Respiratory Disorders (Part 2)

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1. A client who has been hospitalized for treatment of a pneumothoraxis ready for discharge. Which outcome indicates that the client has adequate respiratory function?

Explanation

RATIONALE: A respiratory rate of 12 to 20 breaths/minute is a normal finding, indicating adequate respiratory function. Orthopneic breathing, accessory muscle use, and bilateral cracklesindicate an interference with respiratory function.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. p. 571. Philadelphia: Lippincott Williams & Wilkins, 2008.

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About This Quiz
Respiratory Disorders (Part 2) - Quiz

As a medical practitioner, proper diagnosis of a respiratory disorder will lead to giving the correct care and medication to a patient. Are you studying to be or... see morepracticing as a medical practitioner? Take the quiz below and see how conversant you are with issues regarding the respiratory disorders. Good luck! see less

2. A client with Guillain-Barré syndromedevelopsrespiratory acidosisas a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

Explanation

RATIONALE: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2value of 30 mm Hg indicatesrespiratory alkalosis. A ph value of 7.40 with a PaCO2value of 35 mm Hg and a pH value of 7.35 with a PaCO2value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE:Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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3. A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

Explanation

RATIONALE: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging him to perform ADLs, and preventing him from developing an infectionare important to the client's well-being but not as important as having sufficient oxygen to breathe.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 739.

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4. A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?

Explanation

RATIONALE: A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothoraxor bleeding. An oxygen saturation level of 96% on 3 L of oxygen, a pain level of 7 out of 10 that decreases with pain medication, and dozing when left alone are normal and don't require further intervention.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 585.

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5. A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Explanation

RATIONALE: A patent airway and an adequate breathing pattern are the top priority for any client, making Impaired gas exchange related to airflow obstructionthe most important nursing diagnosis. AlthoughActivity intolerance, Anxiety,andRisk for infectionmay also apply to this client, they aren't as important asImpaired gas exchange.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 696.

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6. A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Explanation

RATIONALE: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2value. Based on the PaO2value, the nurse may adjust the type of oxygen delivery (cannula,Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3–, and PaCO2

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 724.

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7. A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Explanation

RATIONALE: Impaired gas exchangeshould be the nurse's first priority. After ensuring that the client has adequate gas exchange, she can address the other diagnoses ofAnxiety,Impaired physical mobility,andDeficient knowledge: Home Care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 771.

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8. A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?

Explanation

RATIONALE: Although all of these nursing diagnoses are appropriate for this client, Ineffective breathing patterntakes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 664.

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9. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Explanation

RATIONALE: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 752.

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10. A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?

Explanation

RATIONALE: Pneumoniais the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterialinfection. Other complications of influenza include myositis,exacerbationofchronic obstructive pulmonary disease, andReye's syndrome. Myocarditis,pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis andpulmonary edemaaren't associated with influenza.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2488.

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11. A nurse is caring for a client experiencing an acute asthmaattack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

Explanation

RATIONALE: During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Cracklesdon't replace wheezes during an acute asthma attack.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 711.

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12. When a client's ventilation is impaired, the body retains which substance?

Explanation

RATIONALE: When ventilation is impaired, the body retains CO2because the carbonic acid level increases in the blood. Sodium bicarbonate is used to treat acidosis. Nitrous oxide, which hasanalgesicand anesthetic properties, commonly is administered before minor surgical procedures. When ventilation is impaired, the body doesn't retain oxygen. Instead, the tissues use oxygen and CO2results.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 336.

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13. A nurse preparing to administer medications on the respiratory floor is using the computerized medication-dispensing system. Her password isn't working. The nurse should:

Explanation

RATIONALE: The nurse should have computer support reset her password. A nurse should never give her password to anyone. It's inappropriate for the nurse to delegate medication administration to a nursing assistant. The nurse shouldn't override the machine to dispense the medications; doing so is unsafe and could cause medication errors.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 564.

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14. A nurse is planning postoperative care for a client who has received general anesthesia. During the immediate postoperative period, which nursing activity takes the highest priority?

Explanation

RATIONALE: The nurse's first priority for the postoperative client is to maintain a patent airway because lack of a patent airway is rapidly fatal. The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 291.

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15. A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

Explanation

RATIONALE: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be ordered. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompanydiabetes mellitus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p.1177.

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16. A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder?

Explanation

RATIONALE: This client's pH value is below normal, indicating acidosis. The HCO3–value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggestsmetabolic acidosis. The PaCO2value is normal, indicating absence of respiratory compensation. These ABG values eliminaterespiratory alkalosis,respiratory acidosis, andmetabolic alkalosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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17. A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

Explanation

RATIONALE: A 10-mm indurationstrongly suggests a positive response in thistuberculosisscreening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

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18. A client undergoes a tracheostomyafter many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Explanation

RATIONALE: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 739.

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19. A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Explanation

RATIONALE: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 692.

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20. A client who just emigrated from Mexico is admitted with tuberculosis. The client explains to the nurse through an interpreter that he's concerned about paying for his medications after discharge. The nurse should collaborate with which health care team member about the client's financial concerns?

Explanation

RATIONALE: The nurse should collaborate with the social worker about the client's financial concerns. This collaboration can be done independently without a physician's order. The physician must notify the public health department of the client's diagnosis, but a public health worker doesn't get involved with the client's financial concerns. The physician and home health nurse aren't typically involved with the client's financial concerns until after the client is discharged.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

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21. A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?

Explanation

RATIONALE: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterialinfection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2511.

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22. A client with an exacerbation of chronic obstructive pulmonary disease(COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?

Explanation

RATIONALE: Impaired gas exchangerequires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen,nebulizertreatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist.Impaired skin integrity, Activity intolerance,andImbalanced nutrition: Less than body requirements(when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

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23. A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

Explanation

RATIONALE: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and indurationof 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

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24. A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

Explanation

RATIONALE: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2typically rises, reaching 85 to 100 mm Hg. A PaCO2of 65 mm Hg or higher is above normal and indicates CO2retention — common during the acute phase of pneumonia. Restlessness and confusion indicatehypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 640.

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25. The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Explanation

RATIONALE: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 582.

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26. A client has undergone a left hemicolectomyfor bowel cancer. Which activities prevent the occurrence of postoperativepneumoniain this client?

Explanation

RATIONALE: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 627.

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27. A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:

Explanation

RATIONALE: After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Bickley, L.S. Bates' Guide to Physical Examination and History Taking,9th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 202.

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28. A client with chronic obstructive pulmonary disease(COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

Explanation

RATIONALE: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space).Pulmonary edemausually results from left-sidedheart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 707.

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29. Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

Explanation

RATIONALE: The RN may safely delegate assistance with eating to the nursing assistant. An RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring nasotracheal suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 323.

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30. To prevent oral complications when using a metered-dose inhaler, a nurse should instruct the client to:

Explanation

RATIONALE: To prevent mouth sores, the nurse should teach the client to rinse his mouth after using a metered-dose inhaler. Keeping the head of the bed at a 30-degree angle, using the inhaler before meals, and using the inhaler as needed aren't appropriate considerations.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 809.

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31. A physician orders home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use?

Explanation

RATIONALE: The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is responsible only for coordinating the services. The hospital staff nurse and physician don't observe the client in the home, so they can't adequately evaluate the client's knowledge of home oxygen use.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

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32. When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Explanation

RATIONALE: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, andhypoxemia. The nurse should focus on resolving these problems.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 656.

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33. For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour?

Explanation

RATIONALE: The nurse should administer 22 ml/hour. To determine the number of units per milliliter: 25,000 units of heparin divided by 50 units/ml equals 500 ml of fluid. Because each milliliter of D5W contains 50 units of heparin and the nurse must deliver 1,100 units/hour, perform this calculation to determine the milliliters per hour of I.V. solution flow: 1,100 units/hour ÷ 50 units/ml = 22 ml/hour.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology,4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

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34. A physician orders prednisone (Deltasone) to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

Explanation

RATIONALE: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology,4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 564.

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35. A client with chronic obstructive pulmonary disease(COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

Explanation

RATIONALE: The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failureor cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 704.

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36. A client with chronic obstructive pulmonary disease(COPD) is admitted to an acute care facility because of an acute respiratoryinfection. When assessing the client's respiratory status, which finding should the nurse anticipate?

Explanation

RATIONALE: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 689.

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37. A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

Explanation

RATIONALE: Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothoraxwill have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 760.

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38. A client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician, who instructs her to change the dosage to 0.45 mg/kg/hour. The nurse should:

Explanation

RATIONALE: The nurse should question the order because the dosage is too low. A therapeutic theophylline level is 10 to 20 mcg/ml. The client is currently receiving 0.5 mg/kg/hour of aminophylline. Because the client's theophylline level is sub-therapeutic, reducing the dose (which is what the physician's order would do) would be inappropriate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1225.

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39. For a client with impaired gas exchange, which position is best?

Explanation

RATIONALE: For a client with impaired gas exchange, high Fowler's positionis the best position because it allows maximal chest expansion. If the client can't tolerate high Fowler's position, semi-Fowler's is the next best choice because it increases comfort and allows chest expansion. The lateral decubitus and supine positions don't promote chest expansion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1620.

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40. A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Explanation

RATIONALE: The client with respiratory alkalosis may complain of light-headedness or paresthesia(numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompanyrespiratory acidosis.Hallucinationsand tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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41. A nurse is teaching a client with chronic bronchitisabout breathing exercises. Which instruction should the nurse include in the teaching?

Explanation

RATIONALE: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 494.

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42. A client who has started therapy for drug-resistant tuberculosisdemonstrates understanding of tuberculosis transmission when he says:

Explanation

RATIONALE: A client with drug-resistant tuberculosis isn't contagious when he's had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce negative acid-fast test results for several days. The client won't have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they don't indicate whether the client is contagious.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

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43. A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3–), 24 mEq/L. Based on these values, the nurse suspects:

Explanation

RATIONALE: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2value indicates acid loss via hyperventilation; this type of acid loss occurs only inrespiratory alkalosis. These ABG values wouldn't occur inmetabolic acidosis,respiratory acidosis, ormetabolic alkalosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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44. On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

Explanation

RATIONALE: Hypotension, hypothermia, and vasoconstrictionmay alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere withinterpretationof SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever,tachypnea, andtachycardiadon't affect pulse oximetry values directly.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 579.

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45. A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

Explanation

RATIONALE: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 604.

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46. After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Explanation

RATIONALE: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 600.

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47. For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Explanation

RATIONALE: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 759.

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48. A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal?

Explanation

RATIONALE: As suggested by the ABCs of cardiopulmonary resuscitation— airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation. Although maintaining an adequate circulatory volume, reducing anxiety, and relieving pain are pertinent for this client, they're secondary to maintaining effective respirations.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 291.

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49. A client with asthmais receiving a theophylline (Uniphyl) preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

Explanation

RATIONALE: The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1225.

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50. A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

Explanation

RATIONALE: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation.COPDrefers to a group of chronic diseases, including bronchialasthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 657.

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51. During inspiration, which action occurs?

Explanation

RATIONALE: During inspiration, inspiratory muscles contract, the diaphragm descends, alveolar pressure is negative, and air moves into the lungs. The lungs recoil during expiration.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1606.

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52. Which performance improvement strategy helps prevent adverse reactions to blood products?

Explanation

RATIONALE: The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 635.

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53. Which assessment finding puts a client at increased risk for epistaxis?

Explanation

RATIONALE: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 605.

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54. Which task may be safely delegated to a licensed practical nurse (LPN)?

Explanation

RATIONALE: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 323.

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55. A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Explanation

RATIONALE: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces aproductive coughand fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratoryinfectionsuch as pneumonia.Hemoptysisanddysuriaaren't associated with pneumonia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 636.

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56. A client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination. When percussing the client's chest wall, the nurse expects to elicit:

Explanation

RATIONALE: When percussing the chest wall of a client with allergy-induced asthma, the nurse should expect to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as fromconsolidationor a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 76.

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57. A client is experiencing dryness in the nares while receiving oxygen via nasal cannulaat 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

Explanation

RATIONALE: Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares. Petroleum jelly is combustible; it isn't safe to use with oxygen. The nurse shouldn't use sterile water or antibiotic ointment to alleviate dryness in the nares.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 851.

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58. A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventinginfection. Which finding indicates that this outcome has been met?

Explanation

RATIONALE: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 700.

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59. A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Explanation

RATIONALE: Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 745.

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60. A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

Explanation

RATIONALE: Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds. Tactile fremitusis the vibration felt when the client speaks while the nurse holds her hand against his chest. Crepitation is a crackling sound heard in certain diseases such as pneumonia. Egophony is an abnormal change in tone heard when the client speaks normally as the nurse auscultates his chest.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 576.

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61. A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?

Explanation

RATIONALE: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2566.

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62. After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

Explanation

RATIONALE: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 648.

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63. A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?

Explanation

RATIONALE: As a centrally acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is an opioid, it can cause dependence.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p.357.

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64. A physician orders metaproterenol (Alupent) by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

Explanation

RATIONALE: The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever he feels out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardiais an expected adverse reaction to metaproterenol. The client should be taught how to monitor his heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 698.

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65. A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

Explanation

RATIONALE: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 344.

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66. A client presents to a physician's office complaining of dyspneawith exertion, weakness, and coughing up blood. Further examination reveals peripheral edema,crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

Explanation

RATIONALE: Dyspnea, weakness, hemoptysis, and right-sidedheart failureare all signs of pulmonary hypertension. Clients withCOPDpresent with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratoryinfectionorpneumonia. Clients with pulmonarytuberculosisusually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 659.

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67. A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease(COPD). The nurse bases her next action on the principle that:

Explanation

RATIONALE: The nurse should consider positioning when caring for a client who has COPD and difficulty breathing. Elevating the head of the bed assists these clients in breathing. There's no indication that it's necessary to intubate the client. A Foley catheter isn't indicated. Prophylactic I.V. antibiotics aren't administered with moderate sedation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 515.

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68. A client recovering from an acute asthmaattack experiencesrespiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:

Explanation

RATIONALE: A client recovering from an acute asthma attack who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). An NG tube would be indicated for a client with metabolic alkalosissecondary to ingestion of toxic substances; there is no reason to believe that this has occurred. Fever may cause metabolic (not respiratory) alkalosis and would be treated with acetaminophen. A client withsepsisalso may have metabolic alkalosis and probably would receive antibiotics; however, this clinical situation doesn't suggest sepsis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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69. After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?

Explanation

RATIONALE: Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1398.

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70. Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Explanation

RATIONALE: PEEP reduces cardiac outputby increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 745.

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71. A client with myasthenia gravisis receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Explanation

RATIONALE: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 745.

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72. A client with cystic fibrosisdevelopspneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history forasthma. Acetylcysteine must be used cautiously in a client with asthma because it:

Explanation

RATIONALE: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 103.

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73. A client has hypoxemiaof pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

Explanation

RATIONALE: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2requires positive end-expiratory pressure. In both situations, the PaCO2is elevated and the pH and HCO3–are depressed.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 655.

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74. A nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the:

Explanation

RATIONALE: The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothoraxand hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea won't shift. Tracheal deviation toward the contralateral side occurs in simplepneumothoraxwhen the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Bickley, L.S. Bates' Guide to Physical Examination and Health History,9th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 298.

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75. A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

Explanation

RATIONALE: A cough that changes in character is one of the hallmark signs of lung cancer. Low-grade fever, hoarseness, and weight loss may be attributed to other disease processes and don't necessarily indicate lung cancer.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 671.

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76. A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess:

Explanation

RATIONALE: The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say the word "ninety-nine" the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1612.

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77. A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?

Explanation

RATIONALE: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 628.

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78. A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next?

Explanation

RATIONALE: A client who's restless may be in pain and may not be able to communicate well because of the ET tube. Therefore, the nurse should assess the client and administer medication as appropriate. The nurse shouldn't apply restraints without trying less-restrictive calming measures, which may include decreasing stimulation by turning the light off or diversional activities, such as music or television. It's never appropriate for the nurse to threaten the client with restraints.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 681.

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79. A client being treated for complications of chronic obstructive pulmonary diseaseneeds to be intubated. The client has previously discussed his wish to not be intubated with his girlfriend of 5 years, whom he's designated as hishealth care power of attorney. The client's children want their father to be intubated. A nurse caring for this client knows that:

Explanation

RATIONALE: The health care power of attorney is someone who can make decisions when the client can't. Clients tend to select individuals who share their personal values and beliefs as their health care power of attorney. Family members and designated surrogates don't always agree; state laws regarding surrogate decision makers may differ. The legal rights of a health care power of attorney in regards to health care decisions supersede those of family members. The law designates the health care power of attorney as the person to make decision; violating this designation could result in a lawsuit.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 97.

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80. A client admitted to the facility for treatment for tuberculosisreceives instructions about the disease. Which statement made by the client indicates the need for further instruction?

Explanation

RATIONALE: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 648.

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81. A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Explanation

RATIONALE: Pneumothorax(air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain,dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension,cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, orheart failure.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 679.

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82. A nurse is completing her annual cardiopulmonary resuscitationtraining. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?

Explanation

RATIONALE: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2524.

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83. A home health nurse visits a client with chronic obstructive pulmonary diseasewho requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

Explanation

RATIONALE: The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a water-soluble lubricant, such as K-Y jelly, to prevent drying. Smoking is contraindicated wherever oxygen is in use; posting of a "no smoking" sign warns people against smoking in the client's house. Cleaning the mask with water two or three times per day removes secretions and decreases the risk of infection.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 726.

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84. A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Explanation

RATIONALE: In a client with a respiratory disorder, anxiety worsens such problems as dyspneaand bronchospasm. Therefore,Anxietyis a likely nursing diagnosis. This client may have inadequate nutrition, makingImbalanced nutrition: More than body requirementsan unlikely nursing diagnosis.Impaired swallowingmay occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder.Unilateral neglectmay be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 698.

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85. The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse manager should take which step to meet the needs of her staff?

Explanation

RATIONALE: The institutional ethics committee can help the staff develop strategies to resolve their ethical dilemma. The Patient's Bill of Rights states that the client (not the family) has the right to make decisions about the care plan and to refuse recommended treatment. Arranging a meeting with the client's family is inappropriate, whether or not they're in agreement with the client's wishes. The physician must comply with the client's wishes, so scheduling a meeting with the physician isn't beneficial to the staff. Reinforcing to the staff that the decision is the client's to make dismisses the staff's concerns.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 113.

Submit
86. A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary diseasewho wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?

Explanation

RATIONALE: The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 989.

Submit
87. An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?

Explanation

RATIONALE: This client is exhibiting Deficient knowledgeabout the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, his question reflects sadness at the prospect of being separated from his family rather than anxiety about the disease. Because he has just been diagnosed and hasn't had a chance to demonstratecompliance, a nursing diagnosis ofSocial isolationisn't appropriate. A diagnosis ofImpaired social interactionusually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 650.

Submit
88. A nurse recognizes that a client with tuberculosisneeds further teaching when the client states:

Explanation

RATIONALE: The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 650.

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89. A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

Explanation

RATIONALE: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 648.

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90. A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3–) 25 mEq/L. What should the nurse do first?

Explanation

RATIONALE: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2value of 60 mm Hg, which indicateshypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 664.

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91. A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear?

Explanation

RATIONALE: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Cracklescommonly accompanyatelectasis, interstitial fibrosis, and left-sidedheart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as inasthma,chronic obstructive pulmonary disease, and bronchitis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 653.

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92. A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Explanation

RATIONALE: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2ranges from 95% to 100%. Therefore, an SaO2of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 581.

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93. A client with severe acute respiratory syndromeprivately informs a nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate action by the nurse would be to:

Explanation

RATIONALE: The nurse is obligated to act as the client's advocate. The nurse shouldn't discuss the issue with the client's family unless the client gives permission. Assuring the family and client that all possible measures will be taken opposes the client's wishes and doesn't demonstrate client advocacy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 114.

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94. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2of 96% or better. The client most likely has:

Explanation

RATIONALE: SaO2is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sidedheart failure, the client would exhibit pulmonarycrackles.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 579.

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95. A client with chronic obstructive pulmonary disease(COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? Select all that apply.

Explanation

RATIONALE: Typical findings in clients with COPD include dyspneaon exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usuallytachypneicwith a prolonged expiratory phase. Fever isn't associated with COPD unless aninfectionis also present.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 689.

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96. A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next?

Explanation

RATIONALE: The incident report, also known as an unusual occurrence report,is a confidential document completed for the agency's risk-management personnel. Incident reports aren't part of the client's chart. The incident should be documented factually in the client's chart, but the documentation shouldn't mention the incident report. Incident reports shouldn't be copied for anyone.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 253.

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97. A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Explanation

RATIONALE: Ineffective airway clearanceis the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have anIneffective breathing pattern,such astachypnea,bradypnea, orCheyne-Stokes respirations.Risk for fallsandImpaired tissue integrityaren't priority diagnoses for this client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 639.

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98. Inspiratory and expiratory stridor may be heard in a client who:

Explanation

RATIONALE: Inspiratory and expiratory stridor is a low-pitched crowing sound heard in a client who has a foreign body obstructing the trachea or mainstem bronchi. Acute asthmatic attacks are characterized by wheezing. Goiter attacks and severe laryngotracheitis are associated with inspiratory stridor only.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 628.

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99. An adult client with cystic fibrosisis admitted to an acute care facility with an acute respiratoryinfection. Ordered respiratory treatment includeschest physiotherapy. When should the nurse perform this procedure?

Explanation

RATIONALE: The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 731.

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100. A client with multiple trauma and acute respiratory insufficiency is admitted to the intensive care unit. The physician orders arterial blood gas (ABG) analysis to determine the client's ventilatory and gas exchange status. Because the client's arms are in casts from above the elbow to the fingertips, the ABG sample is taken from the femoral artery. After the sample is drawn, the nurse should apply continuous pressure to the puncture site for:

Explanation

RATIONALE: After a blood sample is drawn from the femoral artery, the nurse should apply continuous pressure to the puncture site for 10 minutes to prevent bleeding. Applying pressure for shorter periods wouldn't allow enough time for clotting to occur. The radial and brachial sites require only 5 minutes of continuous pressure.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1616.

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101. A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax? Select all that apply.

Explanation

RATIONALE: Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not allowing it to escape on expiration. The air presses against the mediastinum, causing a shift to the opposite side and decreased venous return (reflected by decreased cardiac outputand hypotension). As the air presses against the mediastinum, compensatorytachycardiaandtachypneaalso occur. Decreased cardiac output may cause distended, not flattened, jugular veins.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 679.

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A client with an exacerbation of chronic obstructive pulmonary...
A nurse is administering a purified protein derivative (PPD) test to a...
A client has been hospitalized for treatment of acute bacterial...
The nurse is admitting a client who just had a bronchoscopy. Which...
A client has undergone a left hemicolectomyfor bowel cancer. Which...
A client with chronic sinusitis comes to the outpatient department...
A client with chronic obstructive pulmonary disease(COPD) is...
Which client's care may a registered nurse (RN) safely delegate to...
To prevent oral complications when using a metered-dose inhaler, a...
A physician orders home oxygen therapy for a client with pulmonary...
When caring for a client with acute respiratory failure, the nurse...
For a client with an acute pulmonary embolism, the physician orders...
A physician orders prednisone (Deltasone) to control inflammation in a...
A client with chronic obstructive pulmonary disease(COPD) and cor...
A client with chronic obstructive pulmonary disease(COPD) is admitted...
A nurse observes constant bubbling in the water-seal chamber of a...
A client who weighs 175 lb (79.4 kg) is receiving aminophylline...
For a client with impaired gas exchange, which position is best?
A client hospitalized for treatment of a pulmonary embolism develops...
A nurse is teaching a client with chronic bronchitisabout breathing...
A client who has started therapy for drug-resistant...
A client admitted with acute anxiety has the following arterial blood...
On arrival at the intensive care unit, a critically ill client suffers...
A nurse is caring for a client who has a history of sleep apnea. The...
After a tonsillectomy, a client is being prepared for discharge. The...
For a client who has a chest tube connected to a closed water-seal...
A client reports difficulty breathing and a sharp pain in the right...
A client with asthmais receiving a theophylline (Uniphyl) preparation...
A client admitted with multiple traumatic injuries receives massive...
During inspiration, which action occurs?
Which performance improvement strategy helps prevent adverse reactions...
Which assessment finding puts a client at increased risk for...
Which task may be safely delegated to a licensed practical nurse...
A nurse is assessing a client who comes to the clinic for care. Which...
A client with a history of allergy-induced asthma, hypertension, and...
A client is experiencing dryness in the nares while receiving oxygen...
A home health nurse sees a client with end-stage chronic obstructive...
A client suffers acute respiratory distress syndrome as a consequence...
A nurse is performing a respiratory assessment on a client with...
A client with suspected inhalation anthrax is admitted to the...
After diagnosing a client with pulmonary tuberculosis, the physician...
A client with lung cancer has developed an intractable, nonproductive...
A physician orders metaproterenol (Alupent) by metered-dose inhalation...
A nurse is conducting an initial assessment on a client with possible...
A client presents to a physician's office complaining of...
A nurse is administering moderate sedation to a client with chronic...
A client recovering from an acute asthmaattack experiencesrespiratory...
After undergoing a thoracotomy, a client is receiving epidural...
Positive end-expiratory pressure (PEEP) therapy has which effect on...
A client with myasthenia gravisis receiving continuous mechanical...
A client with cystic fibrosisdevelopspneumonia. To decrease the...
A client has hypoxemiaof pulmonary origin. What portion of arterial...
A nurse assessing a client for tracheal displacement should know that...
A client is being evaluated for possible lung cancer. Which client...
A client is undergoing a complete physical examination as a...
A healthy client comes to the clinic for a routine examination. When...
A nurse is caring for a client on mechanical ventilation who's...
A client being treated for complications of chronic obstructive...
A client admitted to the facility for treatment for...
A client who has just had a triple-lumen catheter placed in his right...
A nurse is completing her annual cardiopulmonary...
A home health nurse visits a client with chronic obstructive pulmonary...
A client is diagnosed with a chronic respiratory disorder. After...
The nursing staff is divided over withdrawing care from a competent,...
A physician orders a palliative care consult for a client with...
An elderly client is diagnosed with pulmonary tuberculosis. Upset and...
A nurse recognizes that a client with tuberculosisneeds further...
A physician determines that a client has been exposed to someone with...
A client with a pulmonary embolus has the following arterial blood gas...
A client with lung cancer develops pleural effusion. During chest...
A client is receiving moderate sedation while undergoing bronchoscopy....
A client with severe acute respiratory syndromeprivately informs a...
A client is chronically short of breath and yet has normal lung...
A client with chronic obstructive pulmonary disease(COPD) is being...
A client's breathing stops after receiving the wrong medication....
A nurse is caring for a client who was admitted with pneumonia, has a...
Inspiratory and expiratory stridor may be heard in a client who:
An adult client with cystic fibrosisis admitted to an acute care...
A client with multiple trauma and acute respiratory insufficiency is...
A trauma victim in the intensive care unit has a tension pneumothorax....
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