Med surge Critical care
Med surge Critical care
1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and
... [Show More] having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.
ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.
2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.
3. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
a. "Breathing so rapidly interferes with oxygenation."
b. "Maybe the client has respiratory distress syndrome."
c. "The blood clot interferes with perfusion in the lungs."
d. "The client needs immediate intubation and mechanical ventilation."
ANS: C
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin).
ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush.
ANS: B
Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.
6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L 3
c. Red blood cell count: 4.8/mm 3 d. White blood cell count: 8.7/mm
ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.
ANS: A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.
8. A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.
ANS: C
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.
9. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.
ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.
10. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.
ANS: C
The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.
11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.
ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.
12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client's hands.
d. Sedate the client immediately.
ANS: A
The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.
13. A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
ANS: B
Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.
14. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?
a. "It will increase the motility of the gastrointestinal tract."
b. "It will keep the gastrointestinal tract functioning normally."
c. "It will prepare the gastrointestinal tract for enteral feedings."
d. "It will prevent ulcers from the stress of mechanical ventilation."
ANS: D
Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.
15. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines.
ANS: C
The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.
16. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chef's salad and muffin
c. No selection; spouse brings pizza d. Tuna salad sandwich and chips
ANS: B
Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medication's mechanism of action.
17. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
a. Poor visual acuity
b. Strict vegetarian
c. Refusal to stop smoking d. Wants weight loss surgery
ANS: B
Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.
18. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
a. Assessing the client's platelet count
b. Choosing an 18-gauge, 2-inch needle
c. Not aspirating prior to injection
d. Swabbing the injection site with alcohol
ANS: B
Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.
19. A client in the emergency department has several broken ribs. What care measure will best promote comfort?
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets
ANS: A
Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.
20. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium (Coumadin)
ANS: A
Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.
21. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?
a. Administer oxygen and reassess.
b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
ANS: D
This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.
22. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?
a. "It is chronic hypoxemia that accompanies restrictive airway disease."
b. "It is hypoxemia from lung damage due to mechanical ventilation."
c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."
ANS: D
Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.
23. A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:
What action by the nurse is most appropriate?
a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography.
c. Prepare for immediate endotracheal intubation.
d. Prepare to administer intravenous anticoagulants.
ANS: B
This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.
1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur
ANS: B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
2. When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids. c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
ANS: C, D, E
Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel (UAP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E
Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.
. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule
ANS: A, B, C, D
The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.
5. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
a. Allow visitors at the client's bedside.
b. Ensure the client can communicate if awake.
c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.
ANS: A, B, D, E
There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.
6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle strength c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
ANS: A, B, D
Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.
1. A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL
ANS:
660 mL
A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg.
110 kg × 6 mL/kg = 660 mL.
1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.
ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.
DIF: Applying/Application REF: 494
KEY: Patient-centered care| smoking cessation
MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial Integrity
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry.
b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication.
c. Client has reduced breath sounds. - Nurse calls physician immediately.
d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.
ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.
DIF: Applying/Application REF: 512
KEY: Assessment/diagnostic examination| respiratory distress/failure MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaption
3. A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?
a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.
DIF: Applying/Application REF: 496
KEY: Assessment/diagnostic examination
MSC: IntegratedProcess:NursingProcess:Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the client's level of consciousness.
c. Raise the head of the bed to at least 45 degrees.
d. Provide the client with humidified oxygen.
ANS: B
Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.
DIF: Applying/Application REF: 501
KEY: Older adult| pulmonary infection
MSC: IntegratedProcess:NursingProcess:Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?
a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow
rate.
b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully.
c. Wheezes are heard in central areas. - The nurse administers an inhaled
bronchodilator.
d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe
deeply.
ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.
DIF: Applying/Application REF: 506
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
a. "Are you taking any medications or herbal supplements?"
b. "Do you have any chronic breathing problems?"
c. "How often do you perform aerobic exercise?"
d. "What is your occupation and what are your hobbies?"
ANS: B
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.
DIF: Applying/Application REF: 503
KEY: Assessment/diagnostic examination
MSC: IntegratedProcess:NursingProcess:Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
a. Increased temperature
b. Absent breath sounds
c. Productive cough
d. Incisional discomfort
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.
DIF: Applying/Application REF: 512
KEY: Assessment/diagnostic examination| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client
.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.
DIF: Applying/Application REF: 511
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 liters of oxygen.
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.
DIF: Applying/Application REF: 511
KEY: Assessment/diagnostic examination| respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
a. Call the physician and request a prescription for food and water.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client's gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.
DIF: Applying/Application REF: 511
KEY: Assessment/diagnostic examination
MSC: IntegratedProcess:NursingProcess:Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning
ANS: A
A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
DIF: Applying/Application REF: 503
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
12. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?
a. "Make a list of reasons why smoking is a bad habit."
b. "Rise slowly when getting out of bed in the morning."
c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."
ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.
DIF: Applying/Application REF: 495
KEY: Smoking cessation| medication MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.
ANS: B
Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.
DIF: Applying/Application REF: 510
KEY: Assessment/diagnostic examination| medication
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler's position. d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.
DIF: Remembering/Knowledge REF: 506
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings d. Impaired judgment e. Increased thirst
ANS: A, D
Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.
DIF: Understanding/Comprehension REF: 496
KEY: Medication| smoking cessation
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encourage deep breathing and coughing.
b. Implement an air mattress overlay.
c. Ambulate the client three times each day.
d. Provide a diet high in protein and vitamins.
e. Administer acetaminophen (Tylenol) twice daily.
ANS: A, C, D
Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.
DIF: Applying/Application REF: 501
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.)
a. "What response do you have when you eat avocados?"
b. "I will remove any avocados that are on your lunch tray."
c. "When was the last time you ate foods containing avocados?"
d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?"
ANS: A, D, E
Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the client's medical record. The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care.
DIF: Applying/Application REF: 502
KEY: Allergies/allergic response
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)
a. "I held the client's morning bronchodilator medication."
b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill."
d. "I advised the client not to smoke for 6 hours prior to the test."
e. "The client is alert and can follow your commands."
ANS: A, D, E
To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.
DIF: Applying/Application REF: 509
KEY: Assessment/diagnostic examination
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.)
a. "Find an activity that you enjoy and will keep your hands busy."
b. "Keep snacks like potato chips on hand to nibble on."
c. "Identify a punishment for yourself in case you backslide." d. "Drink at least eight glasses of water each day."
e. "Make a list of reasons you want to stop smoking."
ANS: A, D, E
The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.
DIF: Applying/Application REF: 496
KEY: Smoking cessation| patient-centered care
MSC: IntegratedProcess:Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
SHORT ANSWER
1. A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years
ANS:
45 pack-years
66 (current age) - 16 (year started smoking) = 50 years of smoking.
(40 years × 1 pack per day) + (10 years × 0.5 pack per day) = 45 pack-years.
DIF: Applying/Application REF: 495
KEY: Smoking cessation
MSC: IntegratedProcess:NursingProcess:Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation [Show Less]