MED SURG TEST BANK RED HESI TEST BANK MED-
SURG AND OTHER RESOURCES COMLETE TEST
13. Which of the following nursing interventions is most
... [Show More] appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down" - D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient?
A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. - C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.
15. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance - D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. - C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to have supplemental oxygen applied.
17. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room - B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions should the nurse take first? A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen. - D. Sit the patient up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with use of a contrast dye.
C. This test will use magnetic fields to produce images of the lungs and chest. D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs. - A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes? A. Laryngospasm B. Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema - C. Narrowing of the airwayNarrowing of the airway leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing.
21. A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which of the following clinical manifestations might be present as an early symptom during an exacerbation of asthma?
A. Anxiety
B. Cyanosis
C. Hypercapnia
D. Bradycardia - A. Anxiety An early symptom during an asthma attack is anxiety because he is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating.
22. The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Observe for signs of diaphoresis
B. Allow time to calm the patient
C. Monitor the patient for bilateral chest expansion
D. Evaluate the use of intercostal muscles - D. Evaluate the use of intercostal muscles
The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient.
23. Which of the following positions is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?
A. Supine
B. Lithotomy
C. High-Fowler's
D. Reverse Trendelenburg - C. High-Fowler'sThe patient experiencing an asthma attack should be placed in high-Fowler's position to allow for optimal chest expansion and enlist the aid of gravity during inspiration.
24. The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicates to the nurse that the patient's respiratory status is improving?
A. Wheezing becomes louder
B. Vesicular breath sounds decrease
C. Aerosol bronchodilators stimulate coughing
D. The cough remains nonproductive - A. Wheezing becomes louder The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange.
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base - D. The fingernail and its base Clubbing, a sign of longstanding hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes - B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
3. The nurse notices clear nasal drainage in
e patient this is normal. - A. test the drainage for the presence of glucose. Cl [Show Less]