Chapter 25 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 25

Question 1

Type: MCSA

The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process?

1. Beginning of the gas exchange process

2. Neutralizing the air

3. Filtering the air

4. Separating the air

Correct Answer: 3

Rationale 1: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through the anatomical dead space, but these structures do not participate in gas exchange.

Rationale 2: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through this space, but it is not neutralized.

Rationale 3: The trachea is part of the anatomical dead space. It traps particulate matter to keep it from entering the lungs.

Rationale 4: The anatomical dead space includes the structures from the nose to the terminal bronchioles. The air is not separated in these structures.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-1

Question 2

Type: MCSA

During an assessment, a patient begins to cough. How would the nurse evaluate this finding?

1. The patient has a cold.

2. The patient is nervous.

3. Something other than air was entering the larynx.

4. The patient is not fully conscious.

Correct Answer: 3

Rationale 1: A cough does not indicate the presence of a cold. Additional assessment would be necessary.

Rationale 2: A cough is not sufficient assessment data to determine that a patient is nervous.

Rationale 3: If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs.

Rationale 4: The protective reflex of coughing may not be present if the person is unconscious. A cough is not enough data to determine level of consciousness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 3

Type: MCSA

A patient is diagnosed with a low iron count. The nurse would be alert for which finding associated with this condition?

1. Increased carbon dioxide in the blood

2. Nausea

3. Anxiety

4. Poor tissue oxygenation

Correct Answer: 4

Rationale 1: Low iron would not increase carbon dioxide levels in the blood.

Rationale 2: Nausea is not generally associated with low iron count.

Rationale 3: Anxiety is not generally associated with low iron count.

Rationale 4: Oxygen is carried in the blood either bound to hemoglobin or dissolved in the plasma. Oxygen is not very soluble in water, so almost all oxygen that enters the blood from the respiratory system is carried to the cells of the body by hemoglobin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-1

Question 4

Type: MCMA

During the palpation of a patients chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with which condition?

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

Standard Text: Select all that apply.

1. Emphysema

2. Pneumothorax

3. Flail chest

4. Heart failure

5. Influenza

Correct Answer: 2,3

Rationale 1: Bilateral chest expansion is decreased in emphysema.

Rationale 2: Thoracic expansion is altered on the affected side in patients with pneumothorax.

Rationale 3: One side of the chest would not expand at the correct time if the patient has a flail chest.

Rationale 4: Heart failure does not result in a change in chest expansion.

Rationale 5: Thoracic expansion is not affected by influenza.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 5

Type: MCMA

The nurse is preparing to auscultate a patients lungs. Which breath sounds would the nurse consider abnormal?

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

Standard Text: Select all that apply.

1. Crackles

2. Vesicular breath sounds

3. Bronchovesicular breath sounds

4. Wheezes

5. Bronchial breath sounds

Correct Answer: 1,4

Rationale 1: Crackles are caused by airways that collapse during expiration and pop open during inspiration or by air bubbles passing through fluid. They are not normal breath sounds.

Rationale 2: Vesicular breath sounds are the soft, low-pitched sounds heard over the majority of lung fields. They are normal.

Rationale 3: Bronchovesicular breath sounds represent air movement in the moderate airways between the main bronchi and smaller airways. They are normal breath sounds.

Rationale 4: Wheezes are continuous musical sounds caused by air flowing across airways that are narrowed or obstructed. They are abnormal breath sounds.

Rationale 5: Bronchial breath sounds are heard over the major airways and are normal.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-4

Question 6

Type: FIB

During a bronchoscopy, the nurse is to initially give 1.5 mg of midazolam hydrochloride (Versed) and another 1.5 mg of Versed in 2 minutes. Based on a concentration of 5 mg/mL, the nurse will draw up a total of ______ mL for the two doses.

Standard Text:

Correct Answer: 0.6

Rationale : 0.3 mL is to be given for the initial dose and another 0.3 mL in 2 minutes. 0.3 x 2 = 0.6 mL

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

Question 7

Type: MCSA

A patient has these arterial blood gas (ABG) results. In analyzing the data, the nurse recognizes the patient has which condition?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

Correct Answer: 3

Rationale 1: The PaO2 is 75100 mmHg, HCO3 is 2428 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate metabolic acidosis.

Rationale 2: The PaO2 is 75100 mmHg, HCO3 is 2428 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate metabolic alkalosis.

Rationale 3: The patient is in respiratory acidosis, as the pH is decreased below normal (7.357.45) and the PaCO2 is increased from normal (3545 mmHg).

Rationale 4: The PaO2 is 75100 mmHg, HCO3 is 2428 mEq/L, and the base excess (BE) is + 2 mEq/L, which would not indicate respiratory alkalosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-6

Question 8

Type: SEQ

The nurse is conducting a health history on a patient with dyspnea. Place the questions in correct sequence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. How would you describe the dyspnea?

Choice 2. What severity rating would you assign the dyspnea?

Choice 3. Does the dyspnea seem to affect both lungs?

Choice 4. How long does the dyspnea last?

Choice 5. What makes the dyspnea better or worse?

Choice 6. When did the dyspnea start?

Correct Answer: 6,5,1,3,2,4

Rationale 1: This question addresses the quality (Q) component of OPQRST.

Rationale 2: This question addresses the severity (S) component of OPQRST.

Rationale 3: This question addresses the radiation (R) component of OPQRST.

Rationale 4: This question addresses the timing (T) component of OPQRST.

Rationale 5: This question addresses palliating or provoking factors (P) component of OPQRST.

Rationale 6: This question addresses the onset (O) component of OPQRST.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 9

Type: MCSA

The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. What is the primary rationale for this nursing action?

1. To ease the work of breathing

2. To compensate for the reduction in circulating oxygen

3. To provide comfort

4. To prevent shock

Correct Answer: 2

Rationale 1: Breathing might be easier, but this is an additional benefit, not the primary reason.

Rationale 2: As blood volume is lost, hemoglobin is lost. Oxygen is carried from the respiratory system to the cells by hemoglobin in the blood.

Rationale 3: The patient might be more comfortable, but this is an additional benefit not the primary reason.

Rationale 4: The risk of shock might be decreased through oxygen administration, but this is an additional benefit not the primary reason.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-1

Question 10

Type: MCSA

The nurse anticipates that a patient with multiple fractured ribs is at risk for which condition?

1. Decreased lung expansion

2. Increased respiratory rate

3. Prolonged expiratory phase

4. Low arterial carbon dioxide level

Correct Answer: 1

Rationale 1: Due to the rib fractures, it might be difficult for the patient to have full rib cage expansion because of the pain.

Rationale 2: The respiratory rate might tend to be slower and more shallow than usual.

Rationale 3: The expiratory phase might be shortened due to the pain.

Rationale 4: The carbon dioxide would be high rather than low.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25-5

Question 11

Type: MCSA

A patient admitted with probable emphysema is scheduled for diagnostic tests. Which test would assess the patients acid-base balance?

1. Bronchoscopy

2. Sputum studies

3. Pulse oximetry

4. Arterial blood gases (ABGs)

Correct Answer: 4

Rationale 1: A bronchoscopy provides visualization of internal respiratory structures.

Rationale 2: Sputum studies can provide specific information about bacterial organisms.

Rationale 3: Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

Rationale 4: ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-6

Question 12

Type: MCSA

After auscultating a patients chest, the nurse reports the findings to the preceptor. Which statement would indicate the need for immediate reassessment by the preceptor?

1. I heard coarse crackles earlier, but now they sound finer.

2. I heard wheezing earlier, but now I dont hear it.

3. There are coarse crackles that clear with coughing.

4. The patient was clear, but now there are scattered wheezes bilaterally.

Correct Answer: 2

Rationale 1: Coarse and fine are descriptors for crackles.

Rationale 2: The absence of wheezing in a patient who had wheezing before may indicate impending respiratory arrest. The preceptor should reassess the patient immediately. There is also a possibility that therapy has reduced the wheezes and that no emergency exists.

Rationale 3: This finding is not indicative of the need for immediate action.

Rationale 4: This finding is not indicative of the need for immediate action.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 25-4

Question 13

Type: MCMA

The nurse is planning a class for unlicensed assistive personnel. Which factors should the nurse describe as causing interference with accurate pulse oximeter readings?

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

Standard Text: Select all that apply.

1. Ambient light

2. Nail polish

3. Inhalation injuries

4. Arterial pulse deficit

5. Sensor placement on the ear

Correct Answer: 1,2,3,4

Rationale 1: Ambient light can cause inaccurate readings.

Rationale 2: Nail polish on finger- or toenails can cause inaccurate readings.

Rationale 3: Inhalation injuries can cause inaccurate readings.

Rationale 4: Inadequate arterial pulses can cause inaccurate readings.

Rationale 5: As long as the sensor is not placed on cartilage, the reading should be accurate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-6

Question 14

Type: MCSA

The nurse wants to assess the apex of a patients right lung. In which location should the nurse place the stethoscope?

1. Intercostal space, sixth rib near the sternum

2. Intercostal space, fourth rib near the axillary line

3. Below the scapula

4. Near the right clavicle

Correct Answer: 4

Rationale 1: This placement is too low.

Rationale 2: This placement is too low.

Rationale 3: The scapulae are located posterior to the lungs.

Rationale 4: The apex of each lung lies just below the clavicle, whereas the base of each lung rests on the diaphragm.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 15

Type: MCSA

The nurse knows that the caregiver of a patient with a respiratory illness understands discharge teaching when the caregiver makes which statement?

1. I can expect to hear adventitious sounds only in the mornings; the rest of the day, breath sounds should be normal.

2. If I hear extra sounds during a deep breath, I know I am hearing adventitious sounds.

3. Adventitious sounds may be heard during inspiration or expiration because of secretions or inflammation.

4. I will know I am hearing adventitious breath sounds if I hear any sounds when I listen over the lower chest.

Correct Answer: 3

Rationale 1: Adventitious or abnormal breath sounds may be heard at any time of day or night.

Rationale 2: The patient does not need to take a deep breath for adventitious or abnormal sounds to be heard.

Rationale 3: Adventitious or abnormal breath sounds may be heard during inspiration and expiration.

Rationale 4: Adventitious or abnormal breath sounds may be heard over any portion of the chest or back.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 25-4

Question 16

Type: MCMA

A review of a patients medical record reveals that the patient is using accessory muscles to aid breathing. Which muscle groups would the nurse expect to see in use?

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

Standard Text: Select all that apply.

1. Abdominals

2. Scalene

3. Brachialis

4. Trapezius

5. Sternocleidomastoid

Correct Answer: 1,2,4,5

Rationale 1: Abdominal muscles are used to augment respiratory effort.

Rationale 2: Scalene muscles are the muscles of the lateral neck. These muscles can be used to augment respiratory effort.

Rationale 3: The brachialis muscles are in the arm and are not useful in augmenting respiratory effort.

Rationale 4: The trapezius muscles of the upper back can augment respiratory effort.

Rationale 5: The sternocleidomastoid muscles are in the anterior neck and are often used to augment respiratory effort.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-1

Question 17

Type: MCMA

A patient with pneumonia is experiencing shunt ventilation. The nurse plans care for the patient based on which considerations?

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

Standard Text: Select all that apply.

1. Shunt ventilation is the normal state for a patient who has pneumonia.

2. Blood flow to the alveoli is compromised.

3. Blood is flowing past the alveoli but is not being oxygenated.

4. Ventilation is inadequate at the alveolar level.

5. Hypoxia may occur if the unaffected lung cannot compensate.

Correct Answer: 3,4,5

Rationale 1: Shunt ventilation is not normal and the patient may decompensate quickly.

Rationale 2: In shunt ventilation, blood flow to the alveoli is normal.

Rationale 3: Blood is shunting past the alveoli, but oxygenation is not taking place.

Rationale 4: Not enough oxygen is being delivered to the alveoli, and blood is not being oxygenated.

Rationale 5: As long as the unaffected lung can supply sufficient oxygen, the patient may show few ill effects from shunt ventilation. However, should the unaffected lung fail to compensate, hypoxia will occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-1

Question 18

Type: MCMA

The nurse had planned to conduct a patient interview regarding pulmonary history. Which patient behaviors would indicate to the nurse that this interview should be delayed?

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 cannot speak in complete sentences.

2. The patient is sitting up at the bedside.

3. The patients respiratory rate has increased from 14 to 20.

4. The patient has assumed a forward leaning posture, braced on the hands.

5. The patients arterial blood gases reveal a pH of 7.38.

Correct Answer: 1,3,4

Rationale 1: The patient who cannot speak in complete sentences may be suffering from respiratory distress. The nurse should delay the interview and should conduct further physical assessment.

Rationale 2: Finding the patient sitting up at the bedside is not a reason to delay the interview unless other, more specific, assessments are also made.

Rationale 3: An increase in respiratory rate may indicate respiratory distress. The nurse should delay the interview and conduct additional physical assessment.

Rationale 4: This position is called the tripod position and is a classic maneuver to expand lung fields. The patient may be in acute respiratory distress, so the interview should be delayed.

Rationale 5: This is a normal arterial blood gas reading and does not indicate respiratory compromise.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-2

Question 19

Type: MCSA

A patient from Southeast Asia presents to the clinic with complaints of shortness of breath. The patient says, I tried to coin my wind illness, but it did not work. Which assessment finding would the nurse expect?

1. The patient is wearing an amulet shaped like a dragon.

2. The patient has burns on the inside of the nose and mouth.

3. The patient is pale from blood loss.

4. The patient has small scrapes across the back and chest.

Correct Answer: 4

Rationale 1: The patient may be wearing an amulet, but probably not to treat the illness.

Rationale 2: Treating wind illness does not include burning the inside of the nose and mouth.

Rationale 3: There is no indication that cultural treatment for wind illness would cause large amounts of blood loss.

Rationale 4: Coining is a cultural practice that involves scraping the skin of the thorax with a coin or spoon. The scraping may leave lesions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-2

Question 20

Type: MCSA

The patient says, I think I am allergic to something in my house. I feel better when I am away for a few days. What should the nurse suggest?

1. You might want to keep your dog outside.

2. You might want to consider having allergy testing done.

3. You should remove dust by vacuuming your house every day and getting rid of your drapes and decorative pillows.

4. You should consider having your home professionally cleaned.

Correct Answer: 2

Rationale 1: The nurse has no reason to suspect that the patient is allergic to the dog.

Rationale 2: Before efforts to rid a home of allergens begin, the patient should be aware of which substances are causing symptoms.

Rationale 3: The nurse does not know if the patient is allergic to dust.

Rationale 4: The nurse is not aware of what or if the patient is allergic to anything in the house. Chemical cleaners can also cause allergies.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-2

Question 21

Type: MCSA

The nurse is conducting a health history interview with a patient who has severe respiratory disease. The nurse asks specific questions about how the patient performs oral hygiene. What is the rationale for this questioning?

1. Oral infections can result in pulmonary infections.

2. The ability to perform good oral hygiene reflects an ability to hold ones breath for several seconds.

3. Respiratory illness is associated with an increased risk for dental caries.

4. People who perform good oral hygiene typically also perform good hand hygiene.

Correct Answer: 1

Rationale 1: This patient is at risk for pulmonary infection. Oral infections can travel down the pulmonary tree and cause pulmonary access formation.

Rationale 2: This may be accurate, but it is not the rationale for this questioning.

Rationale 3: There is no indication that respiratory illness causes tooth decay.

Rationale 4: There is no association between these two hygiene practices that would serve as a rationale for these questions.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-2

Question 22

Type: MCSA

A patient with a preexisting pulmonary illness is being seen in the clinic for a routine assessment. The patient says, My family and I are going skiing for our next vacation. What information should the nurse provide?

1. Going to high altitudes is not a good idea for your health.

2. You should be watchful for any respiratory problems while you are there.

3. You should go to the seashore instead.

4. Be certain to fly directly to the resort if possible.

Correct Answer: 2

Rationale 1: High altitudes may or may not affect the patients health.

Rationale 2: High altitudes may cause decompensation of respiratory status for any person, but persons with preexisting pulmonary illness are at greater risk.

Rationale 3: The nurse should not tell the patient where to go on vacation.

Rationale 4: There is no indication that flying directly to the resort should be recommended.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-2

Question 23

Type: MCMA

A nurse researcher is planning a study regarding occupational exposure to asbestos and the development of asbestos-related pulmonary disease. The researcher should look to workers from which occupations as commonly having this exposure?

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

Standard Text: Select all that apply.

1. Firefighters

2. Auto mechanics

3. Those involved in new home construction

4. Teachers

5. Cooks

Correct Answer: 1,2

Rationale 1: Older buildings may contain significant amounts of asbestos. Firefighters may be exposed during fire events.

Rationale 2: Auto mechanics may be exposed to the asbestos in vehicle brake linings.

Rationale 3: Asbestos has been removed from modern construction materials. Construction workers in new home construction would not be likely to have high exposure rates.

Rationale 4: There is no reason to believe that teachers are at risk for exposure to asbestos.

Rationale 5: There is no reason to believe that cooks are at high risk for exposure to asbestos.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-3

Question 24

Type: FIB

A review of a patients medical record reveals a 70-pack-year smoking history. The patient says he smokes two packs of cigarettes every day. The nurse calculates that this patient has been smoking for ______ years.

Standard Text:

Correct Answer: 35

Rationale : Pack years are figured by the number of packs a day times the years smoked. This patient has a 70-pack-year history and smokes two packs per day. He has been smoking for approximately 35 years.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-3

Question 25

Type: MCSA

A patient has been admitted for exacerbation of a chronic pulmonary disease. The nurse would assign the nursing diagnosis Activity Intolerance when which assessment is made?

1. The patients heart rate increases by 20 beats per minute when she ambulates to the bathroom in her hospital room.

2. The patients husband reports that she sits in a recliner chair most of the day.

3. The patient complains of cramping in her legs at night.

4. The patients ankles demonstrate 3+ edema bilaterally.

Correct Answer: 1

Rationale 1: Increasing heart rate on exertion is a finding associated with intolerance of activity.

Rationale 2: This is not enough evidence to support activity intolerance as a nursing diagnosis. The patient may be depressed or simply desire to stay in the chair.

Rationale 3: Night leg cramps may or may not be associated with activity intolerance.

Rationale 4: Ankle edema may or may not be associated with activity intolerance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-3

Question 26

Type: MCMA

A patient is admitted after falling down a flight of stairs. The nurse notes that the patients larynx is slightly left of center. The nurse should assess for which conditions?

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

Standard Text: Select all that apply.

1. Right heart failure

2. Left hemothorax

3. Right pneumothorax

4. Right hemothorax

5. Central pneumothorax

Correct Answer: 3,4

Rationale 1: Tracheal deviation does not indicate right heart failure.

Rationale 2: Left hemothorax is not occurring in this case.

Rationale 3: Collection of fluid or air in the right chest cavity results in tracheal deviation to the left.

Rationale 4: Collection of fluid or air in the right chest cavity results in tracheal deviation to the left.

Rationale 5: Pneumothorax is classified as right or left, not central.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 27

Type: FIB

The nurse is assessing a patient for pedal edema. If using the correct technique, the nurse will depress the tissue for _____ seconds.

Standard Text:

Correct Answer: 5

Rationale : To assess edema and to elicit pitting edema, the nurse would depress the tissue of the ankle for 5 seconds.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 28

Type: MCSA

To establish the location of a respiratory sound, the nurse uses standard landmarks. The nurse locates the second rib as adjacent to which structure?

1. Supersternal notch

2. Sternal angle

3. Costal margin

4. Xiphoid process

Correct Answer: 2

Rationale 1: The second rib is below this area.

Rationale 2: The rib that is adjacent to the sternal angle is the second rib.

Rationale 3: The costal margin is the bottom of the rib cage.

Rationale 4: The xiphoid process is the distal end of the sternum and is closest to the seventh rib.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 29

Type: MCSA

During auscultation of the thorax, the nurse hears a low-pitched creaking sound. What should be the nurses next action?

1. Have the patient cough to attempt to clear the sound.

2. Have the patient turn to the left side.

3. Collaborate with the physician regarding a chest X-ray.

4. Ask the patient to hold her breath.

Correct Answer: 4

Rationale 1: Crackles may clear with coughing, but this description does not match that of crackles.

Rationale 2: Positioning the patient will not change this assessment finding.

Rationale 3: An X-ray will likely be ordered, but this is not the first action indicated.

Rationale 4: This assessment represents a rub. The next assessment step is to differentiate pleural rub from cardiac rub by asking the patient to hold the breath. If the sound disappears, it is a cardiac rub.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-4

Question 30

Type: MCSA

A parent has just started using a red, yellow, green peak flow meter to monitor his young sons pulmonary disease at home. The parent calls the clinic and reports that the last two results have been in the red zone. What advice should the nurse offer this parent?

1. Rinse the meter out with warm salt water and repeat the test.

2. Bring your son and the meter to the clinic for evaluation.

3. Dont bother using the meter until I can check your technique at next weeks appointment.

4. These are the results we hope to see, so it sounds like you are doing a good job managing your sons illness.

Correct Answer: 2

Rationale 1: There is no indication that the meter needs any type of maintenance.

Rationale 2: Two red readings may indicate respiratory complications. The patient should be evaluated. The nurse should also have the parent bring in the meter so his or her technique can be evaluated.

Rationale 3: The parents technique may be wrong, but the patient may be experiencing significant respiratory changes. Assessment cannot wait until next week.

Rationale 4: Red readings indicate potential respiratory complications.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

 

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