotherapy
A: Peripheral arterial disease of the lower extremities
A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. Which is the nurse's priority intervention? A: Starting oxygen therapy B: Administering an opioid C: Elevating the head of the bed D: Drawing blood for laboratory tests
A: Starting oxygen therapy
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? A: Their gag reflex has returned. B: They are confused due to anesthesia. C: They are nauseated and want to vomit. D: Their airway is becoming obstructed.
A: Their gag reflex has returned.
The nurse is assessing a client with a cast to the extremity. Which assessment finding would the nurse document in the electronic health record without any follow-up intervention required? A: Warmth B: Numbness C: Skin desquamation D: Generalized discomfort
A: Warmth
Which priority nursing action during a primary assessment benefits the client who fell down the stairs? A:Monitoring the client for hemorrhage B: Anticipating for rapid blood component administration C: Inserting 16-gauge needle at the antecubital area for intravenous (IV) line D: Infusing warm intravenous (IV) fluids at a rate of 8 drops per minute
A:Monitoring the client for hemorrhage
A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is the highest priority for client teaching? A: Older age B: Low activity level C: Blood glucose control D: Family history of cardiac disease
B: Low activity level
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? A: "Central perfusion is monitored only by the physician." B: "Central perfusion involves the entire body." C: "Central perfusion is decreased with hypertension." D: "Central perfusion is toxic to the cardiac system."
B: "Central perfusion involves the entire body."
Which statement by the nurse regarding anesthetic drugs in pediatric clients requires correction? A: "Pediatric clients are more affected by anesthesia than adults." B: "During general anesthesia, the upper airway obstruction risk is less in pediatrics." C: "Cardiac abnormalities are more common in pediatric clients receiving anesthesia." D: "The central nervous system of pediatric clients is more sensitive to the effects of anesthetics."
B: "During general anesthesia, the upper airway obstruction risk is less in pediatrics."
After the nurse completes teaching for a client with foot pain who has peripheral arterial disease, which client statement indicates that further teaching is needed? A: "I will wear socks." B: "I will elevate my foot." C: "I will increase fluid intake." D: "I will drink a moderate amount of alcohol."
B: "I will elevate my foot."
The nurse provides education about self-care management to a client who was recently diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? A: "I will try to avoid smoking." B: "I will maintain complete bed rest." C: "I'll control the temperature in my home." D: "I'll need to clean my mouth several times a day."
B: "I will maintain complete bed rest."
A patient is questioning the nurse about circulation and perfusion. Which is the best response by the nurse? A: "Perfusion assists the body by preventing clots and increasing stamina." B: "Perfusion assists the cell by delivering oxygen and removing waste products." C: "Perfusion assists the heart by increasing the cardiac output." D: "Perfusion assists the brain by increasing mental alertness."
B: "Perfusion assists the cell by delivering oxygen and removing waste products."
A newborn with a diaphragmatic hernia has impaired gas exchange. Which would the nurse identify as the cause of the infant's decreased gas exchange? A: Incarcerated hernia B: Decreased oxygen intake C: Increased basal metabolic rate D: Excessive respiratory secretions
B: Decreased oxygen intake
Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? A: Prevents bronchial spasm B: Decreases air trapping in lung C: Improves alveolar surface area D: Strengthens diaphragmatic contraction
B: Decreases air trapping in lung
When evaluating the concept of gas exchange, how should the nurse best describe the movement of oxygen and carbon dioxide? A: Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B: Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C: The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D: Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.
B: Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of which? A: Binder B: Ice bag C: Elastic bandage D: Warm compress
B: Ice bag
Which action would the nurse take to decrease retained secretions in an 11-year-old child hospitalized with an exacerbation of chronic bronchitis? A: Administer oxygen as prescribed. B: Increase fluid intake to at least 2000 mL/day. C: Encourage the child to rest in the high-Fowler position. D: Teach the child to gargle with a saline solution every 2 hours
B: Increase fluid intake to at least 2000 mL/day.
Which information obtained by the nurse about a client would represent risk factors for the client's admission diagnosis of hypertension? (Select all that apply) A: Daily use of 1 aspirin B: Occasional cocaine use C: Reduced hemoglobin level D: African American heritage E: Increased high-density lipoprotein (HDL
B: Occasional cocaine use D: African American heritage
A chronically ill, older client lives with their daughter. The client reports the daughter, who has three small children, seems run-down, coughs a lot, and sleeps all the time. Which statement supports the need for the nurse to pursue the daughter's condition as a potential case finding? A: Tuberculosis has been rising dramatically in the general population. B: Older adults with chronic illness are more susceptible to tuberculosis. C: There is a high incidence of tuberculosis in children less than 12 years of age. D: Death from tuberculosis has been decreasing in the United States and Canada
B: Older adults with chronic illness are more susceptible to tuberculosis.
Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse? A: Irregular apical pulse B: Oxygen saturation 86% C: Crackles at both lung bases D: Atrial fibrillation on cardiac monitor
B: Oxygen saturation 86%
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) A: Respiratory rate is 24 breaths/min. B: Oxygen saturation level is 98%. C: The right side of the thorax expands slightly more than the left. D: Trachea is just to the left of the sternal notch. E: Nail beds are pink with good capillary refill. F: There is presence of quiet, effortless breath sounds at lung base bilaterally.
B: Oxygen saturation level is 98%. E: Nail beds are pink with good capillary refill. F: There is presence of quiet, effortless breath sounds at lung base bilaterally.
The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? A: Obtain a pulse oximeter to determine the client's oxygen saturation level. B: Put the client in a high Fowler position. C: Darken the lights and provide a rest period of at least 15 minutes. D: Continue the hygiene activities while reassuring the client.
B: Put the client in a high Fowler position.
A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? A: Level of pain B: Quality and depth of respirations C: Amount of serosanguinous drainage D: Blood pressure and pupillary response
B: Quality and depth of respirations
Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. A: Palpate the chest and back for masses. B: Question the client about shortness of breath. C: Check the hematocrit and hemoglobin values. D: Inspect the skin and nails for integrity and color. E: Ask the client about color and quantity of sputum.
B: Question the client about shortness of breath. E: Ask the client about color and quantity of sputum.
A patient is having the arterial blood gas (ABG) measured. What should the nurse identify as the parameters to be evaluated by this test? A: Ratio of hemoglobin and hematocrit B: Status of acid-base balance in arterial blood C: Adequacy of oxygen transport D: Presence of a pulmonary embolus
B: Status of acid-base balance in arterial blood
Which nursing intervention would the nurse implement for a client in the immediate postoperative period after an abdominal cholecystectomy with common duct exploration? A: Irrigate the T-tube every hour. B: Change the dressing every 2 hours. C: Encourage coughing and deep breathing. D: Promote an adequate fluid and food intake.
C: Encourage coughing and deep breathing.
The nurse is providing care in the postanesthesia care unit to a client who underwent a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness? A: Assessing for pain B: Assessing for gag reflex C: Encouraging deep breathing D: Encouraging ankle pump exercises
C: Encouraging deep breathing
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? A: Blood glucose of 350 mg/dL B: Anticoagulant therapy for 10 days C: Hemoglobin of 8.5 g/dL D: Heart rate of 100 beats/min and blood pressure of 100/60
C: Hemoglobin of 8.5 g/dL
How would the nurse document a drop in blood pressure when a client moves rapidly from a lying to a standing position? A: Malignant hypotension B: Orthostatic dehydration C: Orthostatic hypotension D: Vasomotor instability
C: Orthostatic hypotension
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? A: Level of consciousness and pupil size B: Characteristics of pain and blood pressure C: Quality of respiration's and presence of pulses D: Observation of abdominal contusions and other wounds
C: Quality of respiration's and presence of pulses
A client takes morphine sulfate for severe metastatic bone pain. The nurse will assess the client for which adverse effect? A: Diarrhea B: Addiction C: Respiratory depression D: Diuresis
C: Respiratory depression
After an abdominal cholecystectomy, the client refuses to take deep breaths and cough, saying, "It's too painful." Which action would the nurse take? A: Give pain medication regularly as soon as possible. B: Obtain a prescription to increase the client's pain medication. C: Schedule coughing and deep-breathing exercises after analgesic has taken effect. D: Substitute incentive spirometry for coughing and deep breathing.
C: Schedule coughing and deep-breathing exercises after analgesic has taken effect.
In which position would the nurse place a 5-week-old infant who has difficulty breathing and feeding related to a suspected congenital heart defect? A: Supine, with the knees flexed B: Orthopneic, with pillows for support C: Side-lying, with the upper body elevated D: Prone, with the head supported by pillows
C: Side-lying, with the upper body elevated
Which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity? A: Give prescribed intravenous antibiotic. B: Administer oxygen per nonrebreather mask. C: Teach the client coughing and deep-breathing exercises. D: Keep the client on the mechanical ventilation for several days.
C: Teach the client coughing and deep-breathing exercises.
A child with cystic fibrosis (CF) has recurrent episodes of bronchitis, and the parents ask why this happens. Which reason would the nurse include in the reply? A: Associated heart defects cause heart failure and respiratory depression. B: Neuromuscular irritability causes spasm and constriction of the bronchi. C: Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. D: The increased salt content in saliva irritates the mucous membranes, resulting in inflammation of the nasopharynx
C: Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.
When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? A: Losing weight over the past week B: Tingling in the upper extremities C: Using several pillows at night to sleep D: Wheezing when exposed to dust or pollen
C: Using several pillows at night to sleep
Which site would be monitored for a pulse to assess the status of circulation to the foot? (Select all that apply) A: Carotid artery B: Femoral artery C: Popliteal artery D: Dorsalis pedis artery E: Posterior tibial artery
D: Dorsalis pedis artery E: Posterior tibial artery
The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? A: Teaching how to make a room allergy-free B: Referring to a support group for individuals with asthma C: Arranging with the college to ensure a speedy return to classes D: Evaluating whether the necessary lifestyle changes are understood
D: Evaluating whether the necessary lifestyle changes are understood
The nurse is caring for a postoperative client who had general anesthesia. Which independent nursing intervention would prevent an accumulation of secretions? A: Postural drainage B: Cupping the chest C: Nasotracheal suctioning D: Frequent changes of position
D: Frequent changes of position
A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give? A: Compression of the heart muscle B: Release of myocardial isoenzymes C: Rapid vasodilation of the coronary arteries D: Inadequate oxygenation of the myocardium
D: Inadequate oxygenation of the myocardium
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A: Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B: Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C: Encourage coughing and deep breathing to clear the airway. D: Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min.
D: Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min.
The nurse is administering high concentrations of oxygen (O 2) to a child. Which is the nurse's most important consideration concerning the O 2? A: A nonrebreather mask should be used. B: The tank should be labeled flammable. C: O2 must be warmed before administration. D: O2 must be humidified before administration
D: O2 must be humidified before administration
Which clinical management prevention concept would the nurse identify as representative of secondary prevention? A: Decreasing venous stasis and risk for pulmonary emboli B: Implementation of strict hand washing routines C: Maintaining current vaccination schedules D: Prevention of pneumonia in patients with chronic lung disease
D: Prevention of pneumonia in patients with chronic lung disease
