Question 1

A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk, or perform any rehabilitative activities. The best initial nursing approach would be to:

Accepted Answer

Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving. The withdrawal provides time for the client to assimilate to what has occurred and integrate the change in the body image. Acceptance of the client's behavior is an important factor in the nurse's intervention.

Question 2

A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the:

Accepted Answer

Lower half of the sternum. The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression, which can lead to a possible aspiration.

Question 3

Which of the following statements concerning ARDS is true?

Accepted Answer

Type II alveolar cells are damaged as part of the ARDS cascade, leading to a decrease in surfactant production and alveolar collapse. Risk factors for developing this non-cardiogenic pulmonary edema include aspiration of gastric contents, all types of shock, oxygen toxicity, fat embolism, major trauma, smoke inhalation, multiple blood transfusions, viral pneumonia, and burns. The PCWP is elevated in pulmonary edema caused by CHF, but is normal in pulmonary edema caused by ARDS since the edema is not caused by a deficient heart muscle. ARDS has a high mortality rate.

Question 4

A client, newly diagnosed with asthma, is started on theophylline (Theo-Dur, SloBid) and is going to be discharged. In the discharge teaching, the nurse instructs the client that this medication will cause which of the following?

Accepted Answer

Tachycardia is a side effect of theophylline. It causes CNS stimulation. Increased intraocular pressure and hemolytic anemia are not side effects of theophylline. Anorexia is also a side effect of theophylline.

Question 5

Which of the following physiologic effects of a pulmonary embolism would initially affect oxygenation?

Accepted Answer

The blood clot blocks blood flow to a region of the lung tissue. That area remains ventilated, but because blood flow is blocked, no gas exchange can occur in that region and a ventilation-perfusion mismatch is present. Ventilation isn't initially affected by a blood clot because air can still move normally through the bronchial tree.

Question 6

Dr) Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to:

Accepted Answer

Delay resistance and increase the tuberculostatic effect. Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 months. Prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.

Question 7

A thoracentesis is performed on a chest-injured client and no fluid or air is found. Blood and fluid is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?

Accepted Answer

Pericardial tamponade. Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles, causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. This leads to right atrial and venous congestion manifested by a CVP reading above normal.

Question 8

To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:

Accepted Answer

Encourage frequent coughing and deep breathing. This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

Question 9

Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit, Mario is placed in Fowler's position on either his right side or on his back to:

Accepted Answer

Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining left lung by positioning the client on the opposite un-operated side.

Question 10

A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse's highest priority of information would be

Accepted Answer

Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctor sprays the back of the throat with anesthetic to minimize the gag reflex and thus, facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

Question 11

Which nursing goal would be appropriate for a client with sepsis who has developed acute respiratory distress syndrome?

Accepted Answer

The primary and priority concern for a client with acute respiratory distress syndrome is maintaining oxygenation and preventing hypoxia.

Question 12

The nurse is assessing Mr. Guzman, a 40-year-old baker with no significant past medical history, who was admitted to the Emergency Department. The assessment findings include a decrease in level of consciousness; rapid, shallow respirations; nasal flaring; sterna and intercostals retractions; and cyanosis around the lips and oral mucosa. The ABG reveals pH - 7.24, pCO2 - 55, and PaO2 - 50. Which statement best describes these findings?

Accepted Answer

The analysis of the blood gas information, in conjunction with the clinical manifestations, indicates acute respiratory distress with respiratory acidosis and hypoxemia. The client's blood gas pH is low and represents acidosis. The pCO2 is elevated (normal pCO2 is 35-45 mmHg) and demonstrates hypercapnia. A normal PaO2 is in the range of 75 to 100 mmHg, so this client's PaO2 is considered low.

Question 13

A client had a respiratory arrest and required endotracheal intubation. Which auscultory findings would indicate correct placement of the tube?

Accepted Answer

An endotracheal tube has been correctly placed when it is located approximately 3 to 4 centimeters above the carina. Ventilation of correct placement is done by auscultating the chest for equal bilateral symmetrical rise and fall of the chest with ventilation.

Question 14

While the nurse is caring for a client on a ventilator, the low-pressure ventilator alarm sounds. What should the nurse's first action be?

Accepted Answer

A low-pressure ventilator alarm most likely signals a disconnection from the ventilator.

Question 15

Mr) Kent, 42 years old, had a cuffed tracheostomy tube placed 4 weeks ago. This morning, his doctor made an order for him to begin eating by mouth, with the tracheostomy in place. To prevent aspiration, the nurse will: Select all that apply:

Accepted Answer

(A) By raising the head of the bed, gravity helps the client swallow and helps prevent aspiration; (C) the cuff should initially be deflated to assess gag and swallowing ability; (D) the client's airway should be patent and secretions removed before deflating the cuff; and (E) assessing the client's gag and swallowing ability is crucial before starting the client on PO food and fluids. Choice B is incorrect because there is no reason to increase FiO2. Choice F is incorrect because it is not necessary to replace the tracheostomy ties before the client eats, unless they are noted to soiled or loose.

Question 16

A nurse is reading the results of a TB skin test on Ms. Dressler, a 72-year-old resident in a Nursing Home. Ms. Dressler has never had a TB skin test. There is no induration around the injection site. The nurse should document the test as negative and:

Accepted Answer

The client who is elderly may test as false negative because of diminished hypersensitivity-type immune response. It is best to do the 2-step TB skin test and have client repeat the test 1-3 weeks after the first test. If the second skin test is still negative, then the client can be informed that she does not have TB. If the second test is positive, then the client should receive a follow up chest X-ray and prophylactic treatment.

Question 17

The nurse explains to a client's family that humidification is given with oxygen administration because:

Accepted Answer

Humidification of oxygen is extremely important in reducing its drying effects on the mucous membranes of the bronchial tree. Humidification of oxygen is generally provided by a water nebulizer. Choices A, C, and D are incorrect because oxygen is not highly permeable in water; thus, water tends to inhibit rather than facilitate oxygen diffusion across the respiratory membrane. Humidification expands the volume of the inhaled gas, but by doing so it decreases the partial pressure of the gas in the alveoli. Normal alveolar partial pressures of oxygen are approximately 100 mmHg, whereas the partial pressures of oxygen in the atmosphere are approximately 135 mmHg.

Quiz 2: Neuro Muscular and Pulmonary