Respiratory Disorders (Part 2)

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  • 1/101 Questions

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

    • The client exhibits orthopneic breathing.
    • The client breathes at a rate of 12 to 20 breaths/minute.
    • The client uses accessory muscles to breathe.
    • The client exhibits bilateral crackles on auscultation.
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About This 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 practicing as a medical practitioner? Take the quiz below and see how conversant you are with issues regarding the respiratory disorders. Good luck!

Respiratory Disorders (Part 2) - Quiz

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  • 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?

    • PH, 7.5; PaCO230 mm Hg

    • PH, 7.40; PaCO235 mm Hg

    • PH, 7.35; PaCO240 mm Hg

    • PH, 7.25; PaCO250 mm Hg

    Correct Answer
    A. pH, 7.25; PaCO250 mm Hg
    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:

    • Helping him communicate.

    • Keeping his airway patent.

    • Encouraging him to perform activities of daily living (ADLs).

    • Preventing him from developing an infection.

    Correct Answer
    A. Keeping his airway patent.
    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 client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?

    • Excess fluid volume related to excess sodium intake

    • Acute pain related to tissue trauma

    • Ineffective breathing pattern related to tissue trauma

    • Activity intolerance related to insufficient energy to carry out activities of daily living

    Correct Answer
    A. Ineffective breathing pattern related to tissue trauma
    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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  • 5. 

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

    • Respiratory rate of 44 breaths/minute

    • Oxygen saturation level of 96% on 3 L of oxygen

    • Client stating pain level of 7 out of 10 that decreases with pain medication

    • Client dozing when left alone but awakening easily

    Correct Answer
    A. Respiratory rate of 44 breaths/minute
    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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  • 6. 

    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?

    • Activity intolerance related to fatigue

    • Anxiety related to actual threat to health status

    • Risk for infection related to retained secretions

    • Impaired gas exchange related to airflow obstruction

    Correct Answer
    A. Impaired gas exchange related to airflow obstruction
    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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  • 7. 

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

    • PH

    • Bicarbonate (HCO3–)

    • Partial pressure of arterial oxygen (PaO2)

    • Partial pressure of arterial carbon dioxide (PaCO2)

    Correct Answer
    A. Partial pressure of arterial oxygen (PaO2)
    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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  • 8. 

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

    • Anxiety

    • Impaired gas exchange

    • Impaired physical mobility

    • Deficient knowledge: Home care

    Correct Answer
    A. Impaired gas exchange
    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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  • 9. 

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

    • Fluid intake for the past 24 hours

    • Baseline arterial blood gas (ABG) levels

    • Prior outcomes of weaning

    • Electrocardiogram (ECG) results

    Correct Answer
    A. Baseline arterial blood gas (ABG) levels
    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 nurse is caring for a client experiencing an acute asthmaattack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

    • The attack is over.

    • The airways are so swollen that no air can get through.

    • The swelling has decreased.

    • Crackles have replaced wheezes.

    Correct Answer
    A. The airways are so swollen that no air can get through.
    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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  • 11. 

    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:

    • Ask computer support to reset her password.

    • Use another nurse's password to finish dispensing the medications.

    • Have a nursing assistant administer the medications while she resets her password.

    • Override the machine and deliver the medications.

    Correct Answer
    A. Ask computer support to reset her password.
    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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  • 12. 

    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?

    • Septicemia

    • Pneumonia

    • Meningitis

    • Pulmonary edema

    Correct Answer
    A. Pneumonia
    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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  • 13. 

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

    • Sodium bicarbonate

    • Carbon dioxide (CO2)

    • Nitrous oxide

    • Oxygen

    Correct Answer
    A. Carbon dioxide (CO2)
    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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  • 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?

    • Checking the dressing for bleeding

    • Maintaining a patent airway

    • Monitoring the vital signs

    • Promoting urine output

    Correct Answer
    A. Maintaining a patent airway
    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?

    • Impaired color discrimination

    • Increased urinary frequency

    • Decreased hearing acuity

    • Increased appetite

    Correct Answer
    A. Decreased hearing acuity
    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?

    • Respiratory alkalosis

    • Respiratory acidosis

    • Metabolic alkalosis

    • Metabolic acidosis

    Correct Answer
    A. Metabolic acidosis
    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?

    • 5-mm induration

    • Reddened area

    • 15-mm induration

    • A blister

    Correct Answer
    A. 15-mm induration
    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?

    • Call the physician.

    • Remove the malfunctioning cuff.

    • Add more air to the cuff.

    • Suction the client, withdraw residual air from the cuff, and reinflate it.

    Correct Answer
    A. Suction the client, withdraw residual air from the cuff, and reinflate it.
    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 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?

    • Azithromycin (Zithromax)

    • Rifampin (Rifadin)

    • Amantadine (Symmetrel)

    • Amphotericin B (Fungizone)

    Correct Answer
    A. Azithromycin (Zithromax)
    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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  • 20. 

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

    • Respiratory rate of 22 breaths/minute

    • Dilated and reactive pupils

    • Urine output of 40 ml/hour

    • Heart rate of 100 beats/minute

    Correct Answer
    A. Respiratory rate of 22 breaths/minute
    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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  • 21. 

    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?

    • Public health worker

    • Home health nurse

    • Physician

    • Social worker

    Correct Answer
    A. Social worker
    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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  • 22. 

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

    • Medication allergies

    • Swallow reflex

    • Presence of carotid pulse

    • Ability to deep breathe

    Correct Answer
    A. Swallow reflex
    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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  • 23. 

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

    • Administering oxygen, coughing, breathing deeply, and maintaining bed rest

    • Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer

    • Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

    • Administering pain medications, frequent repositioning, and limiting fluid intake

    Correct Answer
    A. Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
    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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  • 24. 

    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?

    • Impaired gas exchange

    • Impaired skin integrity

    • Activity intolerance

    • Imbalanced nutrition: Less than body requirements

    Correct Answer
    A. Impaired gas exchange
    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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  • 25. 

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

    • A positive reaction indicates that the client has active tuberculosis (TB).

    • A positive reaction indicates that the client has been exposed to the disease.

    • A negative reaction always excludes the diagnosis of TB.

    • The PPD can be read within 12 hours after the injection.

    Correct Answer
    A. A positive reaction indicates that the client has been exposed to the disease.
    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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  • 26. 

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

    • The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

    • The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.

    • The client exhibits restlessness and confusion.

    • The client exhibits bronchial breath sounds over the affected area.

    Correct Answer
    A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
    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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  • 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:

    • Frontal sinuses only.

    • Sphenoidal sinuses only.

    • Frontal and maxillary sinuses.

    • Sphenoidal and ethmoidal sinuses.

    Correct Answer
    A. Frontal and maxillary sinuses.
    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:

    • Pleural effusion.

    • Pulmonary edema.

    • Atelectasis.

    • Oxygen toxicity.

    Correct Answer
    A. Atelectasis.
    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?

    • The client who requires continuous pulse oximetry monitoring

    • The client who requires assistance with eating

    • The client who requires intermittent nasotracheal suctioning

    • The client receiving patient-controlled analgesia

    Correct Answer
    A. The client who requires assistance with eating
    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. 

    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:

    • Hyperglycemia and glycosuria.

    • Acute adrenocortical insufficiency.

    • GI bleeding.

    • Restlessness and seizures.

    Correct Answer
    A. Acute adrenocortical insufficiency.
    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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  • 31. 

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

    • "Limit yourself to smoking only 2 cigarettes per day."

    • "Eat a high-sodium diet."

    • "Weigh yourself daily and report a gain of 2 lb in 1 day."

    • "Maintain bed rest."

    Correct Answer
    A. "Weigh yourself daily and report a gain of 2 lb in 1 day."
    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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  • 32. 

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

    • Keep the head of the bed at a 30-degree angle.

    • Use the inhaler before meals.

    • Rinse out his mouth after using the inhaler

    • Use the inhaler as needed.

    Correct Answer
    A. Rinse out his mouth after using the inhaler
    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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  • 33. 

    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?

    • Home health nurse

    • Physician

    • Hospital staff nurse

    • Social worker

    Correct Answer
    A. Home health nurse
    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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  • 34. 

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

    • Hypotension, hyperoxemia, and hypercapnia

    • Hyperventilation, hypertension, and hypocapnia

    • Hyperoxemia, hypocapnia, and hyperventilation

    • Hypercapnia, hypoventilation, and hypoxemia

    Correct Answer
    A. Hypercapnia, hypoventilation, and hypoxemia
    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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  • 35. 

    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?

    • 8

    • 22

    • 30

    • 50

    Correct Answer
    A. 22
    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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  • 36. 

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

    • Lateral decubitus

    • High Fowler's

    • Supine

    • Semi-Fowler's

    Correct Answer
    A. High Fowler's
    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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  • 37. 

    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?

    • An inspiratory-expiratory (I:E) ratio of 2:1

    • A transverse chest diameter twice that of the anteroposterior diameter

    • An oxygen saturation of 99%

    • A respiratory rate of 12 breaths/minute

    Correct Answer
    A. An inspiratory-expiratory (I:E) ratio of 2:1
    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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  • 38. 

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

    • The system is functioning normally.

    • The client has a pneumothorax.

    • The system has an air leak.

    • The chest tube is obstructed.

    Correct Answer
    A. The system has an air leak.
    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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  • 39. 

    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:

    • Question the order because the dosage is too low.

    • Question the order because the dosage is too high.

    • Set the pump at 45 ml/hour.

    • Stop the infusion and have the laboratory repeat the theophylline measurement.

    Correct Answer
    A. Question the order because the dosage is too low.
    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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  • 40. 

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

    • Nausea or vomiting

    • Abdominal pain or diarrhea

    • Hallucinations or tinnitus

    • Light-headedness or paresthesia

    Correct Answer
    A. Light-headedness or paresthesia
    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 caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

    • "I need to keep my inhaler at the bedside."

    • "I should eat a high-protein diet."

    • "I should become involved in a weight loss program."

    • "I should sleep on my side all night long."

    Correct Answer
    A. "I should become involved in a weight loss program."
    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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  • 42. 

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

    • "My tuberculosis isn't contagious after I take the medication for 24 hours."

    • "I'm clear when my chest X-ray is negative."

    • "I'm contagious as long as I have night sweats."

    • "I'll stop being contagious when I have a negative acid-fast bacilli test."

    Correct Answer
    A. "I'll stop being contagious when I have a negative acid-fast bacilli test."
    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:

    • Metabolic acidosis.

    • Metabolic alkalosis.

    • Respiratory acidosis.

    • Respiratory alkalosis.

    Correct Answer
    A. Respiratory alkalosis.
    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?

    • Fever

    • Tachypnea

    • Tachycardia

    • Hypotension

    Correct Answer
    A. Hypotension
    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 teaching a client with chronic bronchitisabout breathing exercises. Which instruction should the nurse include in the teaching?

    • Make inhalation longer than exhalation.

    • Exhale through an open mouth.

    • Use diaphragmatic breathing.

    • Use chest breathing.

    Correct Answer
    A. Use diaphragmatic breathing.
    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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  • 46. 

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

    • Bleeding

    • Difficulty swallowing

    • Throat pain

    • Difficulty talking

    Correct Answer
    A. Bleeding
    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?

    • Measuring and documenting the drainage in the collection chamber

    • Maintaining continuous bubbling in the water-seal chamber

    • Keeping the collection chamber at chest level

    • Stripping the chest tube every hour

    Correct Answer
    A. Measuring and documenting the drainage in the collection chamber
    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 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?

    • 2 to 5 mcg/ml

    • 5 to 10 mcg/ml

    • 10 to 20 mcg/ml

    • 21 to 25 mcg/ml

    Correct Answer
    A. 10 to 20 mcg/ml
    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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  • 49. 

    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?

    • Maintaining an adequate circulatory volume

    • Maintaining effective respirations

    • Reducing anxiety

    • Relieving pain

    Correct Answer
    A. Maintaining effective respirations
    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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