Fundamentals Of Nursing NCLEX Quiz 18

Explanation
Heat increases the skin surface temperature. promoting vasodilation. which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction. which decreases blood flow to the area. Both heat and cold relax muscles and thus minimize muscle spasms. There is no advantage to using heat over cold. (option 1). Heat does not prevent hemorrhage; heat causes vasodilation. which promotes hemorrhage (option 2). Both heat and cold can reduce discomfort. Cold reduces discomfort by numbing the area. slowing the transmission of pain impulses. and increasing the pain threshold. Heat reduces the discomfort by relaxing the muscles (option 4).

Explanation
Implementing the practitioners order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. Option 1: These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. Option 3: These are appropriate interventions for a patient with cystic fibrosis cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick. tenacious secretions in the respiratory system that block the bronchioles. creating breathing difficulties. Option 4: These are appropriate interventions for a patient with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.

Explanation
Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs. which prolongs exhalation and maintains positive airway pressure. thereby maintaining an open airway and preventing airway collapse. Deep breathing and huff coughing. not pursed lip breathing. stimulate effective coughing (option 1). Pursed lip breathing increases. not decreases intrathoracic pressure (option 3). The huff coughing stimulates the natural cough reflex and is effective for clearing the central air ways of sputum. Saying the word huff with short forceful exhalations keeps the glottis open. mobilizes sputum. and stimulates a cough (option 4).

Explanation
When a person is choking on food. the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction. the person will be able to make sounds because some air can pass from the lungs through the vocal chords. In this situation the person’s own efforts open parentheses gagging and coughing) should be allowed to clear the airway. With a total airway obstruction. the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver). Thrusts to the xiphoid process may cause a fracture that may result in a pneumothorax (option 1).

Explanation
Restlessness. tachypnea. and pallor are early manifestations of hypoxemia. along with tachycardia. elevated blood pressure. use of accessory muscles. nasal flaring. tracheal tugging. and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia. along with stupor. cyanotic skin and mucous membranes. bradypnea. hypotension. and cardiac dysrhythmias.

Explanation
The priority action the nurse should take when using the airway. breathing. circulation approach to care delivery is to relieve the clients dyspnea. Fowler’s position facilitates maximal long expansion and thus optimizing breathing. With the client in this position. the nurse can better assess and determine the cause of the clients dyspnea. Option 1: The client may need more oxygen. as hypoxemia may be the cause of his difficulty breathing. However. administering oxygen and adjusting the fraction of inspired oxygen requires the providers prescription after a careful assessment of the clients oxygenation status. there is a higher priority given the nature of the client’s distress. Option 3: The client may need suction or expectoration. as pulmonary secretions may be the cause of his difficulty breathing. However. there is a higher priority given the nature of the client’s distress. Option 4: It is important to check the clients oxygenation status. and in many nursing situations. assessment precedes action. but there is a higher priority given the nature of the client’s distress.

Explanation
The nurse should apply suction pressure only while withdrawing the catheter. not while inserting it. The nurse should not reuse the suction catheter unless an in-line suctioning system is in place. To prevent hypoxemia. the nurse should limit each section in session to 2 to 3 attempts and allow at least one minute between passes for ventilation and oxygenation. The nurse should not suction routinely because suctioning is not without risk. It can cause mucosal damage. bleeding. and bronchospasm. Endotracheal suctioning requires surgical asepsis.

Explanation
The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. Option 3 helps move mucus and contaminated material away from the stoma for easy removal. Option 4: To help keep the skin clean and dry. the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgment with replacing the ties. so he should not replace them routinely. Option 5: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate.

Explanation
All other options are indicated of fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit.

Explanation
Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options one. three. and four. assessment is needed initially.