Answers
Key features of left sided heart failure Ans: Oliguria, pallor, and cool extremities
Rhonchi indicate Ans: partial airway obstruction because of bronchiolar alterations
associated with COPD
A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi
mask. What should the nurse do when caring for this client? Ans: Monitor oxygen
saturation levels when eating.
The nurse provides teaching to a client who will begin to receive tube feedings after a
total laryngectomy. The nurse concludes that the teaching was understood when the
client makes which statement about tube feedings? Ans: "I will need tube feedings until
healing of the incision is complete.
mediastinoscopy Ans: endoscopic examination of mediastinal lymph nodes through a
small suprasternal incision
A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The
nurse should encourage the client to assume what position? Ans: The orthopneic
position lowers the diaphragm and provides for maximum thoracic expansion.
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion,
especially upon awakening in the morning. What should the nurse suggest to the
client? Ans: Use a humidifier in the bedroom
A nurse identifies a moderate amount of bright red blood in a client's gastric drainage
four hours after a subtotal gastrectomy. What should the nurse do first? Ans: Some
bright red blood at this point is an expected finding that should be monitored; large
amounts of blood or bleeding should be reported immediately. Clamping the
nasogastric tube is contraindicated; secretions will accumulate and cause pressure on
the suture line. Also, clamping the tube prevents observation of gastric drainage. If the