S2T4 adaptive quizzing

Which early signs of respiratory acidosis would the nurse expect the client with a restrictive airway disease to exhibit? Select all that apply. One, some, or all responses may be correct.

1 Headache 2 Irritability 3 Restlessness Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

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? 1 Older age 2 Low activity level 3 Blood glucose control 4 Family history of cardiac disease

2 The client's low activity level is a modifiable risk factor and would be the focus of client teaching. Older age does increase risk for peripheral arterial disease, but it cannot be changed by the client. Blood glucose control may be a concern in the future for this client, but it is not currently a risk factor. Family history of cardiac disease does increase the client's risk for peripheral arterial disease, but family history is not a modifiable risk factor.

Which information would the nurse include in teaching a client who is advised to wear compression stockings for varicose veins? 1 Put the stockings on at the first sign of discomfort. 2 Don the stockings before getting out of bed in the morning. 3 Ensure that the cuff of the stockings reaches the middle of the knees. 4 Substitute elastic bandages for compression stockings if they are more comfortable

2 To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position, before getting out of bed in the morning. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs. Knee-high stockings should end 2 inches (5.1 cm) below the knee to avoid popliteal pressure, which limits venous return. Stockings apply uniform pressure. Elastic bandages may slip or develop wrinkles, creating uneven pressure and constriction; edema may result.

When suctioning a client with a tracheostomy, which nursing intervention is correct? 1 Hyperventilate the client with room air before suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter

2 Use of suction on withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should be inserted only approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis? 1 Assessing the nail beds 2 Listening to breath sounds 3 Monitoring breathing status 4 Checking muscle contractions

3 The nursing priority for preventing complications when caring for clients with respiratory acidosis is to monitor breathing status hourly and intervening changes. Assessing the nail beds for cyanosis, which is usually a late finding in acidosis, is not a priority intervention. Listening to breath sounds and assessing how easily air moves into and out of the lungs can be a second priority intervention. Checking muscle contractions in the neck region is a later priority intervention.

Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis? 1 Wear snug-fitting pants. 2 Sit with the knees flexed. 3 Apply warm soaks to the legs daily. 4 Put on compression stockings before arising

4 Donning compression stockings before getting out of bed provides support and promotes venous return; applying stockings while the legs are horizontal ensures that the stockings are in place before dependent edema occurs. Wearing snug-fitting pants will cause constriction that will may decrease venous return and increase venous thrombus risk. Sitting with the knees flexed promotes venous stasis and the formation of venous thrombus. Warm soaks resolve inflammation; they do not prevent the development of thrombophlebitis.

A health care provider prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which advice is important for the nurse to teach when the client initially takes the medication? 1 Take the medication with breakfast. 2 Have liver function tests every 6 months. 3 Wear sunscreen to prevent photosensitivity reactions. 4 Inform the health care provider if you wish to become pregnant.

4 Simvastatin is a teratogen that is contraindicated in pregnancy because it is capable of causing fetal damage. Simvastatin should be taken in the evening because most cholesterol is synthesized between midnight and 3:00 AM. Liver function tests should be done at 6 to 12 weeks initially and only then every 6 months. Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence, and this is not as important.

what is measured for acidosis and alkalosis

HCO3 and pH

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

rhonchi

warm extremities and thick hardened skin is found in

venous disease

PO2 norm?

80-100 mmHg

After the nurse has finished teaching a 50-year-old female client about symptoms of coronary artery disease in women, which statement indicates that the teaching has been effective? 1 "I don't need to worry about symptoms like chest pain or pressure." 2 "I will call my health care provider about any unusual fatigue." 3 "Women have less risk of death from heart disease than men." 4 "Bad cholesterol levels are usually higher in women than in men.

2

When a client has venous insufficiency, which finding by the nurse will be of most concern? 1 Bilateral brown lower leg discoloration 2 Calf pain when the feet are dorsiflexed 3 Severe edema from ankles to calves 4 Thickened and dry skin on lower legs

2 Calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptom of possible venous thrombosis and would require further diagnostic testing and treatment. Bilateral brown lower leg discoloration is a common symptom of chronic edema caused by venous insufficiency and would be expected in this client. Severe edema is a common and expected symptom of venous insufficiency and may require actions such as leg elevation, but is not as concerning as a positive Homans sign. Thick and dry skin is common in chronic venous insufficiency and the nurse will plan to use lubricating ointment, but is not as big a concern as a possible venous thrombosis.

When a client with chronic obstructive pulmonary disease (COPD) reports a 5-lb (2.3-kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? 1 Polycythemia 2 Cor pulmonale 3 Compensated acidosis 4 Left ventricular failure

2

When caring for a client with emphysema who becomes more restless, which action would the nurse take first? 1 Auscultate lung sounds. 2 Check oxygen saturation. 3 Observe for increased respiratory effort. 4 Ask about any increased shortness of breath

2

Which information will the nurse include when explaining the planned sclerotherapy to a client with varicose veins? 1 "The solution causes the vein to scar and collapse." 2 "The procedure cleans out plaque from within the vein." 3 "The solution connects superficial veins to deeper veins." 4 "The procedure allows placement of an umbrella filter in the vein."

1

Which statement explains why metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products

1 Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain a nothing-by-mouth (NPO) status

2 For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? 1 Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. 2 Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. 3 Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. 4 Assist the client in assuming a position of comfort and perform postural drainage.

3

A client is admitted with metabolic acidosis. Which two body systems would the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine

3 Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

3 Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysisis the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

A client with chronic obstructive pulmonary disease (COPD) receives information about a rehabilitation plan. To decrease hospital admissions and to live a more active life, which instruction would the nurse provide to the client? 1 Initiate activities to eliminate infection. 2 Inhale during movements that require energy. 3 Implement breathing that uses the thoracic muscles. 4 Incorporate humidification into the home environment

4

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? 1 Count the pulse at another site. 2 Notify the primary health care provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.

4

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort? 1 Side-lying with head elevated 45 degrees 2 Sims with head elevated 90 degrees 3 Semi-Fowler with legs elevated 4 High Fowler using the bedside table to rest the arms

4 The high-Fowler position elevates the clavicles and helps the lungs expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? 1 The partial pressure of oxygen (PO2) value is 80 mm Hg. 2 The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. 3 The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). 4 Serum potassium value is 4 mEq/L (4 mmol/L)

3

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? 1 Cyanosis 2 Bradycardia 3 Mental confusion 4 Distended neck veins

3 Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? Select all that apply. One, some, or all responses may be correct. 1 Using hydrogen peroxide 2 Inserting a catheter without suction 3 Placing the client in the recumbent position 4 Rinsing the inner cannula with normal saline 5 Changing both tracheostomy ties at same time

4 When removing the inner cannula, it must be rinsed with normal saline. A- Hydrogen peroxide Is only used if an infection is present. B- A catheter is inserted into the cannula when suctioning. C- The client would be placed in the semi-Fowler position. E- The nurse would change one tracheostomy tie at a time to ensure that the cannula stays in place.

Which reason would the nurse document as "nonadherence" for the client not adhering to the prescribed antibiotic therapy? 1 "I skipped some doses because I just don't like to take pills." 2 "I left my pills in the bedroom and I forgot to take them with breakfast." 3 "I saw all the side effects on television and decided to not take the pills." 4 "I had to choose between getting my prescription filled and paying the heating bill."

2 Nonadherence is accidental failure to take a medication. Noncompliance is deliberately failing to take a medication as might be done when skipping doses because of not liking to take pills, choosing to not take a medication because of information seen on television, or not being able to afford medication.

When a client with emphysema who smokes 2 packs of cigarettes per day is attempting to quit smoking, which action would the nurse take first? 1 Suggest that the client cut back to 1 pack per day. 2 Refer the client to a tobacco-cessation program. 3 Ask the client about previous attempts at tobacco cessation. 4 Suggest that the client use medication to assist with quitting

3

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which question when completing the initial assessment? 1 "Does walking for long periods of time increase your pain?" 2 "Does standing without moving decrease your pain?" 3 "Have you had your potassium level checked recently?" 4 "Have you had any broken bones in your lower extremities?"

1

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best? 1 "Tell me about your typical day before you were diagnosed with chronic lung disease." 2 "Smoking and not doing the exercises will make your lung disease continue to get worse." 3 "I can't make you stop doing what you are doing, and it's your choice to be sick or well." 4 "Your shortness of breath is probably because of your smoking and not doing the exercises."

1 Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences.

After the nurse teaches a client with coronary artery disease about healthy food choices, which dietary choices by the client indicate that the teaching was effective? Select all that apply. One, some, or all responses may be correct. 1 Olive oil 2 Whole milk 3 Whole-grain bread 4 Vegetables and fruits 5 Red meats, such as beef 6 Liver and other glandular organ meats

1 3 4 Olive oil is an unsaturated fat, which is a healthy choice. Whole-grain bread is high in soluble fiber, which may lower the risk for heart disease. Vegetables and fruits are low in fat and high in soluble fiber, thus lowering risk for heart disease. Whole milk is high in saturated fats, and low-fat or nonfat milk are recommended. Red meats are high in saturated fats and should be limited. Liver and other glandular meats are high in saturated fats and cholesterol and should be limited or avoided.

Which dietary choices would the nurse teach for the client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct. 1 Limit salt intake. 2 Choose foods high in calcium. 3 Eat whole-grain breads. 4 Use liquid vegetable oils. 5 Reduce fresh fruits and vegetables. 6 Avoid processed meats

1 3 4 6 Because peripheral arterial disease is caused by atherosclerosis, the nurse would teach the client heart-healthy diet principles such as limiting salt, eating more whole grains, using liquid rather than solid oils in cooking, and avoiding processed meats. High calcium intake does not prevent atherosclerosis. Intake of fresh fruits and vegetables would be increased because these will help lower atherosclerosis risk.

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? 1 Giving influenza vaccine to the client 2 Having suction available during meals 3 Assisting the client to take deep breaths 4 Teaching about incentive spirometer use

2 Because a client with difficulty swallowing is at risk for aspiration, having suction available will be the most effective intervention in preventing aspiration pneumonia. Giving the influenza vaccine is important in preventing viral pneumonia, but would not help prevent aspiration. Deep breathing is important to prevent atelectasis, but would not prevent aspiration pneumonia. Incentive spirometer use is important in preventing atelectasis, but not helpful in preventing aspiration.

A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function? 1 Blood clotting 2 Bone formation 3 Muscle contraction 4 Cellular membrane structure

4 Cholesterol is an essential structural and functional component of most cellular membranes. The fact that it is associated with atherosclerotic plaques does not detract from its essential functions. Cholesterol is not necessary for blood clotting; calcium and vitamin K are. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are.

Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? Select all that apply. One, some, or all responses may be correct. 1 Level of orientation 2 Arterial blood gases 3 Bilateral lung sounds 4 Complete blood count 5 Pulmonary function test

2 Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs. Pulmonary function tests are used to diagnose pulmonary disorders.

Which client is at an increased risk for hospital-acquired pneumonia? Select all that apply. One, some, or all responses may be correct. 1 Client who was admitted yesterday with hypoxia and fever 2 Client who has been on mechanical ventilation for 5 days 3 Client who reports being on an airplane with other sick individuals 4 Client who presents to the emergency department with cough and crackles 5 Client who was admitted to the hospital 5 days ago for abdominal pain

5 Hospital-acquired pneumonia occurs in nonintubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospital-acquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia. A client in the emergency department has not been admitted to the hospital.

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1 Oxygen saturation: 89% 2 Body temperature: 101°F 3 Blood pressure: 130/80 mm Hg 4 Respiratory rate: 26 beats/minute

1 An oxygen saturation of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

Which pathophysiological changes in the lungs occur with emphysema? Select all that apply. One, some, or all responses may be correct. 1 Collapse of alveolar walls 2 Trapping of air in distal lung structures 3 Increases in pulmonary artery pressures 4 Increase in surface area for gas exchange 5 Movement of fluid from capillaries into alveoli

1 2 3 Destruction of alveolar walls in emphysema leads to alveolar wall collapse and trapping of air in distal lung structures, leading to poor gas exchange. Chronic hypoxemia causes pulmonary hypertension. As alveolar walls collapse, less surface area is available for gas exchange. The alveoli do not become filled with fluid in emphysema. Left-sided heart failure causes pulmonary congestion with fluid-filled alveoli.

Which findings would the nurse expect when assessing a client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct. 1 Pallor of feet 2 Warm extremities 3 Ulcers on the toes 4 Thick, hardened skin 5 Delayed capillary refill

1 3 5 Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool skin, and capillary refill longer than 3 seconds.

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child?" b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."

b. Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences

A client with a history of smoking is suspected of having depression and is prescribed a medication that treats depression and aids in smoking cessation. Which adverse effects would the nurse suspect in this client? Select all that apply. One, some, or all responses may be correct.

1 Asthenia 2 Confusion 3 Tachycardia 4 Constipation 5 Increased appetite 2 3 Bupropion is used to treat depression and aid in smoking cessation. The nurse would suspect confusion and tachycardia in a client who is prescribed bupropion. Mirtazapine is indicated for the treatment of depression. Asthenia, constipation, and increased appetite are adverse effects associated with mirtazapine.

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. 1 Suction the client before starting tracheostomy care. 2 Use sterile technique when cleaning the inner cannula. 3 Use sterile cotton-tipped swabs to clean the inner cannula. 4 Don sterile gloves before removing the inner cannula. 5 Use hydrogen peroxide to clean the skin around the stoma.

2 4 Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. Sterile gloves are worn when removing the inner cannula. There is no need to suction the client before starting tracheostomy care, although the client may be preoxygenated before removing the inner cannula. A brush is used to clean the inner cannula. Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.