NUR 222

NUR 222 Ch 10 Exam A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? - Correct Answer-Encouraging increased fluid intake by the patient with pneumonia has thick, tenacious secretions (p. 286) When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? - Correct Answer-Hypercapnia, hypoventilation, and hypoxemia (p. 297) A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? - Correct Answer-Initiate oxygen therapy. (p. 304) Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? - Correct Answer-Receiving vaccinations (p. 287) What dietary recommendations should a nurse provide a client with a lung abscess? - Correct Answer-A diet rich in protein (p. 288) The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? - Correct Answer-Classes at community centers to teach about smoking cessation strategies (p. 308) The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? - Correct Answer-Tension pneumo-thorax (p. 317) A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? - Correct Answer-"Viruses like influenza are the most common cause of pneumonia." The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? - Correct Answer-6 to 12 months (p. 293) The nurse assigned to a patient with possible pulmonary edema assesses the patient's lungs. Using auscultation, she identifies a characteristic *breath sound diagnostic of pulmonary edema*. Which of the following describes that breath sound? - Correct Answer-Crackles in the lung bases are characteristic of pulmonary edema.(p. 294) The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? - Correct Answer-Acute respiratory distress syndrome (p. 298) A victim has sustained a *blunt force trauma to the chest*. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a *moderate pulmonary contusion*? - Correct Answer-Blood-tinged sputum (p. 320) Which of the following types of hypoxia result from decreased hemoglobin concentration? - Correct Answer-Anemic hypoxia (p. 283) The nurse is planning for the care of a patient with *acute tracheo-bronchitis.* What nursing interventions should be included in the plan of care? (Select all that apply.) - Correct Answer-Increasing fluid intake to remove secretions; Encouraging the patient to remain in bed; Using cool-vapor therapy to relieve laryngeal and tracheal irritation A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? - Correct Answer-0 to 4 mm (p. 292) A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? - Correct Answer-Developing a list of people with whom the client has had contact (p. 290) The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with *occupational lung diseases*? - Correct Answer-*Fibrotic changes in lungs* (p. 308) You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when *bubbling in the water-seal chamber is excessive*? - Correct Answer-See if there are leaks in the system. (p. 314) A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? - Correct Answer-Streptococcus pneumoniae (p. 280) When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of *hypoxemia*? - Correct Answer-PaO2 < 60 mm Hg (p. 283) You are caring for a client with secondary pulmonary hypertension {pulmonary arterial hypertension due to a known cause}. What assessment finding would you expect? - Correct Answer-Orthopnea A nurse is caring for a patient diagnosed with *empyema*. Which of the following interventions does a nurse implement for patients with empyema? - Correct Answer-Encourage breathing exercises. (P. 289) When preparing a chest drainage system, the nurse would fill the water seal chamber to which mark? - Correct Answer-2 cm level (p. 317) The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for *pulmonary edema*? - Correct Answer-*Crackles* in the lung bases are adventitious lung sounds significant for *pulmonary edema* (p. 276) You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? - Correct Answer-Progressive loss of lung function associated with chronic disease (p. 297) You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? - Correct Answer-Encourage increased fluid the patient with viral pneumonia (p. 288) The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? - Correct Answer-Chemical irritation A patient is diagnosed with hypoxemic hypoxia. The nurse knows that the etiology directs medical and nursing interventions. Which of the following is the cause? - Correct Answer-Decreased oxygen diffusion into the tissues (p. 283) A nurse recognizes that a client with tuberculosis needs further teaching when the client states: - Correct Answer-"The people I have contact with at work should be checked regularly." (p. 293) Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? - Correct Answer-Vitamin B6 (p. 293) A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? - Correct Answer-Flail chest (p. 319) The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? - Correct Answer-6 to 12 months (p. 293) A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? - Correct Answer-Dyspnea (p. 301) The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema? - Correct Answer-Elevated B-type natriuretic peptide (BNP) levels A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? - Correct Answer-A client with a nasogastric tube (p. 323) What is the reason for chest tubes after thoracic surgery? - Correct Answer-Draining secretions, air, and blood from the thoracic cavity is necessary. (pp. 313-314) The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? - Correct Answer-Unresponsive arterial hypoxemia (p. 299)