NUR 270 Med Surg Ch 23 Exam With
Complete Solutions
A perioperative nurse is caring for a postoperative patient. The patient has a
shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The
nurse should address the patient's increased risk for what complication? -
ANSWER atelectasis
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the
patient at an increased risk of developing atelectasis. These specific factors are
less likely to result in pulmonary embolism or aspiration. ARDS involves an
exaggerated inflammatory response and does not normally result from factors
such as immobility and shallow breathing.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a
surgical complication. The nurse's assessment reveals that the patient has an
increased work of breathing due to copious tracheobronchial secretions. What
should the nurse encourage the patient to do? - ANSWER Increase oral fluids
unless contraindicated
Rationale
The nurse should encourage hydration because adequate hydration thins and
loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove
tracheobronchial secretions. The patient should have the head of the bed
raised, and rest should be promoted to avoid exacerbation of symptoms.
The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer
this test? - ANSWER administer intradermal injections into the childrens inner
forearms
Rationale
The purified protein derivative (PPD) is always injected into the intradermal
layer of the inner aspect of the forearm. The subcutaneous and intramuscular
routes are not utilized.
The nurse is caring for a patient who has been in a motor vehicle accident and
the care team suspects that the patient has developed pleurisy. Which of the
, nurse's assessment findings would best corroborate this diagnosis? - ANSWER
The patient's pain intensifies when he coughs or takes a deep breath.
Rationale:
The key characteristic of pleuritic pain is its relationship to respiratory
movement. Taking a deep breath, coughing, or sneezing worsens the pain. The
patient's ABGs would most likely be abnormal and shortness of breath would be
expected.
The nurse caring for a patient recently diagnosed with lung disease encourages
the patient not to smoke. What is the primary rationale behind this nursing
action? - ANSWER Smoking damages the ciliary cleansing mechanism.
Rationale:
In addition to irritating the mucous cells of the bronchi and inhibiting the
function of alveolar macrophage (scavenger) cells, smoking damages the ciliary
cleansing mechanism of the respiratory tract. Smoking also increases the
amount of mucus production and distends the alveoli in the lungs. It reduces the
oxygen-carrying capacity of hemoglobin, but not by directly competing for
binding sites.
A pt has been brought to the ED by the paramedics. the pt is suspected of
having ARDS. what intervention should the nurse 1st anticipate? - ANSWER
preparing to assist w/ intubating the client
rationale:
A patient who has ARDS usually requires intubation and mechanical ventilation.
Oxygen by nasal cannula would likely be insufficient. Deep suctioning and
nebulizers may be indicated, but the priority is to secure the airway.
The nurse is caring for a patient who is scheduled for a lobectomy for a
diagnosis of lung cancer. While assisting with a subclavian vein central line
insertion, the nurse notes the client's oxygen saturation rapidly dropping. The
patient complains of shortness of breath and becomes tachypneic. The nurse
suspects a pneumothorax has developed. Further assessment findings
supporting the presence of a pneumothorax include what? - ANSWER
Diminished or absent breath sounds on the affected side
Feedback:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal
absent or diminished breath sounds on the affected side. Paradoxical chest wall
movements occur in flail chest conditions. Sudden loss of consciousness does
not typically occur. Muffled or distant heart sounds occur in pericardial
tamponade.
Complete Solutions
A perioperative nurse is caring for a postoperative patient. The patient has a
shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The
nurse should address the patient's increased risk for what complication? -
ANSWER atelectasis
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the
patient at an increased risk of developing atelectasis. These specific factors are
less likely to result in pulmonary embolism or aspiration. ARDS involves an
exaggerated inflammatory response and does not normally result from factors
such as immobility and shallow breathing.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a
surgical complication. The nurse's assessment reveals that the patient has an
increased work of breathing due to copious tracheobronchial secretions. What
should the nurse encourage the patient to do? - ANSWER Increase oral fluids
unless contraindicated
Rationale
The nurse should encourage hydration because adequate hydration thins and
loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove
tracheobronchial secretions. The patient should have the head of the bed
raised, and rest should be promoted to avoid exacerbation of symptoms.
The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer
this test? - ANSWER administer intradermal injections into the childrens inner
forearms
Rationale
The purified protein derivative (PPD) is always injected into the intradermal
layer of the inner aspect of the forearm. The subcutaneous and intramuscular
routes are not utilized.
The nurse is caring for a patient who has been in a motor vehicle accident and
the care team suspects that the patient has developed pleurisy. Which of the
, nurse's assessment findings would best corroborate this diagnosis? - ANSWER
The patient's pain intensifies when he coughs or takes a deep breath.
Rationale:
The key characteristic of pleuritic pain is its relationship to respiratory
movement. Taking a deep breath, coughing, or sneezing worsens the pain. The
patient's ABGs would most likely be abnormal and shortness of breath would be
expected.
The nurse caring for a patient recently diagnosed with lung disease encourages
the patient not to smoke. What is the primary rationale behind this nursing
action? - ANSWER Smoking damages the ciliary cleansing mechanism.
Rationale:
In addition to irritating the mucous cells of the bronchi and inhibiting the
function of alveolar macrophage (scavenger) cells, smoking damages the ciliary
cleansing mechanism of the respiratory tract. Smoking also increases the
amount of mucus production and distends the alveoli in the lungs. It reduces the
oxygen-carrying capacity of hemoglobin, but not by directly competing for
binding sites.
A pt has been brought to the ED by the paramedics. the pt is suspected of
having ARDS. what intervention should the nurse 1st anticipate? - ANSWER
preparing to assist w/ intubating the client
rationale:
A patient who has ARDS usually requires intubation and mechanical ventilation.
Oxygen by nasal cannula would likely be insufficient. Deep suctioning and
nebulizers may be indicated, but the priority is to secure the airway.
The nurse is caring for a patient who is scheduled for a lobectomy for a
diagnosis of lung cancer. While assisting with a subclavian vein central line
insertion, the nurse notes the client's oxygen saturation rapidly dropping. The
patient complains of shortness of breath and becomes tachypneic. The nurse
suspects a pneumothorax has developed. Further assessment findings
supporting the presence of a pneumothorax include what? - ANSWER
Diminished or absent breath sounds on the affected side
Feedback:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal
absent or diminished breath sounds on the affected side. Paradoxical chest wall
movements occur in flail chest conditions. Sudden loss of consciousness does
not typically occur. Muffled or distant heart sounds occur in pericardial
tamponade.
