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AE III Exam 2 > MedSurge Success Questions > Flashcards

MedSurge Success Questions Flashcards

1
Q

COPD

A

COPD

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2
Q
  1. When assessing the client with COPD, which health promotion information would be most important for the nurse to obtain?
  2. Number of years the client has smoked.
  3. Risk factors for complications.
  4. Ability to administer inhaled medication.
  5. Possibility for lifestyle changes.
A

4

The possibility of lifestyle changes is most
important in health promotion. The most
important is smoking cessation. The nurse
needs to assess if the client has the willingness
to consider cessation of smoking and
carry out the plan. If the client refuses to
stop, treatment will need to be altered.

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3
Q
  1. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
  2. Assist the client into a sitting position at 90 degrees.
  3. Give oxygen at six (6) LPM via nasal cannula.
  4. Monitor vital signs with the client sitting upright.
  5. Notify the health-care provider about the client’s status.
A

1

The client should be assisted into a sitting
position either on the side of the bed or in
the bed. This position decreases the work
of breathing. Some clients find it easier
sitting on the side of the bed leaning over
the bed table. The nurse needs to maintain
the client’s safety.

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4
Q
  1. When assessing the client with the diagnosis of COPD, which data would require the nurse to take immediate action?
  2. Large amounts of thick white sputum.
  3. Oxygen flow meter set on eight (8) liters.
  4. Use of accessory muscles during inspiration.
  5. Presence of a barrel chest and dyspnea.
A

2

The nurse should decrease the oxygen rate.
Hypoxemia is the stimulus for breathing in
the client with COPD. If the hypoxemia
improves and the oxygen level increases,
the drive to breathe may be eliminated.
Careful monitoring is important to prevent
complications.

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5
Q
  1. While the nurse is caring for the client diagnosed with COPD, which outcome would require a revision in the plan of care?
  2. The client has no signs of respiratory distress.
  3. The client shows an improved respiratory pattern.
  4. The client demonstrates intolerance to activity.
  5. The client participates in establishing goals.
A

3

The expected outcome should be that the
client is showing an improved activity tolerance;
because the client is not meeting the
expected outcome, the plan of care needs
revision. The nurse needs to collaborate
with the health-care team and with the
client to establish interventions that will
assist in improving the client’s outcome.

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6
Q
  1. The nurse is caring for the client diagnosed with end-stage COPD. Which data would warrant immediate intervention by the nurse?
  2. The client’s pulse oximeter reading is 92%.
  3. The client’s arterial blood gas level is 74.
  4. The client has SOB when walking to the bathroom.
  5. The client’s sputum is rusty colored.
A

4

Rusty-colored sputum may indicate blood
in the sputum and would require further
assessment by the nurse.

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7
Q
  1. What statement made by the client diagnosed with chronic bronchitis indicates to the nurse that more teaching is needed?
  2. “I should contact my health-care provider if my sputum changes color or amount.”
  3. “I will take my bronchodilator regularly to prevent having bronchospasms.”
  4. “This metered dose inhaler gives a precise amount of medication with each dose.”
  5. “I need to return to the HCP to have my blood drawn with my annual physical.”
A

4

Clients need to have blood levels drawn
every six (6) months when taking bronchodilators.
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8
Q
  1. Which nursing diagnoses would be appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply.
  2. Impaired gas exchange.
  3. Inability to tolerate temperature extremes.
  4. Activity intolerance.
  5. Inability to cope with changes in roles.
  6. Alteration in nutrition.
A

1, 2, 3, 4, 5

  1. The client diagnosed with COPD has difficulty
    exchanging oxygen with carbon dioxide,
    which is manifested by physical signs
    such as fingernail clubbing and metabolic
    acidosis as seen on arterial blood gases.
  2. Clients need to avoid extremes in temperatures.
    Warm temperatures cause an increase
    in the metabolism and increase the
    need for oxygen. Cold temperatures cause
    bronchospasms.
  3. When a client has difficulty breathing the
    client can become fatigued so that the
    client can stop breathing. Activities should
    be timed so rest periods are available to
    prevent fatigue.
  4. Many clients have difficulty adapting to the
    role changes brought about because of the
    disease process. Many cannot maintain
    the activities involved in meeting responsibilities
    at home and at work. Clients should
    be assessed for these issues.
  5. Clients often lose weight because so much
    effort is expended to breathe.
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9
Q
  1. Which outcome would be appropriate for the client problem “ineffective gas exchange” for the client recently diagnosed with COPD?
  2. The client demonstrates the correct way to purse-lip breathe.
  3. The client lists three (3) signs/symptoms to report to the HCP.
  4. The client will drink at least 2500 mL of water daily.
  5. The client will be able to ambulate 100 feet with dyspnea.
A

1

Pursed-lip breathing helps keep the alveoli
open to allow for better oxygen and carbon
dioxide exchange.

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10
Q
  1. The primary nurse observes the unlicensed nursing assistant removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom.
    Which action should the primary nurse take?
  2. Praise the NA because this prevents the client from tripping on the oxygen tubing.
  3. Place the oxygen back on the client while sitting in the bathroom and say nothing.
  4. Explain to the NA in front of the client that the oxygen must be left in place at all times.
  5. Discuss the NA’s action with the charge nurse so that appropriate action can be taken.
A

2

The client needs the oxygen, and the nurse
should not correct the NA in front of the
client; it is embarrassing for the NA, and
the client loses confidence in the staff.

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11
Q
  1. When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse expect?
  2. Clubbing of the client’s fingers.
  3. Infrequent respiratory infections.
  4. Chronic sputum production.
  5. Nonproductive hacking cough.
A

3

  1. Clubbing fingers is the result of chronic hypoxemia, which would be expected with chronic COPD but not with recently diagnosed
    COPD.
  2. These clients have frequent respiratory infections.
  3. Sputum production, along with cough and
    dyspnea on exertion, are the early signs/
    symptoms of COPD.
  4. These clients have a productive cough, not a
    nonproductive cough.
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12
Q
  1. What statement made by the client would indicate that the nurse’s discharge teaching was effective for the client diagnosed with COPD?
  2. “I need to get an influenza vaccine each year, even when there is a shortage.”
  3. “I need to get a vaccine for pneumonia each year with my flu shot.”
  4. “If I reduce my cigarette smoking to six (6) a day, I won’t have difficulty breathing.”
  5. “I need to restrict my drinking liquids to keep from having so much phlegm.”
A

1

Clients diagnosed with COPD should
receive the influenza vaccine each year. If
there is a shortage, these clients have top
priority.

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13
Q
  1. Which referral would be appropriate for a client diagnosed with COPD?
  2. The Asthma Foundation of America.
  3. The American Cancer Society.
  4. The American Lung Association.
  5. The American Heart Association.
A

3

The American Lung Association has information that is helpful for a client with
COPD.

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14
Q

Reactive Airway Disease (Asthma)

A

Reactive Airway Disease (Asthma)

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15
Q
  1. The nurse is completing the admission assessment on a 13-year-old client diagnosed with asthma. Which signs and symptoms would the nurse expect to find?
  2. Fever and crepitus.
  3. Rales and hives.
  4. Dyspnea and wheezing.
  5. Normal chest shape and eupnea.
A

3

During an asthma attack the muscles surrounding
the bronchioles constrict, causing
a narrowing of the bronchioles. The lungs
then respond with the production of secretions
that further narrow the lumen. The
resulting symptoms include wheezing from
air passing through the narrow, clogged
spaces, and dyspnea.

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16
Q
  1. The nurse is planning the care of a client diagnosed with asthma and has written a problem of “anxiety.” Which nursing intervention should be implemented?
  2. Stay with the client.
  3. Notify the health-care provider.
  4. Administer an anxiolytic medication.
  5. Encourage the client to drink fluids.
A

1

Anxiety is an expected sequela of being
unable to meet the oxygen needs of the
body. Staying with the client lets the client
know the nurse will intervene and that the
client is not alone.

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17
Q
  1. The case manager is arranging a care planning meeting regarding the care of a 65- year-old client diagnosed with adult-onset asthma. Which health-care discipline should participate in the meeting? Select all that apply.
  2. Nursing.
  3. Pharmacy.
  4. Social Work.
  5. Occupational Therapy.
  6. Speech Therapy.
A

1, 2, 3

  1. Nursing is the one discipline that is with
    the client around the clock. Therefore
    nurses have knowledge of the client that
    the other disciplines might not know.
  2. The pharmacist will be able to discuss
    the medication regimen that the client is
    receiving and make suggestions regarding
    other medications or medication interactions.
  3. The social worker may be able to assist
    with financial information or home care arrangements.
  4. Occupational therapists help clients with activities
    of daily living and modifications to home
    environments; nothing in the stem indicates a
    need for these services.
  5. Speech therapists assist clients with speech and
    swallowing problems; nothing in the stem
    indicates a need for these services
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18
Q
  1. The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
  2. Daily inhaled corticosteroids.
  3. Use of a “rescue inhaler.”
  4. Use of systemic steroids.
  5. Leukotriene agonists.
A

2

  1. Daily inhaled steroids are used for mild, moderate, or severe persistent asthma, not for intermittent asthma.
  2. Clients with intermittent asthma will have exacerbations that are treated with rescue
    inhalers. Therefore, the nurse should teach
    the client about rescue inhalers.
  3. Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma.
  4. Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma.
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19
Q
  1. The nurse knows the client understands teaching regarding mast cell stabilizer medications when the client makes which statement?
  2. “I should take two (2) puffs when I begin to have an asthma attack.”
  3. “I must taper off the medications and not stop taking them abruptly.”
  4. “These drugs will be most effective if taken at bedtime.”
  5. “These drugs are not good at the time of an attack.”
A

4

Mast cell drugs are routine maintenance
medications and do not treat an attack.

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20
Q
  1. The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client?
  2. Complete blood count.
  3. Pulmonary function test.
  4. Allergy skin testing.
  5. Drug cortisol level.
A

2

Pulmonary functions tests are completed
to determine the forced vital capacity
(FVC), the forced expiratory vital capacity
in the first second (FEV1), and the peak
expiratory flow (PEF). A decline in the
FVC, FEV1, and PEF indicate respiratory
compromise.
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21
Q
  1. The registered nurse and a licensed practical nurse are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the licensed practical nurse?
    Select all that apply.
  2. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1000 mL.
  3. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time.
  4. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed.
  5. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications.
  6. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.
A

1, 2, 5

  1. A forced vital capacity of 1000 mL is considered
    normal for most females.
  2. The client should be encouraged to pace
    the activities of daily living; this is expected
    for a client diagnosed with asthma.
  3. Confusion could be a sign of decreased oxygen
    to the brain and requires the RN’s expertise.
  4. The client’s mother requires teaching, which is
    the registered nurse’s responsibility.
  5. A pulse oximetry level of 95% is normal.
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22
Q
  1. The charge nurse is making rounds. Which client should the nurse assess first?
  2. The 29-year-old client diagnosed with reactive airway disease who is complaining that the nurse caring for him was rude.
  3. The 76-year-old client diagnosed with heart failure who has 2! edema of the lower extremities.
  4. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL.
  5. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.
A

1

The charge nurse is responsible for all
clients. At times it is necessary to see clients
with a psychosocial need before other
clients who have situations that are expected
and are not life threatening.

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23
Q
  1. The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching?
  2. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise.
  3. Warmup exercises will increase the potential for developing the asthma attacks.
  4. Use the bronchodilator inhaler immediately prior to beginning to exercise.
  5. Increase dietary intake of food high in monosodium glutamate (MSG).
A

3

Using a bronchodilator immediately prior
to exercising will reduce bronchospasms.

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24
Q
  1. The client diagnosed with restrictive airway disease, asthma, has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?
  2. Do not abruptly stop taking this medication; it must be tapered off.
  3. Immediately rinse the mouth following administration of the drug.
  4. Hold the medication in the mouth for fifteen (15) seconds before swallowing.
  5. Take the medication immediately when an attack starts.
A

2

The steroids must pass through the oral
cavity before reaching the lungs. Allowing
the medication to stay within the oral cavity
will suppress the normal flora found there,
and the client could develop a yeast infection
of the mouth, oral candidiasis.

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25
Q
  1. The nurse is discussing the care of a child diagnosed with asthma with the parent.
    Which referral would be important to include?
  2. Referral to a dietitian.
  3. Referral for allergy testing.
  4. Referral to the developmental psychologist.
  5. Referral to a home health nurse.
A

2

Because asthma can be a reaction to an
allergen, it is important to determine which
substances may trigger an attack.

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26
Q
  1. The nurse is discharging a client newly diagnosed with restrictive airway disease, asthma. Which statement indicates the client understands the discharge instructions?
  2. “I will call 911 if my medications don’t control an attack.”
  3. “I should wash my bedding in warm water.”
  4. “I can still eat at the Chinese restaurant when I want.”
  5. “If I get a headache I should take a nonsteroidal anti-inflammatory drug.”
A

1

The client must be able to recognize a lifethreatening
situation and initiate the correct
procedure.

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27
Q

Lung Cancer

A

Lung Cancer

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28
Q
  1. The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?
  2. The client worked with asbestos for a short time many years ago.
  3. The client has no family history for this type of lung cancer.
  4. The client has numerous tattoos covering both upper and lower arms.
  5. The client has smoked two (2) packs of cigarettes a day for 20 years.
A

4

Smoking is the number-one risk factor for
developing cancer of the lung. More than
85% of lung cancers are attributable to
inhalation of chemicals. There are more
than 400 chemicals in each puff of cigarette
smoke, 17 of which are known to cause
cancer.

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29
Q
  1. The nurse writes a problem of “impaired gas exchange” for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply.
  2. Apply O2 via nasal cannula.
  3. Have the dietitian plan for six (6) small meals per day.
  4. Place the client in respiratory isolation.
  5. Assess vital signs for fever.
  6. Listen to lung sounds every shift.
A

1, 2, 4, 5

  1. Respiratory distress is a common finding in
    clients diagnosed with lung cancer. As the tumor grows and takes up more space or blocks air movement, the client may need to be taught positioning for lung expansion.
    The administration of oxygen will
    help the client to use the lung capacity that
    is available to get oxygen to the tissues.
  2. Clients with lung cancer frequently
    become fatigued trying to eat. Providing six
    (6) small meals spaces the amount of food
    the client eats throughout the day.
  3. Cancer is not communicable, so the client does not need to be in isolation.
  4. Clients with cancer of the lung are at risk
    for developing an infection from lowered
    resistance as a result of treatments or from
    the tumor blocking secretions in the lung.
    Therefore, monitoring for the presence of
    fever, a possible indication of infection, is
    important.
  5. Assessment of the lungs should be completed on a routine and PRN basis.
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30
Q
  1. The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate?
  2. Lung cancer is the number-two cause of cancer deaths in both men and women.
  3. Lung cancer is the number-one cause of cancer deaths in both men and women.
  4. Lung cancer deaths are not significant in relation to other cancers.
  5. Lung cancer deaths have continued to increase in the male population.
A

2

Lung cancers are responsible for almost
twice as many deaths among males as any
other cancer and more deaths than breast
cancer in females.

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31
Q
  1. The nurse and an unlicensed nursing assistant are caring for a group of clients on a medical unit. Which information provided by the assistant warrants immediate intervention by the nurse?
  2. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup.
  3. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table.
  4. The client receiving Procrit, a biologic response modifier, has a T 99.2°, P 68, R 24, and BP of 198/102.
  5. The client receiving prednisone, a steroid, is complaining of an upset stomach after
    eating breakfast.
A

3

Biologic response modifiers that stimulate
the bone marrow can increase the client’s
blood pressure to dangerous levels. This
BP is very high and warrants immediate
attention.

32
Q
  1. The client diagnosed with lung cancer has been told that the cancer has metastasized to the brain. Which intervention should the nurse implement?
  2. Discuss implementing an advance directive.
  3. Explain the use of chemotherapy for brain involvement.
  4. Teach the client to discontinue driving.
  5. Have the significant other make decisions for the client.
A

1

This situation indicates a terminal process,
and the client should make decisions for
the end of life.

33
Q
  1. The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach?
  2. Investigational regimens provide a better chance of survival for the client.
  3. Investigational treatments have not been proved helpful to clients.
  4. Clients will be paid to participate in an investigational program.
  5. Only clients that are dying qualify for investigational treatments.
A

2

Investigational treatments are just that—
treatments being investigated to see if they
are effective in the care of clients diagnosed
with cancer. There is no guarantee the
treatments will help the client.

34
Q
  1. The staff on an oncology unit is interviewing applicants for a position as the unit manager. Which type of organizational structure does this represent?
  2. Centralized decision-making.
  3. Decentralized decision-making.
  4. Shared governance.
  5. Pyramid with filtered-down decisions.
A

3

Shared governance is a system where the
staff is empowered to make decisions such
as scheduling and hiring of certain staff.
Staff members are encouraged to participate
in developing policies and procedures
to reach set goals.

35
Q
  1. The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates that more teaching is needed?
  2. “It doesn’t matter if I smoke now. I already have cancer.”
  3. “I should see the oncologist at my scheduled appointment.”
  4. “If I begin to run a fever I should notify the HCP.”
  5. “I should plan for periods of rest throughout the day.”
A

1

Research indicates that smoking will still
interfere with the client’s response to treatment.

36
Q
  1. The nurse working in an outpatient clinic is interviewing clients. Which information provided by the client warrants further investigation?
  2. The client uses Vicks VapoRub every night before bed.
  3. The client has had an appendectomy.
  4. The client takes a multiple vitamin pill every day.
  5. The client has been coughing up blood in the mornings.
A

4

Coughing up blood could indicate a lung
cancer and should be investigated.

37
Q
  1. The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
  2. The client has an intake of 1500 mL IV and an output of 1000 mL.
  3. The client has 450 mL of bright-red drainage in the chest tube.
  4. The client is complaining of pain at a “10” on a 1–10 scale.
  5. The client has absent lung sound on the side of the surgery.
A

2

  1. This is an adequate output. After a major surgery, clients will frequently have an intake
    greater than the output because of the fluid
    shift occurring as a result of trauma to the body.
  2. This is about a pint of blood loss and could
    indicate the client is hemorrhaging.
  3. The nurse should intervene and medicate the
    client, but pain, although a client comfort
    issue, is not life threatening.
  4. The client will have a chest tube to assist in
    reinflation of the lung, and absent lung sounds
    are expected at this point in the client’s recovery.
38
Q
  1. The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
  2. The test will confirm the MRI results.
  3. The client can eat and drink immediately after the test.
  4. The HCP can do a biopsy of the tumor through the scope.
  5. There is no discomfort associated with this procedure.
A

3

The HCP can take biopsies and wash of the
lung tissue for pathological diagnosis during
the procedure.

39
Q
  1. The client diagnosed with oat cell carcinoma of the lung tells the nurse, “I am so tired of all this. I might as well just end it all.” Which should be the nurse’s first response?
  2. Respond by saying, “This must be hard for you. Would you like to talk?”
  3. Tell the HCP of the client’s statement.
  4. Refer the client to a social worker or spiritual advisor.
  5. Find out if the client has a plan to carry out suicide.
A

4

  1. The nurse might enter into a therapeutic
    conversation, but client safety is the priority.
  2. The nurse must first assess the seriousness of
    the client’s statement and whether he or she
    has a plan to carry out suicide. Depending
    on the client’s responses, the nurse will notify
    the HCP.
  3. The client can be referred for assistance in
    dealing with the disease and its ramifications,
    but this is not the priority.
  4. The priority action any time a client makes
    a statement regarding taking his or her
    own life is to determine if the client has
    thought it through enough to have a plan.
    A plan indicates an emergency situation.
40
Q

Respiratory Disorders Comprehensive Examination

A

Respiratory Disorders Comprehensive Examination

41
Q
  1. Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma?
  2. A bronchoscopy.
  3. An immunoglobulin E.
  4. An arterial blood gas.
  5. A bronchodilator reversibility test.
A

4

  1. A bronchoscope visualizes the bronchial tree under sedation, but it does not confirm the diagnosis of asthma.
  2. An immunoglobulin E is a blood test for the presence of an antibody protein indicating allergic reactions.
  3. Arterial blood gases analyze levels that provide information about the exchange of oxygen and carbon dioxide, but they are not diagnostic of asthma.
  4. During a bronchodilator reversibility test,
    the client’s positive response to a bronchodilator
    confirms the diagnosis of asthma.
42
Q
  1. Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
  2. “I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks.”
  3. “I need to use my Intal, Cromolyn inhaler 15 minutes before I begin my exercise.”
  4. “I need to take oral glucocorticoids every day to prevent my asthma attacks.”
  5. “If I have an asthma attack, I need to use my Albuterol, a beta2 agonist, inhaler.”
A

3

Glucocorticoids are given orally or intravenously during acute exacerbations of
asthma, not on a daily basis because of the
long-term complications of steroid therapy.

43
Q
  1. Which clinical manifestation would the nurse expect to find in the client newly diagnosed with intrinsic lung cancer?
  2. Dysphagia.
  3. Foul-smelling breath.
  4. Hoarseness.
  5. Weight loss.
A

3

Hoarseness is an early clinical manifestation
of intrinsic lung cancer.

44
Q
  1. The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the “Right to Know Law.” Which information should the nurse include in the presentation? Select all that apply.
  2. A client who smokes cigarettes has a drastically increased risk for lung cancer.
  3. Floors need to be clean and dust needs to be wet to prevent transfer of dust.
  4. The air needs to be monitored at specific times to evaluate for exposure.
  5. All surface areas need to be painted every year to prevent the accumulation of dust.
  6. Employees should wear the appropriate personal protective equipment.
A

1, 2, 3, 5

  1. Clients who smoke cigarettes and work
    with toxic substances have increased risk of
    lung cancer because many of the substances
    are carcinogenic.
  2. When floors and surfaces are kept clean,
    toxic dust particles, such as asbestos and
    silica, are controlled and this decreases exposure.
    Covering areas with water controls
    dust.
  3. The quality of air is monitored to determine
    what toxic substances are present and
    in what amount. The information is then
    used in efforts to minimize the amount of
    exposure.
  4. Applying paint to a surface does not eliminate
    or minimize exposure.
  5. Employees must wear protective coverings,
    goggles, and other equipment needed to
    eliminate exposure to the toxic substances.
45
Q
  1. Which statement indicates the need for further teaching for the client diagnosed with sleep apnea?
  2. “If I lose weight and stop smoking cigarettes I may not need treatment for sleep apnea.”
  3. “The continuous positive airway pressure (CPAP) holds my airway open with pressure.”
  4. “The CPAP will help me stay awake during the day while I am at work.”
  5. “It is all right to have a couple of beers at night because I have this CPAP machine.”
A

4

Drinking alcohol before sleep sedates the
client, causing the muscles to relax, which,
in turn, causes an obstruction of the client’s
airway. Thus, drinking alcohol should
be avoided even if the client uses a CPAP
machine.

46
Q
  1. The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
  2. The client diagnosed with congestive heart failure.
  3. The client with a documented allergy to eggs.
  4. The client who has had an anaphylactic reaction to penicillin.
  5. The client who has an elevated blood pressure and pulse.
A

2

In clients who are allergic to egg protein, a
significant hypersensitivity response may
occur when they are receiving the influenza
vaccine.

47
Q
  1. The nurse is preparing the client for a polysomnography to confirm sleep apnea.
    Which preprocedure instruction should the nurse include?
  2. The client should not eat or drink past midnight.
  3. The client will receive a sedative for relaxation.
  4. The client will sleep in a laboratory for evaluation.
  5. The client will wear a monitor at home for this test.
A

3

The polysomnography is completed in a
sleep laboratory to observe all the stages of
sleep. Equipment is attached to the client
to monitor depth, stage, movement, respiratory effort, and oxygen saturation level during sleep.

48
Q
  1. The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg.
    Which order would the nurse question?
  2. Administer intravenous fluids of normal saline at 125 mL/hr.
  3. Provide supplemental oxygen per nasal cannula at 2 liters/min.
  4. Continuous telemetry monitoring with strips every four (4) hours.
  5. Administer a loop diuretic intravenously every six (6) hours.
A

1

  1. Normal mean pulmonary artery pressure is
    about 15 mm Hg and an elevation indicates
    right ventricular heart failure or cor pulmonale,
    which occurs in chronic obstructive
    pulmonary disease. The nurse should question
    this order because this rate is too high
    and sodium should be restricted.
  2. Supplemental oxygen should be administered
    at the lowest amount; therefore this order
    should not be questioned.
  3. Clients with hypoxia and cor pulmonale are at
    risk for dysrhythmias so monitoring the ECG
    is an appropriate intervention.
  4. Loop diuretics are administered to decrease
    the fluid and decrease the circulatory load on
    the right side of the heart;
49
Q
  1. The nurse and an unlicensed nursing assistant (NA) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the NA to improve gas exchange? Select all that apply.
  2. Keep the head of the bed elevated.
  3. Encourage deep breathing exercises.
  4. Record pulse oximeter reading.
  5. Assess level of conscious.
  6. Auscultate breath sounds.
A

1, 2, 3

  1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated.
  2. Encouraging breathing exercises can be
    delegated.
  3. Recording pulse oximeter readings can be
    delegated.
  4. Assessment cannot be delegated. Confusion is
    one of the first symptoms of hypoxia in the
    elderly.
  5. Auscultation is a technique of assessment that
    cannot be delegated.
50
Q
  1. The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
  2. Assess respiratory rate and depth.
  3. Provide for adequate rest period.
  4. Administer oxygen as prescribed.
  5. Teach slow abdominal breathing.
A

1

Because tachypnea and dyspnea may be
early indicators of respiratory compromise,
the assessment of respiratory rate and
depth is the priority intervention.

51
Q
  1. The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first?
  2. Take the client’s vital signs.
  3. Check the client’s pulse oximeter reading.
  4. Elevate the client’s head of the bed.
  5. Notify the respiratory therapist STAT.
A

3

Elevating the head of the bed promotes
lung expansion and will directly help the
client’s breathing.

52
Q
  1. The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions
    (PVC). Which intervention should the nurse implement first?
  2. Request STAT arterial blood gases.
  3. Administer lidocaine intravenous push.
  4. Assess for possible causes.
  5. Request a STAT electrocardiogram (ECG).
A

3

The nurse should assess for possible causes
of the PVCs; these causes may include
hypoxia or hypokalemia.

53
Q
  1. The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data would require immediate intervention by the nurse?
  2. The client refuses to perform shoulder exercises.
  3. The client complains of a sore throat and is hoarse.
  4. The client has crackles that clear with cough.
  5. The client is coughing up pink frothy sputum.
A

4

Pink frothy sputum indicates pulmonary
edema and would require immediate intervention.

54
Q
  1. The nurse is caring for a client on a mechanical ventilator and the alarm goes off. The nurse is unable to determine what is wrong with the ventilator and the client is in respiratory
    distress. Which action should the nurse implement first?
  2. Notify the respiratory therapist immediately.
  3. Use the ambu bag to ventilate the client.
  4. Elevate the head of the client’s bed.
  5. Assess the client’s oxygen saturation.
A

2

The nurse must first disconnect the client
from the ventilator and bag the client until
the ventilator can be fixed.

55
Q
  1. Which intervention should the nurse implement for the client experiencing bronchospasms?
  2. Administer intravenous epinephrine, a bronchodilator.
  3. Administer albuterol, a bronchodilator, via nebulizer.
  4. Request a STAT portable chest x-ray at the bedside.
  5. Insert a small nasal trumpet in the right nostril.
A

2

  1. Epinephrine is administered intravenously
    during an arrest in a code situation, but it is not a treatment of choice for bronchospasms.
  2. Albuterol given via nebulizer is administered to stop the bronchospasms. If the client continues to have the bronchospasms, intubation may be needed.
56
Q
  1. The nurse is caring for a female client that is very anxious, has a respiratory rate of 40, and is complaining of her fingers tingling and her lips feeling numb. Which intervention should the nurse implement?
  2. Have the client take slow, deep breaths.
  3. Instruct her to put her head between her legs.
  4. Determine why she is feeling so anxious.
  5. Administer Xanax, an antianxiety agent.
A

1

The client is hyperventilating and blowing
off too much CO2, which is why her fingers
are tingling and her mouth is numb; she
needs to retain CO2 by taking slow deep
breaths.

57
Q
  1. The client with pneumonia that has the following arterial blood gases: pH 7.33, PaO2 94, PaCO2 47, HCO3 25. Which intervention should the nurse implement?
  2. Administer sodium bicarbonate.
  3. Administer oxygen via nasal cannula.
  4. Have the client cough and deep breathe.
  5. Instruct the client to breathe in a paper bag.
A

3

The client is retaining CO2, which causes
respiratory acidosis, and the nurse should
help the client remove the CO2 by instructing them to cough and deep breathe.

58
Q
  1. When assessing the client diagnosed with a lung abscess, which information would the nurse expect to find to support the diagnosis?
  2. Tympanic sounds elicited by percussion over the site.
  3. Inspiratory and expiratory wheezes heard over the upper lobes.
  4. Decreased breath sounds with a pleural friction rub.
  5. Asymmetric movement of the chest wall with inspiration.
A

3

Diminished or absent sounds are heard
with intermittent pleural friction rubs. A
lung abscess is the accumulation of pus in
an area where pneumonia was present that
becomes encapsulated and can extend to
the bronchus or pleural space.

59
Q
  1. When caring for the client with a respiratory disorder, which intervention should the nurse implement first?
  2. Administer a respiratory treatment.
  3. Assess the client’s radial pulses daily.
  4. Monitor the client’s vital signs daily.
  5. Assess the client’s capillary refill time.
A

4

Assessing the client’s capillary time has the
highest priority for the nurse because it
indicates the oxygenation of the client.

60
Q
  1. The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL.
    Which intervention should the nurse implement?
  2. Hang the next bag and continue the infusion.
  3. Do not hang the next bag and decrease the rate.
  4. Notify the health-care provider of the level.
  5. Confirm the current serum theophylline level.
A

1

The therapeutic level is 10 to 20 mcg/mL;
therefore, the nurse should hang the bag
and continue the infusion to maintain the
level.

61
Q
  1. Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection?
  2. Monitor the client’s current temperature.
  3. Monitor the client’s white blood cells.
  4. Determine if a culture has been collected.
  5. Determine the compatibility of fluids.
A

3

A culture needs to be collected prior to the
first dose of antibiotic, or the culture and
sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified.

62
Q
  1. Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply.
  2. Administer oxygen via a nasal cannula.
  3. Assess the client’s lung sounds.
  4. Encourage the client to cough and deep breathe.
  5. Monitor the client’s pulse oximeter reading.
  6. Increase the client’s fluid intake.
A

1, 2, 3, 4, 5

  1. A client with a respiratory disorder may
    have decreased oxygen saturation; therefore,
    administering oxygen via a nasal
    cannula is appropriate.
  2. The client’s lungs sounds should be assessed
    to determine how much air is being
    exchanged in the lungs.
  3. Coughing and deep breathing will help the client expectorate sputum, thus clearing
    the bronchial tree.
  4. The pulse oximeter evaluates how much
    oxygen is reaching the periphery.
  5. Increasing fluids will help thin secretions,
    making them easier to expectorate.
63
Q
  1. The client in the intensive care unit on a mechanical ventilator is bucking the ventilator, causing the alarms to sound. Which assessment data should the nurse obtain? List in the order of priority.
  2. Assess the ventilator alarms.
  3. Assess the client’s pulse oximetry reading.
  4. Assess the client’s lung sounds.
  5. Assess for symmetry of the client’s chest expansion.
  6. Assess the client’s endotracheal tube for secretions.
A

5, 2, 3, 4, 1

  1. The most common cause of bucking the
    ventilator is obstructed airway, which could
    be secondary to secretions in the airway.
  2. Clients in the ICU are constantly monitored by pulse oximetry; therefore, the
    nurse should determine if the client has
    decreased oxygenation saturation and if so
    the nurse should start to “bag” the client.
  3. The nurse should assess the client’s lung
    fields to determine if air movement is
    occurring.
  4. A complication of mechanical ventilation is
    a pneumothorax, and the nurse should
    assess for this.
  5. The machine is alerting the nurse that a
    problem with the client is occurring; the
    nurse should assess the client, not the
    machine.
64
Q

Pressure Ulcers

A

Pressure Ulcers

65
Q
  1. The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
  2. Keep the skin moist by leaving the skin damp after the bath.
  3. Do not rub any lotion into the skin.
  4. Turn clients who are immobile at least every two (2) hours.
  5. Only the licensed nursing staff may care for the client’s skin.
A

3

Clients should be turned at least every one (1) to two (2) hours to prevent pressure
areas on the skin.

66
Q
  1. The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
  2. Impaired cognition.
  3. Altered nutrition.
  4. Self-care deficit.
  5. Altered coping.
A

2

Altered nutrition is a collaborative problem
involving the nurse, dietitian, and HCP.
The client will need a diet high in protein
and vitamins if there is a chance for the
client to heal.

67
Q
  1. The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
  2. Constant perineal moisture.
  3. Ability of the clients to reposition themselves.
  4. Decreased elasticity of the skin.
  5. Impaired cardiovascular perfusion of the periphery.
A

1

All the skin should be kept free of moisture.
This is within the realm of nursing to
provide this service. Clients with constant
moisture on the skin are at high risk for
impaired skin integrity.

68
Q
  1. What is the scientific rationale for placing lift pads under an immobile client?
  2. The pads will absorb any urinary incontinence and contain stool.
  3. The pads will prevent the client from being diaphoretic.
  4. The pads will keep the staff from workplace injuries such as a pulled muscle.
  5. The pads will help prevent friction shearing when repositioning the client.
A

4

Lifting the client with a “lift” pad rather
than pulling the client against the sheets
helps to prevent skin damage from friction
shearing.

69
Q
  1. The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on
    admission to the hospital?
  2. Complete the Braden Scale.
  3. Monitor the client on a Glasgow Coma Scale.
  4. Assess for a Babinski sign.
  5. Initiate a Brudzinski flow sheet.
A

1

The Braden and Norton scales are tools
that identify clients at risk for skin problems.
This client should be ranked on this
scale, and appropriate measures should be
initiated for controlling further damage to
the skin.

70
Q
  1. The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm by 4.0 cm stage II on the coccyx. Which information would alert the nurse that the client’s
    pressure ulcer is getting worse?
  2. The skin is not broken and is 2.5cm ! 3.5 cm with erythema that does not blanch.
  3. There is a 3.2-cm ! 4.1-cm blister that is red and drains occasionally.
  4. The skin covering the coccyx is intact but the client complains of pain in the area.
  5. The coccyx wound extends to the subcutaneous layer and there is drainage.
A

4

This is a stage III ulcer and is a worsening
of the client’s condition.

71
Q
  1. The nurse and unlicensed assistive personnel on a medical floor are caring for clients who are elderly and immobile. Which action by the assistant warrants immediate intervention by the nurse?
  2. The assistant elevates the head of the bed of a client that can feed himself with minimal assistance.
  3. The assistant asks to take a meal break before turning the clients at the two (2)-hour time limit.
  4. The assistant restocks the rooms that need unsterile gloves before clocking out for the shift.
  5. The assistant mixes Thick-It® into the glass of water for a client who has difficulty swallowing.
A

2

It is important to turn bedfast clients every
one (1) to two (2) hours and to encourage
them, if they are able, to make minor readjustments
to their position at least every 15
minutes. Allowing the client to lie in the
same position for at least another 30
minutes before being turned should not be
allowed.

72
Q
  1. The nurse is caring for clients on a medical unit. After the shift report which client should the nurse assess first?
  2. The 34-year-old client who is quadriplegic and cannot move his arms.
  3. The elderly client diagnosed with a CVA who is weak on the right side.
  4. The 78-year-old client with pressure ulcers who has a temperature of 102.3”F.
  5. The young adult who is unhappy with the care that was provided last shift.
A

3

The client has a fever indicating an infection.
Clients with pressure ulcers frequently
develop infections in the wounds,
which can lead to further complications.

73
Q
  1. The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included
    in the interventions?
  2. Use a pillow to keep the heels off the bed when supine.
  3. Order a low air loss therapy bed immediately.
  4. Prepare to insert a nasogastric feeding tube.
  5. Order an occupational therapy consult for strength training.
A

1

Using a pillow to suspend the heels of the
bed when a client is supine prevents the development of pressure ulcers on the heels.

74
Q
  1. The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is “tired of it all.” Which is the nurse’s best
    therapeutic response?
  2. “These wound can heal if we get enough protein into you.”
  3. “Are you tired of the treatments and needing to be cared for?”
  4. “Why would you say that? We are doing our best.”
  5. “Have you made out an advance directive to let the HCP know your wishes?”
A

2

This is restating and clarifying, both therapeutic responses.

75
Q
  1. The nurse writes the problem “impaired skin integrity” for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that
    apply.
  2. Turn the client every three (3) to four (4) hours.
  3. Ask the dietician to consult.
  4. Have the client sign a consent for pictures of the wounds.
  5. Obtain an order for a low air loss bed.
  6. Elevate the head of the bed at all times.
A

2, 4

  1. The client must be turned every one (1) to two (2) hours.
  2. Clients with pressure ulcers usually are
    debilitated and have a poor nutritional base
    for healing. An increase in protein and
    vitamins is needed in the diet to promote
    healing.
  3. Clients must sign consents if they are recognizable
    in the pictures. It is standard practice to
    document wounds by taking an instant imaging
    picture and placing the picture in the chart
    for reference by all concerned staff. In this
    instance a consent is not needed.
  4. A client with a stage IV pressure ulcer
    needs a higher level of pressure reduction
    than a normal hospital mattress can provide.
  5. The head of the bed can be in any position of comfort for the client, but the head should not be elevated at “all” times because the pressure applied to the lower body region.
76
Q
  1. The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective
    when the client makes which statement?
  2. “This surgery will create a skin flap to cover my wounds.”
  3. “This surgery will get all the old black tissue out of the wound so it can heal.”
  4. “The surgery is important to allow oxygen to get to the tissue for healing to occur.”
  5. “Stool will come out an opening in my abdomen so it won’t get in the sore.”
A

4

AE III Exam 2 (1 decks)

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