Chapter 11 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 11

Question 1

Type: MCSA

A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?

1. Prolonged expiratory time

2. Increased lung compliance

3. Reduced tidal volume

4. Hyper-inflated lungs

Correct Answer: 3

Rationale 1: Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax.

Rationale 2: With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance.

Rationale 3: Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patients tidal volume will be reduced.

Rationale 4: Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1

Question 2

Type: MCSA

A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?

1. Decreased total lung capacity

2. Progressive respiratory alkalosis

3. Increased PaCO2

4. Increased forced expiratory volume (FEV)

Correct Answer: 3

Rationale 1: The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity.

Rationale 2: Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis.

Rationale 3: In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping.

Rationale 4: Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1

Question 3

Type: MCSA

A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a high pitched noise in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?

1. COPD

2. Asthma

3. Emphysema

4. Pneumonia

Correct Answer: 2

Rationale 1: COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.

Rationale 2: The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma.

Rationale 3: Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.

Rationale 4: Pneumonia will not suddenly appear after exposure to cigarette smoke to cause the onset of the patients symptoms.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1

Question 4

Type: MCSA

The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?

1. The patient is now able to rest and sleep.

2. The patients condition has significantly deteriorated.

3. The patients condition shows some slight improvement.

4. The patients condition has stabilized significantly.

Correct Answer: 2

Rationale 1: These findings do not indicate that the patient is resting and now able to sleep.

Rationale 2: The patients condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acidbase balance.

Rationale 3: These findings do not indicate that the patients condition is improving.

Rationale 4: These findings do not indicate significant stabilization of the patients condition.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-2

Question 5

Type: MCMA

A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has ventilation failure.

2. Without treatment the patients oxygen saturation is likely to drop rapidly.

3. The patient has decreased airflow.

4. The patient is at risk for respiratory muscle fatigue.

5. Acute respiratory failure is present.

Correct Answer: 2,4

Rationale 1: Ventilation failure is reflected by an increased PaCO2.

Rationale 2: Once the PaO2 drops below 60 mm Hg oxygens affinity to hemoglobin drops.

Rationale 3: When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2.

Rationale 4: As respiratory rate increases the risk of respiratory muscle fatigue also increases.

Rationale 5: Currently the patient does not have acute respiratory failure because the PaCO2 is normal.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-2

Question 6

Type: MCMA

The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient who sustained a severe chest contusion.

2. A patient hospitalized for treatment of drug overdose.

3. A patient who sustained severe head trauma.

4. A patient hospitalized for treatment of pneumonia.

5. A patient diagnosed with sepsis.

Correct Answer: 4,5

Rationale 1: Chest contusion can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 2: Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 3: Head trauma can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 4: Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS.

Rationale 5: Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

Question 7

Type: MCSA

The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing?

1. Increased lung compliance

2. Decrease in heart rate

3. Hypoxemia refractory to oxygen therapy

4. Respiratory acidosis

Correct Answer: 3

Rationale 1: Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease.

Rationale 2: The heart rate increases as the work of breathing increases.

Rationale 3: In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting.

Rationale 4: In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

Question 8

Type: MCSA

A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?

1. Obstructed endotracheal tube

2. Increased severity of ARDS

3. Decreased cardiac output

4. Pneumothorax

Correct Answer: 4

Rationale 1: An obstructed endotracheal tube would affect both lung fields.

Rationale 2: If the disease process was worsening it would be likely that both lung fields would be involved.

Rationale 3: Decreased cardiac output would affect vital signs but not breath sounds.

Rationale 4: A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

Question 9

Type: MCSA

The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?

1. Administer pain medication as ordered.

2. Increase intravenous fluids.

3. Evaluate the patients oxygen saturation.

4. Help the patient assume a more comfortable position.

Correct Answer: 3

Rationale 1: The patients pain should be treated but this is not the priority intervention.

Rationale 2: Intravenous fluids may be increased, but this is not the priority intervention.

Rationale 3: The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography.

Rationale 4: Positioning is not the priority intervention.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

Question 10

Type: MCMA

The patients Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor daily D-dimer levels.

2. Strictly measure all intake and output.

3. Encourage ambulation.

4. Instruct the patient on use of antiembolism stockings.

5. Prevention of leg injury

Correct Answer: 3,4,5

Rationale 1: D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus.

Rationale 2: Measuring intake and output will not prevent development of thrombus.

Rationale 3: Ambulation will help to support circulation and prevent clot development.

Rationale 4: Proper use of antiembolism stocking is helpful in decreasing development of thrombus.

Rationale 5: One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

Question 11

Type: MCSA

The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include?

1. It is thought that SARS is a nonhuman virus that has crossed species.

2. SARS is more common in patients also infected with HIV.

3. SARS is a form of influenza virus, so additional cases are probable.

4. SARS is related to RSV, so young children will be the most likely patients.

Correct Answer: 1

Rationale 1: Although the origin of SARS-CoV is unknown, it is suspected to be a nonhuman virus that jumped to humans.

Rationale 2: SARS is not associated with HIV.

Rationale 3: SARS is not a form on influenza virus.

Rationale 4: SARS is not related to RSV.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-5

Question 12

Type: MCMA

The nurse is preparing to participate in evaluation of the severity of a patients community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients respiratory rates for the last several hours

2. BUN results

3. If the patient has a history of smoking

4. The patients gender.

5. The patients age

Correct Answer: 1,2,5

Rationale 1: CURB-65 evaluates the patients respiratory rate. Rate of 30 or over is scored as a 1.

Rationale 2: CURB-65 evaluates that patients BUN level. BUN greater than 19.6 mg/dL is scored as a 1.

Rationale 3: Tobacco use history is not considered in CURB-65 scoring.

Rationale 4: Gender is not considered in CURB-65 scoring.

Rationale 5: The patients age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-5

Question 13

Type: MCSA

The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient?

1. Do a portable film in the patients room.

2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive.

3. Disconnect the drainage system from the wall suction and transport.

4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive.

Correct Answer: 3

Rationale 1: Changing of a physicians order is not within the scope of practice of the nurse.

Rationale 2: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

Rationale 3: The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity.

Rationale 4: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

Question 14

Type: MCSA

A patient has been uncooperative with pulmonary hygiene following thoracic surgery because it hurts more than I can bear. Which intervention should the nurse employ?

1. Instruct the patient to cough 3 to 4 times with each exhalation.

2. Assist the patient to a sitting position to lean over the bedside table while coughing.

3. Provide the patient with a pillow to splint the incision while coughing.

4. Guide the patient to cough with the glottis open.

Correct Answer: 4

Rationale 1: The cascade cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort.

Rationale 2: Positioning the patient over the bedside table might cause injury during coughing.

Rationale 3: A pillow is too soft to effectively splint the incision for best pain relief.

Rationale 4: Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the huff cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

Question 15

Type: MCSA

The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient?

1. Ineffective Breathing Pattern

2. Ineffective Airway Clearance

3. Potential for Pneumonia

4. Impaired Gas Exchange

Correct Answer: 1

Rationale 1: The patient has documented shallow breathing, indicative of an ineffective breathing pattern.

Rationale 2: Since there is no evidence of inability to clear secretions, this is not the best NDX choice for this patient.

Rationale 3: Potential for pneumonia is not a nursing diagnosis.

Rationale 4: In order to support the NDX Impaired Gas Exchange, the patient must exhibit cyanosis or have arterial blood gas evidence of poor oxygenation or carbon dioxide retention.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11-7

Question 16

Type: MCMA

A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encourage bedrest to conserve energy.

2. Administer pain medications as needed.

3. Position the patient on the unaffected side.

4. Encourage the patient to provide as much self-care as possible.

5. Encourage slow, deep breaths

Correct Answer: 2,4

Rationale 1: Bedrest will impair the patients ability to mobilize secretions. Activity as tolerated will help mobilize secretions.

Rationale 2: The nurse should treat the patients pain but avoid oversedation.

Rationale 3: Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involved both lungs and the trachea.

Rationale 4: Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions.

Rationale 5: Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated for impaired gas exchange.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-7

Question 17

Type: MCSA

A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis?

1. Teach the patient to use the incentive spirometer every 1 to 2 hours.

2. Suction as necessary.

3. Splint the chest when coughing.

4. Encourage fluids up to 2.5 liters per day.

Correct Answer: 1

Rationale 1: Using the incentive spirometer correctly every 1 to 2 hours will help to improve gas exchange.

Rationale 2: Suctioning is related more to Ineffective Airway Clearance.

Rationale 3: Using a splint with coughing will help reduce pain so that the airway can be cleared. This intervention is most related to Ineffective Airway Clearance.

Rationale 4: Increasing fluids will help to thin secretions so that they are more easily mobilized. This intervention is most related to Ineffective Airway Clearance.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-7

Question 18

Type: MCSA

An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic?

1. Whenever the drug is received from the pharmacy

2. After the preliminary results of the sputum specimen are obtained

3. Within 30 minutes of the order being received

4. Within 4 hours of diagnosis

Correct Answer: 4

Rationale 1: There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patients diagnosis and need to start the antibiotic quickly.

Rationale 2: The nurse should not wait for sputum specimen results.

Rationale 3: There is no standard by which the antibiotic must be started within 30 minutes of the order being received.

Rationale 4: Standards indicate that antibiotic therapy for pneumonia should be started within 4 hours of diagnosis or while the patient is in the setting where the diagnosis is made.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-5

Question 19

Type: MCSA

A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated?

1. Collaborate with the health care provide regarding need to reinstitute the external suction.

2. Check the connections between the chest tube and the drainage system.

3. No action is necessary as this is an expected occurrence.

4. Have the patient cough forcefully.

Correct Answer: 3

Rationale 1: There is no need for external suction.

Rationale 2: The nurse should always check these connections, but there is no special need for that action related to this assessment.

Rationale 3: The cessation of tidling in this patient likely indicates successful reinflation of the lung which is the desired outcome.

Rationale 4: This assessment does not indicate that coughing is necessary.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

Question 20

Type: MCSA

A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patients trachea is slight displaced toward the left. Which nursing intervention is priority?

1. Have the patient release his arm and sit up straight for reassessment.

2. Notify the emergency room physician immediately.

3. Auscultate the patients lung fields.

4. Position the patient flat in bed without a pillow.

Correct Answer: 2

Rationale 1: Reassessment is not the priority in this situation.

Rationale 2: Deviation of the trachea away from the injured side indicates pressure on the affected side which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patients condition.

Rationale 3: The nurse will auscultate the lungs, but another intervention is the priority.

Rationale 4: This position is not indicated for this patient. Positioning is not the immediate priority.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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