Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
20 Cards in this Set
- Front
- Back
|
A nurse in a provider’s office is collecting data from a client who is states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? |
a. Pericardial friction rub b. Weight gain c. Night sweats d. Cyanosis of the fingertips
Answer
a. Pericardial friction rub A pericardial friction rub is a clinical manifestation of rheumatic carditis. b. Weight gain Anorexia and weight loss are clinical manifestations of tuberculosis. c. Night sweats
CORRECT. Night sweats and fevers are clinical manifestations of tuberculosis. d. Cyanosis of the fingertips Cyanosis of the fingertips is a clinical manifestation of Raynaud’s disease. |
|
|
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease and pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? |
a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
Answer
a. Respiratory alkalosis Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. b. Respiratory acidosis
CORRECT. Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. c. Metabolic alkalosis Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. Excessive vomiting also places a client at risk for development of metabolic alkalosis. d. Metabolic acidosis Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk for the development of metabolic acidosis. |
|
|
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? |
a. The client is unable to speak. b. The client's airway secretions were last suctioned 2 hr ago. c. The client coughs and expectorates a large mucous plug. d. The client has coarse crackles in the lung fields.
Answer
a. The client is unable to speak. The client who has a tracheostomy with an inflated cuff in place is unable to speak. b. The client's airway secretions were last suctioned 2 hr ago. The nurse should assess the need for suctioning every 2 hr and then suction as necessary. c. The client coughs and expectorates a large mucous plug.
The nurse should check the client's airway after coughing and only suction the client's secretions, if the client is able to cough and expectorate secretions. d. The client has coarse crackles in the lung fields.
CORRECT. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client’s airway secretions. |
|
|
A nurse is reinforcing teaching with a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? |
a. Total lung capacity b. Vital lung capacity c. Functional residual capacity d. Residual volume
Answer
a. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. b. Vital lung capacity Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. c. Functional residual capacity Functional residual capacity measures the amount of air in the lungs after normal expiration. d. Residual volume Residual volume measures the amount of air in the lungs after forced expiration. |
|
|
A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? |
a. Clamp the chest tube if there is continuous bubbling in the water seal chamber. b. Keep the chest tube drainage system at the level of the right atrium. c. Tape all connections between the chest tube and drainage system. d. Empty the collection chamber and record the amount of drainage every 8 hr.
Answer
a.Clamp the chest tube if there is continuous bubbling in the water seal chamber. The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless it becomes necessary to replace the drainage unit or locate an air leak. b. Keep the chest tube drainage system at the level of the right atrium. The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. c. Tape all connections between the chest tube and drainage system.
CORRECT. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting. d. Empty the collection chamber and record the amount of drainage every 8 hr. The nurse should not empty the collection chamber or change the system unless it is almost full. |
|
|
A nurse is assisting with the care for a client who had a chest tube inserted 12 hr ago. The nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. The nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications? |
a. Friction rub b. Crackles c. Crepitus d. Tactile fremitus
Answer
a. Friction rub A friction rub is a scratching or squeaking sound the nurse can hear when auscultating the client’s lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. b. Crackles Crackles, which are sometimes called rales, are wet popping sounds the nurse can hear when auscultating the client’s lungs. This condition occurs when there is fluid in the client’s airways or alveoli. Crackles are a clinical manifestation of pneumonia. c. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client’s chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax. d. Tactile fremitus Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client’s chest as the client repeats a syllable such as 'nine-nine'. Increased tactile fremitus is a clinical manifestation of pneumonia. |
|
|
A nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultating the client’s lung sounds? |
a. Absence of breath sounds
b. Expiratory wheezing
c. Inspiratory stridor
d. Rhonchi
Answer
a. Absence of breath sounds
CORRECT. A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. b. Expiratory wheezing A client who has asthma experiences an expiratory wheezing during an acute asthma attack. c. Inspiratory stridor A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound often heard without a stethoscope. d. Rhonchi A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snore-like noises produced in the throat. |
|
|
A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? |
a. Dry cough b. Rhinitis c. Sore throat d. Swollen lymph nodes
Answer
a. Dry cough
CORRECT. The client who has a dry cough has a clinical manifestation found in the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis. b. Rhinitis The client who has rhinitis is not manifesting findings of inhalation anthrax; however, rhinitis is typically seen with colds and influenza. c. Sore throat The client who has a sore throat is not manifesting findings of inhalation anthrax; however, a sore throat is typically seen with colds and influenza. d. Swollen lymph nodes Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax. |
|
|
A nurse in a clinic is reinforcing teaching with a client who is to have a tuberculin skin test. Which of the following information should the nurse include? |
a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
Answer
a. "If the test is positive, it means you have an active case of tuberculosis." A positive test means that the client has been exposed to tubercle bacillus, but it does not mean that the client has an active case of tuberculosis. The client should have a chest x-ray to rule-out active tuberculosis. b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." The client who has a positive tuberculin skin test should have a chest x-ray to rule-out active tuberculosis. When a client has a positive skin test, subsequent skin tests will always be positive. b. "You must return to the clinic to have the test read in 2 or 3 days."
CORRECT. The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another skin test is necessary. c. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance." The nurse will inject 0.1 mL of purified protein derivative intradermally to the dorsal aspect of the client’s forearm. |
|
|
A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? |
a. "Apply warm compresses to the face." b. "Take aspirin 650 milligrams by mouth for mild pain." c. "Close your mouth when sneezing." d. "Lie on your back with your head elevated 30° when resting."
Answer
a. "Apply warm compresses to the face." The client should apply cold compresses to his face to decrease swelling. b. "Take aspirin 650 milligrams by mouth for mild pain." The client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation. b. "Close your mouth when sneezing." The client should open his mouth when sneezing to reduce straining on the incisional site. c. "Lie on your back with your head elevated 30° when resting."
CORRECT. The nurse should instruct the client to rest in the semi-Fowler’s position to prevent aspiration of nasal secretions.
|
|
|
A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments? |
a. To encourage deep breaths
b. To mobilize secretions in the airways
c. To dilate the bronchioles
d. To stimulate the cough reflex
Answer
a. To encourage deep breaths
Chest therapy does not encourage deep breaths. However, once airway secretions are mobilized and expectorated, the client might be able to breathe deeper.
b. To mobilize secretions in the airways
CORRECT. The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.
c. To dilate the bronchioles
Chest physiotherapy does not dilate the bronchioles; however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways.
d. To stimulate the cough reflex
Chest physiotherapy does not stimulate the cough reflex; however, the mobilization of secretions can increase the client’s ability to cough up secretions. |
|
|
A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements should the nurse make? |
a. "After the surgeon removes the lung, you will not need to cough." b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." c. "Don’t worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." d. "I will show you how to splint your incision while coughing."
Answer
a. "After the surgeon removes the lung, you will not need to cough." The client who had a pneumonectomy must cough to clear secretions from the remaining lung. b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." The client who had a pneumonectomy must cough to clear secretions from the remaining lung. c. "Don’t worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." Pain medication reduces pain to a tolerable level; however, it does not necessarily keep the client pain-free. Additionally, telling the client not to worry is a barrier to communication and provides false reassurance. d. "I will show you how to splint your incision while coughing." The client who had a pneumonectomy must cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing. |
|
|
A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following client findings is an adverse effect of this medication? |
a. Hallucinations b. Pruritus c. Hand and foot syndrome d. Tinnitus
Answer
a. Hallucinations Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemia. b. Pruritus Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis. c. Hand and foot syndrome Hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic medication used to treat breast and colorectal cancer. d. Tinnitus
CORRECT. An adverse effect of cisplatin is ototoxicity, which can cause tinnitus |
|
|
A nurse is reinforcing teaching about pursed-lip breathing for a client who has chronic obstructive pulmonary disease and emphysema. The nurse should explain that this breathing technique does which of the following? |
a. Increases oxygen intake
b. Keeps the airways open on exhalation
c. Uses the intercostal muscles
d. Strengthens the diaphragm
Answer
a. Increases oxygen intake The client who uses pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. Increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. b. Keeps the airways open on exhalation
CORRECT. The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client’s pace of breathing and keeps the airway open on exhalation, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. c. Uses the intercostal muscles The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using chest-wall muscles. d. Strengthens the diaphragm The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using the diaphragm. |
|
|
A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure? |
a. Lying flat on the affected side
b. Prone with the arms raised over the head c. Supine with the head of the bed elevated d. Sitting while leaning forward over the bedside table Answer
a. Lying flat on the affected side When preparing a client for a thoracentesis, the nurse should not position the client lying flat on the affected side, because it does not allow access for draining the accumulated fluid and air. b. Prone with the arms raised over the head When preparing a client for a thoracentesis, the nurse should not place the client prone, because it does not position the client for appropriate access for draining the accumulated fluid and air. c. Supine with the head of the bed elevated When preparing a client for a thoracentesis, the nurse should not place the client supine, because it does not position the client for appropriate access for draining accumulated fluid and air. d. Sitting while leaning forward over the bedside table CORRECT. When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client’s ribs and allows for aspiration of accumulated fluid and air. |
|
|
A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first? |
a. Talk about how to eliminate environmental triggers that precipitate attack. b. Determine the client’s perception of the disease process and what might have triggered the current attack. c. Discuss with the client about the client's medication regimen. d. Review the manifestations of respiratory infections.
Answer
a. Talk about how to eliminate environmental triggers that precipitate attack.
Although it is important for the nurse to discuss how to eliminate environmental triggers that precipitate asthma attacks, there is another point the nurse should discuss first.
b. Determine the client’s perception of the disease process and what might have triggered the current attack.
CORRECT. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client’s current knowledge.
c. Discuss with the client about the client's medication regimen.
Although it is important for the nurse to discuss the client’s medication regimen to ensure understanding of how to use each medication, there is another point the nurse should discuss first.
d. Review the manifestations of respiratory infections.
Although it is important for the nurse to review manifestations of respiratory infections with the client, there is another point the nurse should discuss first. |
|
|
A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? |
a. Tympanic temperature 38° C (100.4° F) b. PaO2 50 mm Hg c. Rhonchi d. Hypopnea Answer a. Tympanic temperature 38° C (100.4° F) Although this client's temperature is not within the expected reference range, it is not a clinical manifestation of ARDS. b. PaO2 50 mm Hg CORRECT. The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. c. Rhonchi The client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway. d. Hypopnea The client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing, and indicates the presence of an increase in the work of breathing. |
|
|
A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? |
a. Eat high-calorie foods first. b. Increase intake of water at meal times. c. Perform active range-of-motion exercises before meals. d. Keep saltine crackers nearby for snacking. Answer a. Eat high-calorie foods first. CORRECT. The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first. b. Increase intake of water at meal times. Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at meal times to reduce the feeling of early satiety. c. Perform active range-of-motion exercises before meals. The client should rest before meals to decrease dyspnea while eating. d. Keep saltine crackers nearby for snacking. Although the client should keep foods on hand for snacking, she should avoid dry and salty foods, which can place her at risk for aspiration and make her mouth dry. |
|
|
A nurse is preparing to assist a provider to withdraw arterial blood from a client’s radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? |
a. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. b. Apply ice to the site after obtaining the specimen. c. Check the circulation in the client’s ulnar artery prior to obtaining the specimen. d. Release pressure applied to the puncture site 1 min after the needle is withdrawn. Answer a. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. The nurse should not administer oxygen prior to the blood draw, because the test measures the client’s blood gases when breathing room air. b. Apply ice to the site after obtaining the specimen. The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice to the withdrawal site. c. Check the circulation in the client’s ulnar artery prior to obtaining the specimen. CORRECT. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. d. Release pressure applied to the puncture site 1 min after the needle is withdrawn. The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site. |
|
|
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism? |
a. Sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing Answer a. Sudden onset of dyspnea CORRECT. Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. b. Tracheal deviation Tracheal deviation is an indication of tension pneumothorax and is fatal if not promptly treated. c. Bradycardia Tachycardia is a clinical manifestation of pulmonary embolism. d. Difficulty swallowing Difficulty swallowing is an indication of many conditions, including oral cancer. |
