S2T4 Giddens evolve questions

The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give? 1 Prevents complications that are associated with COPD 2 Relieves shortness of breath by increasing the breath rate 3 Increases the amount of air that the client can inhale with each breath 4 Keeps the airway open longer to decrease the work that goes into breathing

4

what is indicative of hypoxemia

clubbing of nails

pulmonary edema

fluid in the air sacs and bronchioles

dysmenorrhea

painful menstruation

ischemia

Lack of blood supply

pleural effusion

abnormal accumulation of fluid in the pleural space

After abdominal surgery, a client's postoperative prescriptions include a nasogastric (NG) tube to lower intermittent wall suction and an antiemetic every 6 hours as needed for nausea. When the client reports feeling nauseated, which action would the nurse take first? 1 Check for correct placement of the NG tube. 2 Administer the prescribed antiemetic. 3 Assess the client's bowel sounds. 4 Notify the primary health care provider

1 With a nasogastric (NG) tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking its placement can determine whether it is in the stomach; once placement is verified, fluid then can be instilled to ensure patency. The antiemetic may relieve the discomfort, but it will not determine the cause.

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. One, some, or all responses may be correct. 1 Confusion 2 Hypocapnia 3 Tachycardia 4 Constricted pupils 5 Slow respiratory rate

1 2 3 Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.

A client is hospitalized with emphysema. The nurse recognizes the importance of assessing for clinical indicators of hypoxia based on which condition associated with the disease? 1 Pleural effusion 2 Infectious obstructions 3 Loss of aerating surface 4 Respiratory muscle paralysis

3

A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. Which symptom would the client be likely to state as a reason that she is having surgery? 1 Hematuria 2 Dysmenorrhea 3 Pain on urination 4 Stress incontinence

4 Increased intra-abdominal pressure associated with lifting, coughing, or laughing, in conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, may result in stress incontinence.

dialysis

a procedure to remove waste products from the blood of patients whose kidneys no longer function

Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? 1 Encourage frequent coughing. 2 Elevate the client's lower extremities. 3 Prepare for modified postural drainage. 4 Place the client in the orthopneic position

4 The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Coughing is useful for clients who have excessive mucus in the airways, such as clients with pneumonia, but is not useful for clearing pulmonary edema.

Vancomycin

antibiotic

Flow rate of nasal cannula

1-6 L/min

subcutaneous emphysema

A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.

hematuria

blood in the urine

A client with a continuous intravenous (IV) heparin drip is prescribed IV vancomycin every 12 hours. Which action will the nurse take when it is time to administer the vancomycin? 1 Stop the heparin, flush the line with normal saline, and administer the vancomycin. 2 Administer the vancomycin into the heparin line using an IV piggyback set. 3 Start a second IV line for the vancomycin and continue the heparin as prescribed. 4 Hold the vancomycin and tell the health care provider that the medication is incompatible with heparin.

3 The vancomycin and heparin are incompatible in the same IV and must be administered separately.

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, which is the next nursing action? 1 Feeding the infant 2 Requesting a complete blood count 3 Monitoring the infant for hyperthermia 4 Allowing the infant to rest undisturbed

1 A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. The blood count will not change during a transient hypothermic episode. If the hypothermic period is treated adequately, hyperthermia is not expected to develop. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.

Which physiologic responses to bronchiolitis would the nurse expect to observe in the pediatric intensive care unit? Select all that apply. One, some, or all responses may be correct. 1 Wheezing 2 Bradycardia 3 Sternal retractions 4 Nasal flaring 5 Prolonged expiratory phase

1 3 4 5

Which action would the nurse take first when a client who is receiving peritoneal dialysis reports difficulty breathing after instillation of dialysate into the peritoneal space? 1 Weigh the client. 2 Check pulse oximetry. 3 Auscultate lung sounds. 4 Reposition the client

2 Pulse oximetry will assess for adequate oxygen saturation and would be done first because a low saturation would indicate the need for rapid implementation of actions such as oxygen administration and notification of the health care provider. Weighing the client would help in determining fluid overload but would be done after assuring adequate oxygen saturation. The lung sounds would be auscultated to see if the client has fluid overload or whether the dialysate infusion is decreasing room for lung expansion, but can be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is decreasing the ability of the lungs to expand, the client can be repositioned to allow better lung expansion.

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? 1 Answer the client's call light immediately to prevent incontinence. 2 Place a waterproof pad under the client to prevent soiling the linens. 3 Check the client's buttocks at least every 2 hours and clean after incontinence. 4 Offer toileting to the client every 2 hours to prevent incontinence.

3 Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool.

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client reports the need to urinate. What would the nurse do first? 1 Encourage the client to drink fluids. 2 Review the client's intake and output. 3 Assess that the tubing attached to the collection bag is patent. 4 Explain that the balloon inflated in the bladder causes this feeling.

3 The drainage tubing may be obstructed. Retained fluid raises bladder pressure, causing discomfort similar to the urge to void.

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? 1 Losing weight over the past week 2 Tingling in the upper extremities 3 Using several pillows at night to sleep 4 Wheezing when exposed to dust or pollen

3 causes pulmonary congestion so HOB needs to be elevated

The nurse provides teaching to a client who is being discharged after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor for which indication of right-sided heart failure? 1 Increased appetite 2 Clubbing of the nail beds 3 Hypertension 4 Weight gain

4 The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites

Venturi mask

A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air.

Tuberculosis

An infectious disease that may affect almost all tissues of the body, especially the lungs

Polycythemia is associated with

COPD A disorder characterized by an abnormal increase in the number of red blood cells in the blood

what is associated with left sided heart failure

hypertension

Bronchiolotis

inflammation of the bronchioles

peritoneal dialysis

the lining of the peritoneal cavity acts as the filter to remove waste from the blood

Which action would the nurse take first when a client with acute bronchitis and emphysema reports feeling anxious and short of breath? 1 Obtain the oxygen saturation. 2 Provide oxygen at 2 L per minute. 3 Offer the prescribed rescue inhaler. 4 Suggest use of pursed-lip breathing

1 More assessment is needed before further actions are taken; the nurse would check the client's oxygen saturation as the initial action. If oxygen saturation is low, then oxygen administration would be needed. The rescue inhaler may be needed if the client has wheezes or decreased breath sounds. Pursed-lip breathing may be helpful if anxiety is causing hyperventilation, but the first action would be to assure that the client is not hypoxemic.

When the nurse in the postanesthesia care unit is caring for a client who had major abdominal surgery, which finding may indicate postoperative bleeding? 1 Oliguria 2 Bradypnea 3 Pulse deficit 4 Hypoglycemia

1 - scanty urination Bleeding leads to poor renal perfusion and compensatory mechanisms that cause sodium and water retention, leading to decreased urine output.

Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct. 1 Floss twice daily to prevent the need for dental work. 2 Avoid eating hot food or liquid that can burn the mouth. 3 Use an electric shaver instead of a straight-bladed razor. 4 Apply ice to any areas of trauma like bumps and scrapes. 5 Use enemas to prevent straining during bowel movements.

2 3 4 The goal of self-care for clients on anticoagulation therapy is to prevent bleeding. Clients should avoid eating hot food or liquid, which can burn the mouth, disrupt the mucous membrane, and encourage bleeding. Clients should use an electric shaver instead of a straight-bladed razor to avoid cuts. Clients should be instructed to apply ice to any areas of trauma, such as bumps and scrapes, to slow blood flow and minimize bleeding.

The nurse providing care for a client admitted to the psychiatric unit with a bipolar disorder strives to provide adequate nutrition during the client's manic phase. Which statement explains the challenge of meeting this client's nutritional needs? 1 The client is too depressed to eat. 2 The client lacks the energy to eat. 3 The client is too busy keeping active to eat. 4 The client is on a restricted diet, limiting cheese. 5 The client is unable to eat favorite foods.

3 The client is too busy keeping active during the manic part of a bipolar disorder. This stage's characteristics include elation, activity, restlessness, and increased energy. Although the client may be using more calories than usual during this period, food is not a priority, and the client will not spend the time to eat. The nurse would need to suggest finger foods and high-calorie snacks.

When the oxygen saturation of a client with pneumonia is at 89% to 90% while using a nonrebreather mask, which collaborative action would the nurse anticipate? 1 Administration of oxygen using a simple face mask 2 Use of a Venturi mask for administration of high-flow oxygen 3 Continued oxygen administration with the nonrebreather mask 4 Oxygen administration with bi-level positive airway pressure (BiPAP)

4 The client's oxygen saturation is low even with the fraction of inspired oxygen (FiO2) levels of up to 95% that can be administered with a nonrebreather mask, and another method of oxygen administration is needed. BiPAP adds positive pressure during inspiration to oxygen administration, decreasing some of the work of breathing and improving tidal volumes and gas exchange without some of the risks that are associated with intubation and mechanical ventilation. The FiO2 levels of 40% to 60% that can be delivered by a simple face mask are adequate to improve oxygenation for this client. A Venturi mask can provide FiO2 levels of up to 50%, which is less than the client is already receiving.

A client is admitted to the emergency department with profuse vomiting, bright red in color. Which intervention would the nurse identify as the priority? 1 Begin gastric lavage. 2 Obtain stool for occult blood. 3 Ascertain the client's eating habits. 4 Draw blood for typing and crossmatching

4 Immediate blood replacement is indicated. A type and crossmatch will ensure that the correct blood type will be administered to the client, preventing a transfusion reaction. Beginning gastric lavage is not the priority, although it may be done later. Obtaining a stool for an occult blood test is not the priority, although it may be done later. Ascertaining the client's eating habits is not the priority, although it may be done later when completing an admission history and physical.

Which action would the nurse plan for a client during the early postoperative period after a prostatectomy? 1 Have the client stand to void. 2 Discourage straining for a bowel movement. 3 Use a bulb syringe to aspirate urine from the retention catheter. 4 Notify the primary health care provider if the client does not void by bedtime.

2 Straining applies pressure to the operative site, which can precipitate bleeding and should be avoided. A retention catheter is routinely put into place, so standing to void and not voiding by bedtime are not applicable. To prevent trauma, negative pressure should not be exerted on the bladder by using a bulb syringe to aspirate.

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. The nurse concludes that which condition is the most likely cause of the pleural effusion? 1 Excessive fluid intake 2 Inadequate chest expansion 3 Extension of cancerous lesions 4 Irritation from the bronchoscopy

3 Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output

A client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output? 1 Increased serum glucose 2 Deficient renal perfusion 3 Inadequate antidiuretic hormone (ADH) secretion 4 Excess amounts of intravenous (IV) fluid

3 Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced.

In which medical conditions would the nurse expect the client's chloride levels in the 24-hour urine sample test to increase? Select all that apply. One, some, or all responses may be correct. 1 Heart failure 2 Emphysema 3 Hypokalemia 4 Pyloric obstruction 5 Adrenal insufficiency

3 5 Generally, hypokalemia and adrenal insufficiency are associated with increased levels of chloride detected in the 24-hour urine sample test. Conditions such as heart failure, emphysema, and pyloric obstruction result in a decrease in the serum sodium levels.