Nursing concepts 120 final (including
pearson)
The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with
respiratory acidosis? Select all that apply.
A) Increased CO2
B) Vasoconstriction
C) Decreased O2
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate - VERIFIED ANSWER A, C, E
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD).
When planning care for this client, which interventions are appropriate to enhance the clients breathing
pattern? Select all that apply.
A) Provide adequate rest periods.
B) Assist with activities of daily living (ADLs).
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer a cough suppressant. - VERIFIED ANSWER A, B, C, D
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Which interventions should the nurse select to meet nutritional needs? Select all that apply.
A) Encourage a diet high in protein and fats.
B) Keep snacks to a minimum.
C) Provide frequent small meals with between-meal supplements.
D) Encourage carbohydrate-rich foods to provide needed calories for energy.
E) Suggest the client eat three meals per day to maintain energy needs. - VERIFIED ANSWER A, C
,The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)
after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when
assessing this client?
A) Tachycardia
B) Cough
C) Barrel chest
D) Wheezing - VERIFIED ANSWER C
The nurse is caring for a 72-year-old client who has presented to the emergency department for the
third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his
inhaler, and sometimes he forgets to take his medication. He is also worried
because he thinks his new drugs are adversely interacting with medications for his other conditions.
What nursing diagnosis is appropriate for this client?
A) Deficient Knowledge
B) Ineffective Health Management
C) Risk for Aspiration
D) Ineffective Coping - VERIFIED ANSWER B
The pathophysiologic stimulus that initiates asthma is
A) bronchoconstriction.
B) inflammation in the airways.
C) airway edema.
D) mucus secretion. - VERIFIED ANSWER B
The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which
client statement indicates a need for further teaching?
A) "I need to rinse my mouth after every use of my inhaler."
B) "I need to take my Singulair at least 1 hour before I eat."
,C) "When inhaling two different medications, I should use the bronchodilator last."
D)"Because I am on theophylline, I will need to have therapeutic blood levels drawn." - VERIFIED
ANSWER C
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon
inspiration. Based on this data, which nursing diagnosis is the most appropriate?
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance - VERIFIED ANSWER C
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation.
What should the nurse consider when planning for this client's potential health problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return - VERIFIED ANSWER B
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which
of the following should be included in this teaching session? Select all that apply.
A) Limit exercise to 15 minutes a day
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
D) Wear elastic hose
E) Limit fluid intake - VERIFIED ANSWER B, C
, The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the
nurse use when auscultating the apical pulse?
A) At the fifth intercostal space
B) At the left nipple
C) At the right nipple
D) At the eighth intercostal space - VERIFIED ANSWER B
Which statements are correct regarding the various layers of the heart? Select all that apply.
A) The endocardium covers the entire heart and great vessels.
B) The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
E) The myocardium has four layers. - VERIFIED ANSWER C, D
Blood pressure is influenced by all except which factor?
A) Pumping action of the heart
B) Peripheral vascular resistance
C) Heart rate
D) Blood volume - VERIFIED ANSWER C
Which nursing intervention related to perfusion can be performed independently?
A) Administration of drug regimens
B) Insertion of device to measure central venous pressure (CVP)
C) Teaching relaxation techniques
D) Thoracentesis - VERIFIED ANSWER C
pearson)
The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with
respiratory acidosis? Select all that apply.
A) Increased CO2
B) Vasoconstriction
C) Decreased O2
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate - VERIFIED ANSWER A, C, E
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD).
When planning care for this client, which interventions are appropriate to enhance the clients breathing
pattern? Select all that apply.
A) Provide adequate rest periods.
B) Assist with activities of daily living (ADLs).
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer a cough suppressant. - VERIFIED ANSWER A, B, C, D
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Which interventions should the nurse select to meet nutritional needs? Select all that apply.
A) Encourage a diet high in protein and fats.
B) Keep snacks to a minimum.
C) Provide frequent small meals with between-meal supplements.
D) Encourage carbohydrate-rich foods to provide needed calories for energy.
E) Suggest the client eat three meals per day to maintain energy needs. - VERIFIED ANSWER A, C
,The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)
after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when
assessing this client?
A) Tachycardia
B) Cough
C) Barrel chest
D) Wheezing - VERIFIED ANSWER C
The nurse is caring for a 72-year-old client who has presented to the emergency department for the
third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his
inhaler, and sometimes he forgets to take his medication. He is also worried
because he thinks his new drugs are adversely interacting with medications for his other conditions.
What nursing diagnosis is appropriate for this client?
A) Deficient Knowledge
B) Ineffective Health Management
C) Risk for Aspiration
D) Ineffective Coping - VERIFIED ANSWER B
The pathophysiologic stimulus that initiates asthma is
A) bronchoconstriction.
B) inflammation in the airways.
C) airway edema.
D) mucus secretion. - VERIFIED ANSWER B
The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which
client statement indicates a need for further teaching?
A) "I need to rinse my mouth after every use of my inhaler."
B) "I need to take my Singulair at least 1 hour before I eat."
,C) "When inhaling two different medications, I should use the bronchodilator last."
D)"Because I am on theophylline, I will need to have therapeutic blood levels drawn." - VERIFIED
ANSWER C
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon
inspiration. Based on this data, which nursing diagnosis is the most appropriate?
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance - VERIFIED ANSWER C
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation.
What should the nurse consider when planning for this client's potential health problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return - VERIFIED ANSWER B
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which
of the following should be included in this teaching session? Select all that apply.
A) Limit exercise to 15 minutes a day
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
D) Wear elastic hose
E) Limit fluid intake - VERIFIED ANSWER B, C
, The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the
nurse use when auscultating the apical pulse?
A) At the fifth intercostal space
B) At the left nipple
C) At the right nipple
D) At the eighth intercostal space - VERIFIED ANSWER B
Which statements are correct regarding the various layers of the heart? Select all that apply.
A) The endocardium covers the entire heart and great vessels.
B) The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
E) The myocardium has four layers. - VERIFIED ANSWER C, D
Blood pressure is influenced by all except which factor?
A) Pumping action of the heart
B) Peripheral vascular resistance
C) Heart rate
D) Blood volume - VERIFIED ANSWER C
Which nursing intervention related to perfusion can be performed independently?
A) Administration of drug regimens
B) Insertion of device to measure central venous pressure (CVP)
C) Teaching relaxation techniques
D) Thoracentesis - VERIFIED ANSWER C
