Respiratory Disorders (Part 1)

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Respiratory Disorders (Part 1) - Quiz

Respiratory disorder is a term that encompasses a variety of pathogenic conditions that affect respiration in living organisms. If you are a student and want to know more then take this quiz. All the very best.


Questions and Answers
  • 1. 

    A competent client requiring long-term mechanical ventilation privately tells a nurse that he wants the ventilator withdrawn. Which response by the nurse is best?

    • A.

      Tell me how you are feeling.

    • B.

      What about your family?

    • C.

      You're asking us to do something we can't do.

    • D.

      You have been doing so well.

    Correct Answer
    A. Tell me how you are feeling.
    Explanation
    RATIONALE: Asking the client how he's feeling uses an open-ended question that encourages the client to express his feelings. Asking the client to consider his family is judgmental and is an inappropriate statement. Ventilation can be withdrawn according to the client's wishes. Telling the client he's doing well is judgmental and dismisses the client'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. 491.

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  • 2. 

    A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

    • A.

      Droplet precautions

    • B.

      Airborne and contact precautions

    • C.

      Contact and droplet precautions

    • D.

      Contact precautions

    Correct Answer
    B. Airborne and contact precautions
    Explanation
    RATIONALE: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

    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. 643.

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  • 3. 

    At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

    • A.

      Alprazolam (Xanax).

    • B.

      Propranolol (Inderal).

    • C.

      Morphine.

    • D.

      Albuterol (Proventil).

    Correct Answer
    D. Albuterol (Proventil).
    Explanation
    RATIONALE: The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

    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. 711.

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  • 4. 

    Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive?

    • A.

      Varicella

    • B.

      Influenza

    • C.

      Hepatitis B

    • D.

      Human papilloma virus (HPV)

    Correct Answer
    B. Influenza
    Explanation
    RATIONALE: Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for women ages 9 to 26.

    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. 698.

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  • 5. 

    A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

    • A.

      Impaired gas exchange

    • B.

      Anxiety

    • C.

      Decreased cardiac output

    • D.

      Ineffective tissue perfusion (cardiopulmonary)

    Correct Answer
    A. Impaired gas exchange
    Explanation
    RATIONALE: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired 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. 675.

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  • 6. 

    A physician orders triamcinolone (Azmacort) and salmeterol (Serevent) for a client with a history of asthma. What action should the nurse take when administering these drugs?

    • A.

      Administer the triamcinolone and then administer the salmeterol.

    • B.

      Administer the salmeterol and then administer the triamcinolone.

    • C.

      Allow the client to choose the order in which the drugs are administered.

    • D.

      Monitor the client's theophylline level before administering the medications.

    Correct Answer
    B. Administer the salmeterol and then administer the triamcinolone.
    Explanation
    RATIONALE: A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    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. 713.

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  • 7. 

    A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

    • A.

      Institute isolation precautions.

    • B.

      Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour.

    • C.

      Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing.

    • D.

      Obtain a sputum specimen for enzyme immunoassay testing.

    Correct Answer
    A. Institute isolation precautions.
    Explanation
    RATIONALE: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

    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. 643.

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  • 8. 

    A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?

    • A.

      Simple mask

    • B.

      Nonrebreather mask

    • C.

      Face tent

    • D.

      Nasal cannula

    Correct Answer
    B. Nonrebreather mask
    Explanation
    RATIONALE: A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

    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. 726.

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  • 9. 

    A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

    • A.

      Mumps

    • B.

      Impetigo

    • C.

      Measles

    • D.

      Cholera

    Correct Answer
    C. Measles
    Explanation
    RATIONALE: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

    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. 2483.

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  • 10. 

    A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that he doesn't want to be resuscitated. The nurse should:

    • A.

      Not provide any care.

    • B.

      Check the client's oxygen saturation.

    • C.

      Get the crash cart.

    • D.

      Call the physician.

    Correct Answer
    B. Check the client's oxygen saturation.
    Explanation
    RATIONALE: The nurse should check the client's oxygen saturation before she calls the physician. The fact that the client has signed an advance directive doesn't mean that the nurse shouldn't provide any care. There's no reason for the nurse to get the crash cart at this point.

    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. 993.

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  • 11. 

    When caring for a client who has just had a total laryngectomy, the nurse should plan to:

    • A.

      Encourage oral feedings as soon as possible.

    • B.

      Develop an alternative communication method.

    • C.

      Keep the tracheostomy cuff fully inflated.

    • D.

      Keep the client flat in bed.

    Correct Answer
    B. Develop an alternative communication method.
    Explanation
    RATIONALE: A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    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. 617.

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  • 12. 

    Which set of arterial blood gas (ABG) results requires further investigation?

    • A.

      PH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3–) 24 mEq/L

    • B.

      PH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3– 18 mEq/L

    • C.

      PH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3– 26 mEq/L

    • D.

      PH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3– 22 mEq/L

    Correct Answer
    B. PH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3– 18 mEq/L
    Explanation
    RATIONALE: The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3– 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3– and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3– 22 to 26 mEq/L.

    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. 338.

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  • 13. 

    A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take?

    • A.

      Notify the physician immediately so he can determine client competency.

    • B.

      Have the client sign a do-not-resuscitate (DNR) form.

    • C.

      Determine whether the client's family was consulted about his decision.

    • D.

      Consult the palliative care group to direct care for the client.

    Correct Answer
    A. Notify the physician immediately so he can determine client competency.
    Explanation
    RATIONALE: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so he can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about his care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.

    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. 92.

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  • 14. 

    A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

    • A.

      Lobar pneumonia.

    • B.

      Empyema.

    • C.

      Pneumocystis carinii pneumonia.

    • D.

      Infected chest tube wound site.

    Correct Answer
    B. Empyema.
    Explanation
    RATIONALE: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

    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. 654.

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  • 15. 

    A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client's blood glucose level in the emergency care unit was 576 mg/dl. The physician orders an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin (Levaquin). The nurse piggybacks the insulin infusion into the normal saline solution. She questions whether she can also piggyback the levofloxacin into the same I.V. line. Which health team member should she collaborate with to check the compatibility of these solutions?

    • A.

      The physician who ordered the medications

    • B.

      The coworker with 20 years of nursing experience

    • C.

      The pharmacist covering the floor

    • D.

      The infectious disease nurse

    Correct Answer
    C. The pharmacist covering the floor
    Explanation
    RATIONALE: The nurse should collaborate with the pharmacist covering the floor for drug compatibility information. The physician ordering the drug, the experienced coworker, and the infectious disease nurse aren't experts in drug compatibility issues.

    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. 815.

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  • 16. 

    A nurse is feeding an average-size client when the client suddenly begins choking on his food. According to the American Heart Association, the nurse should intervene using the actions listed below. List the actions in the sequence in which the nurse should perform them.1. Give abdominal thrusts until effective or until cleint is unresponsive.2. Activate the emergency response team.3. Ask the client if he can speak.4. Perform cardiopulmonary resuscitation (CPR).

    Correct Answer
    3124
    Explanation
    The correct answer is 3,1,2,4

    RATIONALE: According to the American Heart Association, the nurse should ask the client if he's choking and if he can speak. Next, the nurse should administer abdominal thrusts or chest thrusts (if the client is obese or pregnant). The nurse should continue thrusts until they are effective or until the client becomes unresponsive. When the latter occurs, the nurse should activate the emergency response team and then perform CPR.

    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. 2522.

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  • 17. 

    During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:

    • A.

      The client's pupils to become dilated.

    • B.

      The client to experience bronchodilation.

    • C.

      A decrease in the client's gastric secretions.

    • D.

      A drop in the client's heart rate.

    Correct Answer
    D. A drop in the client's heart rate.
    Explanation
    RATIONALE: During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    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. 887.

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  • 18. 

    A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

    • A.

      Keeping the head of the bed at 15 degrees or less

    • B.

      Turning the client every 4 hours to prevent fatigue

    • C.

      Using strict hand hygiene

    • D.

      Providing oral hygiene daily

    Correct Answer
    C. Using strict hand hygiene
    Explanation
    RATIONALE: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

    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. 635.

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  • 19. 

    A chronically ventilated client requests that care be withdrawn. The client is competent and understands the consequences of his decisions. He isn't depressed, but he's certain that he doesn't want to live as he has been living. What should the nurse consider in this situation?

    • A.

      Withdrawing care for this client would be considered euthanasia.

    • B.

      The client will die eventually.

    • C.

      The client has a right to refuse medical treatments.

    • D.

      The family's wish will be granted.

    Correct Answer
    C. The client has a right to refuse medical treatments.
    Explanation
    RATIONALE: The client has the right to refuse medical treatment, even if that treatment could prolong his life. Withdrawing treatment in this case wouldn't be considered euthanasia. Although it's true that the client will die eventually, this consideration isn't appropriate for the situation. The client doesn't provide any information in regards to the family's wishes, so the nurse shouldn't consider this factor.

    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. 993.

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  • 20. 

    A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3−) of 26 mEq/L. What disorder is indicated by these findings?

    • A.

      Metabolic acidosis

    • B.

      Respiratory acidosis

    • C.

      Metabolic alkalosis

    • D.

      Respiratory alkalosis

    Correct Answer
    D. Respiratory alkalosis
    Explanation
    RATIONALE: Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3− to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3− is greater than 26 mEq/L and the pH is greater than 7.45.

    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. 338.

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  • 21. 

    A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

    • A.

      A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

    • B.

      A client who ambulates in the hallway every 4 hours

    • C.

      A client with a nasogastric tube

    • D.

      A client who is receiving acetaminophen (Tylenol) for pain

    Correct Answer
    C. A client with a nasogastric tube
    Explanation
    RATIONALE: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

    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. 635.

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  • 22. 

    A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?

    • A.

      Wear a tight cloth at the stoma to prevent anything from entering it.

    • B.

      Keep the humidity in your house low.

    • C.

      Cover the stoma whenever you shower or bathe.

    • D.

      Swimming is good exercise after this surgery.

    Correct Answer
    C. Cover the stoma whenever you shower or bathe.
    Explanation
    RATIONALE: The nurse should instruct the client to gently cover the stoma with a loose plastic bib, or even a hand, when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. The client should keep his house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming, because it's possible for water to enter the stoma and then enter the client's lung, causing him to drown without submerging his face.

    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. 619.

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  • 23. 

    The amount of air inspired and expired with each breath is called:

    • A.

      Tidal volume.

    • B.

      Residual volume.

    • C.

      Vital capacity.

    • D.

      Dead-space volume.

    Correct Answer
    A. Tidal volume.
    Explanation
    RATIONALE: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

    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. 558.

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  • 24. 

    A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?

    • A.

      The client will remain infection-free.

    • B.

      The client will maintain adequate oxygenation.

    • C.

      The client will maintain adequate urine output.

    • D.

      The client will remain pain-free.

    Correct Answer
    B. The client will maintain adequate oxygenation.
    Explanation
    RATIONALE: BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining infection- and pain-free and maintaining adequate urine output aren't direct outcomes of the client who requires BiPAP and needs restraints to maintain his safety.

    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. 751.

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  • 25. 

    For a client with an endotracheal (ET) tube, which nursing action is the most important?

    • A.

      Auscultating the lungs for bilateral breath sounds

    • B.

      Turning the client from side to side every 2 hours

    • C.

      Monitoring serial blood gas values every 4 hours

    • D.

      Providing frequent oral hygiene

    Correct Answer
    A. Auscultating the lungs for bilateral breath sounds
    Explanation
    RATIONALE: For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 737.

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  • 26. 

    A nurse is caring for a client with cystic fibrosis. With which members of the health care team is it most appropriate for her to collaborate? Select all that apply.

    • A.

      Nutritional services

    • B.

      Physical therapy

    • C.

      Social services

    • D.

      Occupational therapy

    • E.

      Respiratory therapy

    Correct Answer(s)
    A. Nutritional services
    B. Physical therapy
    E. Respiratory therapy
    Explanation
    RATIONALE: The major objectives of therapy for cystic fibrosis are promoting secretion clearance, controlling infection, and providing adequate nutrition. The respiratory therapist would help the client clear his secretions. Nutritional services are vital in promoting optimal nutrition. Exercise, a component of physical therapy, is important in clearing the airways. Social services and occupational therapy could play a role in this client's care but aren't as important as nutrition and physical therapy.

    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. 719.

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  • 27. 

    Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

    • A.

      I will come back in 1 week to have the test read.

    • B.

      If the test area turns red that means I have tuberculosis.

    • C.

      I will avoid contact with my family until I am done with the test.

    • D.

      Because I had a previous reaction to the test, this time I need to get a chest X-ray.

    Correct Answer
    D. Because I had a previous reaction to the test, this time I need to get a chest X-ray.
    Explanation
    RATIONALE: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

    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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  • 28. 

    A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

    • A.

      Client teaching about the cause of TB

    • B.

      Reviewing the risk factors for TB

    • C.

      Developing a list of people with whom the client has had contact

    • D.

      Client teaching about the importance of TB testing

    Correct Answer
    C. Developing a list of people with whom the client has had contact
    Explanation
    RATIONALE: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

    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. 650.

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  • 29. 

    A positive Mantoux test indicates that a client:

    • A.

      Is actively immune to tuberculosis.

    • B.

      Has produced an immune response.

    • C.

      Will develop full-blown tuberculosis.

    • D.

      Has an active case of tuberculosis.

    Correct Answer
    B. Has produced an immune response.
    Explanation
    RATIONALE: The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) 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. 645.

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  • 30. 

    While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

    • A.

      Decrease the heparin infusion rate.

    • B.

      Prepare to administer protamine sulfate.

    • C.

      Monitor the partial thromboplastin time (PTT).

    • D.

      Start an I.V. infusion of dextrose 5% in water (D5W).

    Correct Answer
    B. Prepare to administer protamine sulfate.
    Explanation
    RATIONALE: Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

    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. 1007.

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  • 31. 

    A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

    • A.

      Breathe in and out quickly.

    • B.

      You need to start using the incentive spirometer 2 days after surgery.

    • C.

      Before you do the exercise, I'll give you pain medication if you need it.

    • D.

      Don't use the incentive spirometer more than 5 times every hour.

    Correct Answer
    C. Before you do the exercise, I'll give you pain medication if you need it.
    Explanation
    RATIONALE: The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 729.

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  • 32. 

    A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

    • A.

      Posting a "No smoking" sign over the client's bed

    • B.

      Applying an oil-based lubricant to the client's mouth and nose

    • C.

      Assessing the client's respiratory status, orientation, and skin color

    • D.

      Changing the mask and tubing daily

    Correct Answer
    C. Assessing the client's respiratory status, orientation, and skin color
    Explanation
    RATIONALE: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color.

    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. 724.

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  • 33. 

    A client with end-stage pulmonary hypertension tells the physician he doesn't want any heroic measures should his heart stop, and he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision?

    • A.

      Nonmaleficence

    • B.

      Beneficence

    • C.

      Justice

    • D.

      Autonomy

    Correct Answer
    D. Autonomy
    Explanation
    RATIONALE: Autonomy is the client's right to make his own decisions. This client made the decision to have no heroic measures, so the nurse who supports this is upholding the principle known as autonomy. Nonmaleficence is the duty to "do no harm." Beneficence is characterized by doing good. Justice is equated with fairness.

    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. 92.

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  • 34. 

    A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

    • A.

      0.21.

    • B.

      0.35.

    • C.

      0.5.

    • D.

      0.7.

    Correct Answer
    C. 0.5.
    Explanation
    RATIONALE: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.

    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. 724.

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  • 35. 

    For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?

    • A.

      Restricting fluid intake to 1,000 ml/day

    • B.

      Enforcing absolute bed rest

    • C.

      Teaching the client how to perform controlled coughing

    • D.

      Administering ordered sedatives regularly and in large amounts

    Correct Answer
    C. Teaching the client how to perform controlled coughing
    Explanation
    RATIONALE: Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

    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. 697.

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  • 36. 

    A client with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks the client what treatments he's currently receiving for his disease. He's likely to mention which treatments?Select all that apply.

    • A.

      Oxygen

    • B.

      Aminoglycosides

    • C.

      Diuretics

    • D.

      Vasodilators

    • E.

      Antihistamines

    • F.

      Sulfonamides

    Correct Answer(s)
    A. Oxygen
    C. Diuretics
    D. Vasodilators
    Explanation
    RATIONALE: Oxygen, diuretics, and vasodilators are among the most common therapies used to treat pulmonary hypertension. Others include fluid restriction, digoxin, calcium channel blockers, beta-adrenergic blockers, and bronchodilators. Aminoglycosides and sulfonamides are antibiotics used to treat infections. Antihistamines are indicated to treat allergy, pruritus, vertigo, nausea, and vomiting; to promote sedation; and to suppress cough.

    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. 660.

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  • 37. 

    During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

    • A.

      An 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen.

    • B.

      A 42-year-old client who has left lower lobe pneumonia and an I.V. line.

    • C.

      A 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation.

    • D.

      A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line.

    Correct Answer
    D. A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line.
    Explanation
    RATIONALE: The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if he goes into atrial fibrillation, but he isn't a priority at this time.

    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. 291.

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  • 38. 

    A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

    • A.

      Instruct the client to drink 2 L of fluid daily.

    • B.

      Maintain the client on bed rest.

    • C.

      Administer anxiolytics, as ordered, to control anxiety.

    • D.

      Administer pain medication as ordered.

    Correct Answer
    A. Instruct the client to drink 2 L of fluid daily.
    Explanation
    RATIONALE: Mobilizing secretions is crucial to maintaining a patent airway and maximizing gas exchange in the client with COPD. Measures that help mobilize secretions include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity. Anxiolytics rarely are recommended for the client with COPD because they may cause sedation and subsequent infection from inadequate mobilization of secretions. Because COPD rarely causes pain, pain medication isn't indicated.

    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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  • 39. 

    A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

    • A.

      Endotracheal suctioning

    • B.

      Encouragement of coughing

    • C.

      Use of a cooling blanket

    • D.

      Incentive spirometry

    Correct Answer
    A. Endotracheal suctioning
    Explanation
    RATIONALE: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    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. 740.

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  • 40. 

    On auscultation, which finding suggests a right pneumothorax?

    • A.

      Bilateral inspiratory and expiratory crackles

    • B.

      Absence of breath sounds in the right thorax

    • C.

      Inspiratory wheezes in the right thorax

    • D.

      Bilateral pleural friction rub

    Correct Answer
    B. Absence of breath sounds in the right thorax
    Explanation
    RATIONALE: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

    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. 679.

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  • 41. 

    A nurse is caring for a client who transferred from a local nursing home and who has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). To prevent the spread of MRSA, the nurse knows she must:

    • A.

      Maintain sterile technique at all times.

    • B.

      Wear a mask when caring for the client.

    • C.

      Give the client an I.V. dose of antibiotics.

    • D.

      Keep a mask on the client.

    Correct Answer
    B. Wear a mask when caring for the client.
    Explanation
    RATIONALE: When caring for this client, the nurse should wear a high-efficiency particulate mask to prevent transmission of MRSA. Sterile technique and administration of I.V. antibiotics aren't important considerations when caring for this client. The client should wear a mask only during transfer or when ambulating in the hallway.

    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. 2482.

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  • 42. 

    A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

    • A.

      They help prevent subcutaneous emphysema.

    • B.

      They help prevent pneumothorax.

    • C.

      They help prevent cardiac arrhythmias.

    • D.

      They help prevent pulmonary edema.

    Correct Answer
    C. They help prevent cardiac arrhythmias.
    Explanation
    RATIONALE: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.

    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. 737.

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  • 43. 

    A physician orders albuterol (Proventil) for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:

    • A.

      Nasal congestion.

    • B.

      Nervousness.

    • C.

      Lethargy.

    • D.

      Hyperkalemia.

    Correct Answer
    B. Nervousness.
    Explanation
    RATIONALE: Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps.

    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.114.

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  • 44. 

    A client with chronic obstructive pulmonary disease (COPD) takes theophylline (Uniphyl), 200 mg P.O. twice per day. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of theophylline in treating a nonreversible obstructive airway disease such as COPD?

    • A.

      It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.

    • B.

      It inhibits the enzyme phosphodiesterase, decreasing degradation of cyclic adenosine monophosphate, a bronchodilator.

    • C.

      It stimulates adenosine receptors, causing bronchodilation.

    • D.

      It alters diaphragm movement, increasing chest expansion and enhancing the lung's capacity for gas exchange.

    Correct Answer
    A. It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.
    Explanation
    RATIONALE: Theophylline and other methylxanthine agents make the central respiratory center more sensitive to carbon dioxide and stimulate the respiratory drive. Inhibition of phosphodiesterase is the drug's mechanism of action in treating asthma and other reversible obstructive airway diseases — not COPD. Methylxanthine agents inhibit rather than stimulate adenosine receptors. Although these agents reduce diaphragmatic fatigue in clients with chronic bronchitis or emphysema, they don't alter diaphragm movement to increase chest expansion and enhance gas exchange.

    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. 1224.

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  • 45. 

    A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

    • A.

      Tracheostomy cleaning kit

    • B.

      Water-seal chest drainage set-up

    • C.

      Manual resuscitation bag

    • D.

      Oxygen analyzer

    Correct Answer
    C. Manual resuscitation bag
    Explanation
    RATIONALE: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

    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. 737.

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  • 46. 

    A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

    • A.

      Initiate oxygen therapy.

    • B.

      Administer a heparin bolus and begin an infusion at 500 units/hour.

    • C.

      Administer analgesics as ordered.

    • D.

      Perform nasopharyngeal suctioning.

    Correct Answer
    A. Initiate oxygen therapy.
    Explanation
    RATIONALE: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

    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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  • 47. 

    A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

    • A.

      Serosanguineous drainage on the dressing

    • B.

      Foley catheter bag containing 500 ml of amber urine

    • C.

      A piggyback infusion of levofloxacin (Levaquin)

    • D.

      The client lying in a lateral position, with the head of bed flat

    Correct Answer
    D. The client lying in a lateral position, with the head of bed flat
    Explanation
    RATIONALE: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

    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. 1156.

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  • 48. 

    A nurse is teaching a client about theophylline (Theocron) toxicity. Which is a sign or symptom of theophylline toxicity?

    • A.

      Bradycardia

    • B.

      Constipation

    • C.

      Nausea

    • D.

      Dysuria

    Correct Answer
    C. Nausea
    Explanation
    RATIONALE: Theophylline toxicity causes GI disturbances, such as nausea, vomiting, abdominal cramps, epigastric pain, anorexia, or diarrhea. It also produces central nervous system reactions, including headache, irritability, restlessness, anxiety, insomnia, and dizziness (rarely). However, theophylline toxicity doesn't result in bradycardia, constipation, or dysuria.

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

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

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  • 49. 

    A client comes to the emergency department with status asthmaticus. Based on the documentation note below, the nurse suspects that the client has what abnormality?

    • A.

      Respiratory acidosis

    • B.

      Respiratory alkalosis

    • C.

      Metabolic acidosis

    • D.

      Metabolic alkalosis

    Correct Answer
    B. Respiratory alkalosis
    Explanation
    RATIONALE: Respiratory alkalosis results from alveolar hyperventilation. It's marked by an increase in pH to more than 7.45 and a concurrent decrease in partial pressure of arterial carbon dioxide (PaCO2) to less than 35 mmHg. Metabolic alkalosis shows the same increase in pH but also an increased bicarbonate (HCO3–) level and normal PaCO2. Acidosis of any type means a low pH (below 7.35). Respiratory acidosis shows an elevated PaCO2 and a normal to high HCO3– level. Metabolic acidosis is characterized by a decreased HCO3– level and a normal to low 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. 335.

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  • 50. 

    Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

    • A.

      Myasthenia gravis

    • B.

      Type 1 diabetes mellitus

    • C.

      Extreme anxiety

    • D.

      Opioid overdose

    Correct Answer
    C. Extreme anxiety
    Explanation
    RATIONALE: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

    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. 337.

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  • Mar 22, 2023
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