Respiratory Disorders (Part 1)

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  • 1/97 Questions

    A competent client requiring long-term mechanical ventilation privately tells a nurse that he wants the ventilator withdrawn.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

    • Tell me how you are feeling.
    • What about your family?
    • You're asking us to do something we can't do.
    • You have been doing so well.
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About This 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.

Respiratory Disorders (Part 1) - Quiz

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  • 2. 

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

    • Varicella

    • Influenza

    • Hepatitis B

    • Human papilloma virus (HPV)

    Correct Answer
    A. 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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  • 3. 

    A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

    • Make an effort to read the client's lips to foster communication.

    • Encourage the client's communication attempts by allowing him time to select or write words.

    • Answer questions for the client to reduce his frustration.

    • Avoid using a tracheostomy plug because it blocks the airway.

    Correct Answer
    A. Encourage the client's communication attempts by allowing him time to select or write words.
    Explanation
    RATIONALE: The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate.

    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 home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

    • Hypoxia

    • Delirium

    • Hyperventilation

    • Semiconsciousness

    Correct Answer
    A. Hypoxia
    Explanation
    RATIONALE: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

    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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  • 5. 

    A nurse is caring for a client who was visiting from out of state when he developed severe acute respiratory syndrome (SARS). The nurse receives a phone call from a person who identifies herself as the client's wife. The caller is tearful and requests information about the client. Which response by the nurse is best?

    • How soon can you come? He has SARS.

    • Only the physician may give you that information.

    • I really don't know. I haven't had a chance to look at his chart.

    • I'm sorry, but for confidentiality reasons, I'm not permitted to give you information over the phone.

    Correct Answer
    A. I'm sorry, but for confidentiality reasons, I'm not permitted to give you information over the phone.
    Explanation
    RATIONALE: The Health Insurance Portability and Accountability Act prohibits the nurse from providing information over the phone to an unknown caller. Revealing that the client has SARS breaches confidentiality. Telling the client's wife that only the physician may give information or saying that the chart hasn't been reviewed ignores the caller'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. 357.

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  • 6. 

    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?

    • The client will remain infection-free.

    • The client will maintain adequate oxygenation.

    • The client will maintain adequate urine output.

    • The client will remain pain-free.

    Correct Answer
    A. 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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  • 7. 

    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?

    • Withdrawing care for this client would be considered euthanasia.

    • The client will die eventually.

    • The client has a right to refuse medical treatments.

    • The family's wish will be granted.

    Correct Answer
    A. 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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  • 8. 

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

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

    • Keep the humidity in your house low.

    • Cover the stoma whenever you shower or bathe.

    • Swimming is good exercise after this surgery.

    Correct Answer
    A. 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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  • 9. 

    A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?

    • The client with anorexia, weight loss, and night sweats

    • The client with crackles and fever who is complaining of pleuritic pain

    • The client who had difficulty sleeping, daytime fatigue, and morning headache

    • The client with petechiae over the chest who's complaining of anxiety and shortness of breath

    Correct Answer
    A. The client with petechiae over the chest who's complaining of anxiety and shortness of breath
    Explanation
    RATIONALE: The client who is complaining of anxiety and shortness of breath and has petechiae over his chest should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.

    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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  • 10. 

    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?

    • Initiate oxygen therapy.

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

    • Administer analgesics as ordered.

    • 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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  • 11. 

    A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

    • Vital capacity

    • Functional residual capacity

    • Tidal volume

    • Maximal voluntary ventilation

    Correct Answer
    A. Tidal volume
    Explanation
    RATIONALE: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

    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. 558.

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  • 12. 

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

    • 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

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

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

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

    Correct Answer
    A. 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 nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

    • Diaphragmatic breathing

    • Use of accessory muscles

    • Pursed-lip breathing

    • Controlled breathing

    Correct Answer
    A. Use of accessory muscles
    Explanation
    RATIONALE: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

    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. 563.

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  • 14. 

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

    • Tidal volume.

    • Residual volume.

    • Vital capacity.

    • 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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  • 15. 

    A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

    • Assure the client that everything will be all right and that he shouldn't become upset.

    • Ask a family member to interpret what the client is trying to communicate.

    • Ask the physician to wean the client off the mechanical ventilator to allow the client to talk.

    • Ask the client to write, use a picture board, or spell words with an alphabet board.

    Correct Answer
    A. Ask the client to write, use a picture board, or spell words with an alphabet board.
    Explanation
    RATIONALE: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

    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. 750.

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  • 16. 

    A registered nurse is making the client care assignments. Which staff member should be assigned to the client who had a chest tube inserted yesterday?

    • Charge nurse

    • Nursing assistant

    • Licensed practical nurse

    • Registered nurse

    Correct Answer
    A. Registered nurse
    Explanation
    RATIONALE: According to the National Council of State Boards of Nursing, delegation encompasses five rights — the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. The registered nurse is the most appropriate caregiver to assign to the client with a chest tube because the chest tube system requires frequent assessment and monitoring. In addition, the client may require immediate nursing intervention should the chest tube became obstructed or dislodged. It isn't necessary for the charge nurse to care for this client.

    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. 323.

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  • 17. 

    A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease. The client, who receives I.V. morphine, moans when the nurse repositions him. The client appears to be sleeping at intervals. During morning rounds, the nurse discusses with the physician the need to increase the client's morphine levels to decrease his pain level. She bases her actions on the knowledge that:

    • Increasing morphine is considered euthanasia.

    • Pain control is an important part of nonmaleficence.

    • The client's living will dictates the amount of morphine he may receive.

    • Suctioning secretions will assist with breathing and reduce pain.

    Correct Answer
    A. Pain control is an important part of nonmaleficence.
    Explanation
    RATIONALE: Nonmaleficence involves preventing or reducing harm to the client. Adequate pain relief, particularly for those with terminal illnesses, falls under this concept. Euthanasia is the deliberate act of hastening death. Increasing morphine to relieve the client's pain wouldn't be a deliberate attempt to hasten death. Living wills don't dictate the amount of medication a client may receive. Suctioning is important but won't assist with pain relief.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 1192.

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  • 18. 

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

    • Institute isolation precautions.

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

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

    • 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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  • 19. 

    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?

    • Nonmaleficence

    • Beneficence

    • Justice

    • Autonomy

    Correct Answer
    A. 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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  • 20. 
    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? - ProProfs

    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?

    • Respiratory acidosis

    • Respiratory alkalosis

    • Metabolic acidosis

    • Metabolic alkalosis

    Correct Answer
    A. 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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  • 21. 

    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:

    • Alprazolam (Xanax).

    • Propranolol (Inderal).

    • Morphine.

    • Albuterol (Proventil).

    Correct Answer
    A. 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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  • 22. 

    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?

    • Notify the physician immediately so he can determine client competency.

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

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

    • 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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  • 23. 

    A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

    • Nonproductive cough and abdominal pain

    • Hypertension and lack of fever

    • Bradypnea and bradycardia

    • Chest pain and dyspnea

    Correct Answer
    A. Chest pain and dyspnea
    Explanation
    RATIONALE: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

    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. 663.

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  • 24. 

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

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

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

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

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

    Correct Answer
    A. 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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  • 25. 

    On auscultation, which finding suggests a right pneumothorax?

    • Bilateral inspiratory and expiratory crackles

    • Absence of breath sounds in the right thorax

    • Inspiratory wheezes in the right thorax

    • Bilateral pleural friction rub

    Correct Answer
    A. 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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  • 26. 
    While suctioning a client's tracheostomy tube, the nurse notes the following pattern on the electrocardiogram (ECG) strip. What should the nurse do? - ProProfs

    While suctioning a client's tracheostomy tube, the nurse notes the following pattern on the electrocardiogram (ECG) strip. What should the nurse do?

    • Continue suctioning to remove the mucus.

    • Stop suctioning and provide oxygen as ordered.

    • Turn the client onto his left side.

    • Administer a precordial thump.

    Correct Answer
    A. Stop suctioning and provide oxygen as ordered.
    Explanation
    RATIONALE: This client's ECG strip indicates sinus bradycardia, which may result from a vasovagal response to prolonged suctioning. When this pattern occurs, the nurse should stop suctioning, administer 100% oxygen, and monitor the ECG closely. Continuing suctioning, turning the client onto his left side, and administering a precordial thump are inappropriate and wouldn't correct bradycardia.

    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. 741.

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  • 27. 

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

    • Impaired gas exchange

    • Anxiety

    • Decreased cardiac output

    • 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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  • 28. 

    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?

    • Mumps

    • Impetigo

    • Measles

    • Cholera

    Correct Answer
    A. 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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  • 29. 

    A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

    • Lips.

    • Mucous membranes.

    • Nail beds.

    • Earlobes.

    Correct Answer
    A. Mucous membranes.
    Explanation
    RATIONALE: Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by 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. 568.

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  • 30. 

    A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

    • An inhaled beta2-adrenergic agonist

    • An inhaled corticosteroid

    • An I.V. beta2-adrenergic agonist

    • An oral corticosteroid

    Correct Answer
    A. An inhaled beta2-adrenergic agonist
    Explanation
    RATIONALE: An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

    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. 717.

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  • 31. 

    A client has a sucking stab wound to the chest. Which action should the nurse take first?

    • Draw blood for a hematocrit and hemoglobin level.

    • Apply a dressing over the wound and tape it on three sides.

    • Prepare a chest tube insertion tray.

    • Prepare to start an I.V. line.

    Correct Answer
    A. Apply a dressing over the wound and tape it on three sides.
    Explanation
    RATIONALE: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

    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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  • 32. 

    A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

    • Avoid contact with fur-bearing animals.

    • Change filters on heating and air conditioning units frequently.

    • Take ordered medications as scheduled.

    • Avoid goose down pillows.

    Correct Answer
    A. Take ordered medications as scheduled.
    Explanation
    RATIONALE: Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks.

    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. 714.

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  • 33. 

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

    • Encourage oral feedings as soon as possible.

    • Develop an alternative communication method.

    • Keep the tracheostomy cuff fully inflated.

    • Keep the client flat in bed.

    Correct Answer
    A. 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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  • 34. 

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

    • Auscultating the lungs for bilateral breath sounds

    • Turning the client from side to side every 2 hours

    • Monitoring serial blood gas values every 4 hours

    • 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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  • 35. 

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

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

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

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

    • Changing the mask and tubing daily

    Correct Answer
    A. 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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  • 36. 

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

    • Restricting fluid intake to 1,000 ml/day

    • Enforcing absolute bed rest

    • Teaching the client how to perform controlled coughing

    • Administering ordered sedatives regularly and in large amounts

    Correct Answer
    A. 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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  • 37. 

    A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

    • Inspection

    • Chest X-ray

    • Arterial blood gas (ABG) levels

    • Auscultation

    Correct Answer
    A. Auscultation
    Explanation
    RATIONALE: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural 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. 731.

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  • 38. 

    After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

    • Report fluctuations in the water-seal chamber.

    • Clamp the chest tube once every shift.

    • Encourage coughing and deep breathing.

    • Milk the chest tube every 2 hours.

    Correct Answer
    A. Encourage coughing and deep breathing.
    Explanation
    RATIONALE: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

    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. 760.

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  • 39. 

    A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

    • Assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

    • Raise the arm on the side of the client's body on which the physician will perform the thoracentesis.

    • Place the client supine in the bed, which is flat.

    • Raise the head of the bed to a high Fowler's position.

    Correct Answer
    A. Assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
    Explanation
    RATIONALE: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

    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. 583.

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  • 40. 

    After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

    • 30 minutes

    • 1 hour

    • 2.5 hours

    • 4 hours

    Correct Answer
    A. 30 minutes
    Explanation
    RATIONALE: Codeine's onset of action is 30 minutes. Its peak concentration occurs in about 1 hour; its half-life, in 2.5 hours; and its duration of action is 4 to 6 hours.

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

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

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  • 41. 

    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?

    • Metabolic acidosis

    • Respiratory acidosis

    • Metabolic alkalosis

    • Respiratory alkalosis

    Correct Answer
    A. 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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  • 42. 

    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?

    • Serosanguineous drainage on the dressing

    • Foley catheter bag containing 500 ml of amber urine

    • A piggyback infusion of levofloxacin (Levaquin)

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

    Correct Answer
    A. 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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  • 43. 

    A client recovering from a pulmonary embolism is receiving warfarin (Coumadin). To counteract a warfarin overdose, the nurse should administer:

    • Heparin.

    • Vitamin K1 (phytonadione).

    • Vitamin C.

    • Protamine sulfate.

    Correct Answer
    A. Vitamin K1 (phytonadione).
    Explanation
    RATIONALE: Vitamin K1 is the antidote for a warfarin overdose. Heparin is a parenteral anticoagulant. Vitamin C isn't an antidote. Protamine sulfate is the antidote for heparin.

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

    REFERENCE: Springhouse Nurse's Drug Guide 2007. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1323.

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  • 44. 

    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:

    • 0.21.

    • 0.35.

    • 0.5.

    • 0.7.

    Correct Answer
    A. 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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  • 45. 

    A client on mechanical ventilation is receiving pancuronium (Pavulon) I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?

    • Leg movement

    • Finger movement

    • Lip movement

    • Fighting the ventilator

    Correct Answer
    A. Fighting the ventilator
    Explanation
    RATIONALE: Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so he breathes in synchrony with the ventilator. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer a dose I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn't used to determine the need for another dose.

    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. 975.

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  • 46. 

    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?

    • Simple mask

    • Nonrebreather mask

    • Face tent

    • Nasal cannula

    Correct Answer
    A. 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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  • 47. 

    Nursing assessment reveals that a client has paradoxical chest expansion. Such expansion is best described as:

    • A form of tachypnea.

    • Lung movement inward during expiration and outward during inspiration.

    • A decreased respiratory rate.

    • Lung movement outward during expiration and inward during inspiration.

    Correct Answer
    A. Lung movement outward during expiration and inward during inspiration.
    Explanation
    RATIONALE: In paradoxical chest expansion, the lungs move outward during expiration and inward during inspiration. The client may exhibit signs of ineffective gas exchange, such as tachypnea (an abnormally fast respiratory rate), secondary to a paradoxical breathing pattern.

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

    REFERENCE: REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 626.

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  • 48. 

    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?

    • Droplet precautions

    • Airborne and contact precautions

    • Contact and droplet precautions

    • Contact precautions

    Correct Answer
    A. 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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  • 49. 

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

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

    • A client who ambulates in the hallway every 4 hours

    • A client with a nasogastric tube

    • A client who is receiving acetaminophen (Tylenol) for pain

    Correct Answer
    A. 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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