Chapter 27 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 27

Question 1

Type: MCMA

A patient has been prescribed isoniazid (INH) and rifampin for the treatment of tuberculosis. The nurse should instruct the patient to report which physical changes associated with this therapy?

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

Standard Text: Select all that apply.

1. Fever

2. Yellow tint to the skin

3. Discoloration of tears

4. Visual disturbances

5. Loss of appetite

Correct Answer: 2,4,5

Rationale 1: Fever is not an expected adverse effect of this therapy.

Rationale 2: Jaundice could indicate the patient is developing hepatitis, which is a possible adverse effect of this therapy.

Rationale 3: Discolored tears are an expected effect of rifampin. The nurse should advise the patient that this effect is possible, but reporting it is not necessary.

Rationale 4: Visual disturbance is an adverse effect of isoniazid and should be reported.

Rationale 5: Loss of appetite is an adverse effect of rifampin and should be reported.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 2

Type: MCSA

A patient diagnosed with tuberculosis is prescribed ethambutol (Myambutol). Which nursing statement is indicated?

1. Are you allergic to eggs?

2. Before starting this medication, you must have a baseline eye examination.

3. You will need an influenza vaccine before starting this medication.

4. Before you start this medication, we must schedule a baseline ECG (electrocardiogram).

Correct Answer: 2

Rationale 1: Assessment of an allergy to eggs is not warranted prior to the implementation of this medication.

Rationale 2: A possible toxic but reversible effect of this medication is optic neuritis. Eye exams also may be scheduled during the course of treatment.

Rationale 3: Administration of a flu vaccine is not warranted prior to the implementation of this medication.

Rationale 4: An ECG is not warranted prior to the implementation of this medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 3

Type: MCSA

A patient has been diagnosed with a restrictive lung disease. Which assessment finding would the nurse expect?

1. Cough that the patient describes as occasional for the last 2 weeks

2. Bradycardia

3. Patient report of increased shortness of breath when walking

4. Clear lung sounds

Correct Answer: 3

Rationale 1: The cough associated with restrictive lung disease is chronic and of prolonged duration.

Rationale 2: Tachycardia is the more common cardiac response to restrictive lung disorders.

Rationale 3: Progressive exertional dyspnea is a finding associated with restrictive lung disease.

Rationale 4: Bibasilar inspiratory crackles are a common finding in restrictive lung disorders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-1

Question 4

Type: MCSA

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he does not always wear the prescribed oxygen at home because it is cumbersome and he is rarely short of breath. What is the nurses best response to this patient?

1. Wearing the oxygen will help keep your blood oxygen saturation levels up so your heart does not have to work as hard and will not become enlarged.

2. You really should wear it at least while sleeping.

3. You do seem to be doing fine without it.

4. Keep the oxygen at home and if you become short of breath, you know to put it on until you are able to breathe normally again.

Correct Answer: 1

Rationale 1: The nurse should instruct the patient on the benefit of using long-term oxygen therapy to prevent polycythemia vera, an increase in the hematocrit level above normal as a compensatory mechanism to hypoxia. Cor pulmonale, an enlargement of the right side of the heart, can also develop and can lead to mortality in the patient with COPD.

Rationale 2: The nurse should encourage the patient to wear the oxygen at all times and not just during sleep.

Rationale 3: It may be misleading to state the patient is doing fine without the oxygen.

Rationale 4: The nurse should not instruct the patient to wear the oxygen just when he becomes short of breath but to wear it at all times as prescribed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 5

Type: MCSA

A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation?

1. Until three consecutive sputum specimens for acid fast bacilli are negative

2. Until the Mantoux test (PPD) converts from positive to negative

3. Until the patient has orders for discharge

4. Until the chest X-ray is normal

Correct Answer: 1

Rationale 1: Until three consecutive sputum cultures have tested negative, even with treatment, there is no certainty that the patient is not infectious.

Rationale 2: A positive PPD indicates that an individual has been exposed to tuberculosis and has developed antibodies, so the PPD will not convert back to negative.

Rationale 3: Discharge does not indicate the patient is no longer infectious. Many patients with TB are managed at home. Patients are isolated in the hospital environment because of the number of immunocompromised patients also in the hospital.

Rationale 4: The chest X-ray validates the extent of lung involvement; the patient may experience chronic changes, such as nodules.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 6

Type: MCMA

Which statements would indicate that a patient diagnosed with asthma needs additional teaching at discharge?

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

Standard Text: Select all that apply.

1. I know I shouldnt smoke, but one or two cigarettes a day shouldnt be harmful.

2. I should monitor my peak flow daily and record it in a diary.

3. I should rinse my mouth after each use of my corticosteroid inhaler.

4. Using a spacer with my inhaler will allow for better and more accurate medication delivery.

5. I should plan to have pulmonary function tests done every 5 years.

Correct Answer: 1,5

Rationale 1: Environmental pollutants, smoking, allergens, chemicals, and inhalants can all trigger an asthmatic attack and should be avoided.

Rationale 2: Maintaining a diary of peak flow measurements allows the patient to monitor for decreases that indicate bronchoconstriction.

Rationale 3: Inhaled corticosteroids increase the risk for thrush, so the mouth should be rinsed after inhaler use.

Rationale 4: When a spacer is attached to an inhaler, it allows the medication to accumulate while the patient inhales and prevents escape outside the patients mouth.

Rationale 5: Pulmonary function tests are done frequently until symptoms stabilize and at least once every 1 to 2 years thereafter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27-3

Question 7

Type: MCMA

Which patients would the nurse identify as being at risk for developing cor pulmonale?

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

Standard Text: Select all that apply.

1. Patient with left ventricular heart failure

2. Patient experiencing a massive pulmonary embolism

3. Patient with chronic obstructive pulmonary disease (COPD)

4. Patient with sickle cell anemia

5. Patient with deep vein thrombosis

Correct Answer: 2,3,4

Rationale 1: Right ventricular disease caused by a primary abnormality of the left ventricle is not considered cor pulmonale.

Rationale 2: Cor pulmonale is an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system or a blood disorder. Primary disorders of the respiratory system include pulmonary embolism, interstitial lung disease, COPD, and primary pulmonary hypertension.

Rationale 3: Primary disorders of the respiratory system include pulmonary embolism, interstitial lung disease, COPD, and primary pulmonary hypertension.

Rationale 4: Blood disorders leading to cor pulmonale include polycythemia vera, sickle cell disease, and macro hemoglobinemia.

Rationale 5: Although DVTs may lead to PEs and eventually right-sided heart failure, there is no direct correlation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-3

Question 8

Type: MCSA

A patient diagnosed with chronic bronchitis has the nursing diagnosis Ineffective Airway Clearance related to inadequate cough and excess mucus production. Which intervention would the nurse evaluate as being of the least value in addressing the nursing diagnosis?

1. Check the pulse oximetry reading.

2. Increase fluid intake up to 2 liters/day.

3. Suction the patient.

4. Provide chest physiotherapy.

Correct Answer: 1

Rationale 1: Checking the pulse oximetry reading evaluates the oxygenation status of the patient but has no value in stimulation of cough or expulsion of excess mucous secretions.

Rationale 2: Adequate hydration helps to liquefy secretions.

Rationale 3: Suctioning may be necessary to clear the airway when the cough is ineffective.

Rationale 4: Chest physiotherapy assists in the mobilization of secretions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-1

Question 9

Type: MCSA

The nurse, caring for a patient diagnosed with lung cancer, determines that the patient might be experiencing superior vena cava syndrome when which finding is assessed?

1. Face and neck swelling

2. Hourly urine outputs 250 to 500 mL

3. Calcium level of 14.0 mg/dL

4. Flat jugular veins

Correct Answer: 1

Rationale 1: Superior vena cava (SVC) syndrome is an oncologic emergency and occurs when a lung tumor obstructs the SVC. This results in swelling of the face, hands, arms, and neck; distended jugular veins; cyanosis of the upper torso; and dyspnea.

Rationale 2: Hourly urine outputs of 250 to 500 mL/hour are suggestive of the complication syndrome of inappropriate ADH (SIADH).

Rationale 3: A calcium level of 14.0 mg/dL is considered hypercalcemia, which is a metabolic emergency associated with lung cancers.

Rationale 4: SVC syndrome is characterized by distended jugular veins.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-4

Question 10

Type: MCSA

The patient has a history of interstitial lung disease. Which assessment finding in todays examination would the nurse attribute to a different pathology?

1. New-onset chest pain

2. Increasing shortness of breath

3. Clubbing of the fingers

4. Hemoptysis

Correct Answer: 1

Rationale 1: New-onset chest pain is likely attributable to another source and should be evaluated.

Rationale 2: Progressive exertional dyspnea is a finding associated with pulmonary fibrosis.

Rationale 3: Clubbing of the fingers is frequently present in many chronic respiratory diseases.

Rationale 4: Hemoptysis may occur in some forms of interstitial lung disease.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-5

Question 11

Type: MCSA

A patient states, Ive been sick for days and all the doctor does is take a chest X-ray, hand me prescriptions, and tell me I have bronchitis. How should the nurse respond?

1. Your treatment is appropriate for the diagnosis.

2. You should have had more diagnostic tests.

3. The treatment you are receiving is inadequate for the diagnosis of bronchitis.

4. You should probably be hospitalized.

Correct Answer: 1

Rationale 1: The diagnosis of acute bronchitis typically is based on the history and clinical presentation. Symptoms may last 10 to 20 days.

Rationale 2: Other diagnostic testing is rarely indicated for bronchitis.

Rationale 3: The diagnosis of acute bronchitis typically is based on the history and clinical presentation. The treatment is not inadequate.

Rationale 4: Hospitalization is rarely indicated for acute bronchitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27-2

Question 12

Type: MCSA

A patient who is diagnosed with community-acquired pneumonia tells the nurse, I dont feel too sick. How should the nurse respond?

1. Give it a few days and you will.

2. Youre lucky.

3. You may not need all the medications you have been prescribed.

4. Even though you dont feel too ill, you should get additional rest.

Correct Answer: 4

Rationale 1: Predicting that the patient will feel bad soon is not appropriate.

Rationale 2: This is not an appropriate response.

Rationale 3: The nurse should not make a statement that implies permission to not take the medications as ordered.

Rationale 4: Adequate rest is essential to recovery from pneumonia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 13

Type: MCSA

A patient with a lung abscess is being discharged from the hospital. Appropriate discharge instructions for this patient should include which information?

1. Complete the entire prescription of antibiotics.

2. Expect symptoms to become worse.

3. Return to routine activities of daily living.

4. Lung abscesses rarely cause other problems once treatment is started.

Correct Answer: 1

Rationale 1: The nurse should emphasize the importance of completing the entire course of therapy to eliminate the infecting organisms. The nurse should teach about the medication, including its name, dose, and desired and adverse effects.

Rationale 2: The nurse should stress the need to contact the physician if symptoms do not improve or if they become worse.

Rationale 3: Most lung abscesses are successfully treated with antibiotics; however, treatment may last up to 1 month or more.

Rationale 4: Infection from lung abscess can spread not only to lung and pleural tissue but systemically, and cause sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 14

Type: MCSA

A patient who had a Mantoux test for tuberculosis 2 days ago has a 2 mm area of erythema at the site of the test. How should the nurse evaluate this result?

1. As negative

2. As positive for tuberculosis

3. As indicating a sputum test for acid-fast bacilli is needed

4. As indicating need for a repeat PPD

Correct Answer: 1

Rationale 1: The intradermal PPD or Mantoux test is read within 48 to 72 hours, the peak reaction period, and recorded as the diameter of induration (raised area, not erythema) in millimeters. The area on the patient is erythematous, not an induration. No follow-up is needed, as this patients response is by definition a negative one.

Rationale 2: Mantoux is a screening test for exposure to, not presence of, the disease.

Rationale 3: A sputum test is not indicated at this time.

Rationale 4: The results do not indicate a second PPD is necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-2

Question 15

Type: MCSA

A patient tells the nurse she had the bacilli Calmette-Gurin (BCG) vaccination as a child because her mother had tuberculosis. How will this patient be screened for tuberculosis?

1. Two-step Mantoux test

2. PPD test

3. Sputum tests

4. Chest X-ray

Correct Answer: 4

Rationale 1: The patient will have a positive response to this test, so it is not a valid means of screening.

Rationale 2: The patient will have a positive response to this test, so it is not a valid means of screening.

Rationale 3: Sputum tests are not done for screening purposes.

Rationale 4: Periodic chest X-rays may be required for screening purposes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-2

Question 16

Type: MCSA

The nurse is providing care to a patient with atypical tuberculosis. What should the nurse do to ensure personal protection while caring for this patient?

1. Wear a gown and eye goggles.

2. Wear a gown and surgical mask.

3. Follow the same standard precautions used in the care of all patients.

4. Wear a HEPA respirator.

Correct Answer: 3

Rationale 1: A gown and eye goggles are not required for care of this patient.

Rationale 2: Gowns and surgical masks are not required in the care of this patient.

Rationale 3: Atypical tuberculosis is not a transmissible disease. The nurse should use standard precautions.

Rationale 4: Use of a HEPA respirator is not required in the care of this patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-2

Question 17

Type: MCSA

A patient is diagnosed with histoplasmosis. Which elements of this patients history would help explain the reason for the disease?

1. Lives in a city with chemical plants

2. Drives a vehicle that uses diesel fuel

3. Is an electrical engineer

4. Works part-time for a poultry farm

Correct Answer: 4

Rationale 1: Chemical plants do not generally contribute to histoplasmosis infection.

Rationale 2: Diesel fluid does not contain histoplasmosis.

Rationale 3: Exposure to electricity does not cause histoplasmosis.

Rationale 4: Histoplasmosis, an infectious disease caused by Histoplasma capsulatum, is the most common fungal lung infection in the United States. The organism is found in the soil and is linked to exposure to bird droppings and bats.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-2

Question 18

Type: FIB

A young child has been diagnosed with pneumonia and has been prescribed erythromycin, 45 mg per day for every 1 kilogram of body weight. The patient weighs 46 pounds. The physician asks that the patient receive the medication in three equal doses throughout the day. The patient should receive _____ mg per dose (round the answer to a whole number).

Standard Text:

Correct Answer: 314

Rationale : The patient weighs 46 pounds, or 20.909 kilograms (2.2 pounds per kilogram). The patient is supposed to receive 45 mg of erythromycin per kilogram of body weight, or 940.909 mg, each day. Three equal doses would be 313.64 mg per dose, rounded to 314.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 19

Type: MCSA

The nurse is reviewing the results of a patients diagnostic tests. Based on the chart, which physician order would the nurse question based on the patients most likely diagnosis?

1. Fluid restriction of 1,500 mL per 24 hours

2. Up in chair as tolerated

3. Perform endotracheal suctioning as needed.

4. Administer azithromycin.

Correct Answer: 1

Rationale 1: After reviewing the patients laboratory test results, the nurse would accurately determine that the patient has developed pneumonia. The nurse would encourage the patient to increase fluid intake to 2,5003,000 mL per day to help liquefy the secretions in the lungs and make it easier to cough up and expectorate the secretions. The nurse would not expect the physician to write an order for fluid restriction.

Rationale 2: The patient should be encouraged to continue as much activity as tolerated.

Rationale 3: Endotracheal suctioning may be required if the patients cough is ineffective.

Rationale 4: Azithromycin is a macrolide, a broad-spectrum antibiotic that is often effective against pneumonia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-2

Question 20

Type: MCMA

The newly licensed nurse is learning how to care for patients who have had thoracic surgery following a diagnosis of lung cancer. Which statement by the nurse would the preceptor evaluate as indicating the need for additional teaching?

Standard Text: Select all that apply.

1. I should assess the patients respiratory system at least every 4 hours.

2. I shouldnt offer pain medications to this patient because it will result in severe respiratory depression.

3. If there are items that the patient needs frequently, I should keep them across the hospital room. This will ensure that the patient will get better faster.

4. I will talk with the physical therapist about a plan for the patients activity.

5. I should teach my patient how to splint the incision.

Correct Answer: 2,3

Rationale 1: The nurse should perform a respiratory assessment at least every 4 hours.

Rationale 2: Pain medications should be offered after thoracic surgery to ensure that the patient can perform pulmonary rehabilitation exercises such as coughing, deep breathing, and incentive spirometry. The patient who is using pain medications must be monitored for respiratory depression so that it can be treated.

Rationale 3: This patient should be encouraged to conserve energy. Items that are used frequently should be kept within the patients reach.

Rationale 4: Patients will lung cancer benefit from a multidisciplinary approach to care.

Rationale 5: Splinting the incision will make coughing and moving more comfortable.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27-4

Question 21

Type: MCMA

Which assessment findings would indicate the need for immediate action by the nurse caring for a patient with asthma?

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

Standard Text: Select all that apply.

1. Tachycardia

2. Diffuse wheezing

3. Retractions

4. Inaudible breath sounds

5. Reduced wheezing

Correct Answer: 4,5

Rationale 1: During an asthma attack, tachycardia, tachypnea, and prolonged expirations are common. These would be early symptoms of the disease process that can easily be addressed without urgency.

Rationale 2: A progression of symptoms would include diffuse wheezing and the use of accessory muscles when inhaling. But airflow is still occurring; therefore, these are not as urgent as another symptom.

Rationale 3: Retractions are a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging.

Rationale 4: Inaudible breath sounds are one indication that little or no air movement into and out of the lungs is taking place. These symptoms represent the most urgent need and require immediate intervention by the nurse to open up the lungs and prevent total respiratory failure.

Rationale 5: Reduced wheezing is one indication that little or no air movement into and out of the lungs is taking place. These symptoms represent the most urgent need and require immediate intervention by the nurse to open up the lungs and prevent total respiratory failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-3

Question 22

Type: MCSA

A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 86%, polycythemia, increase in WBC bands count, temperature of 101 F, pulse 100, respirations 35, and a chest X-ray showing evidence of a flattened diaphragm with infiltrates. Which physician order would the nurse question for this patient?

1. Antibiotic therapy

2. Initiation of oxygen by nasal cannula at 12 L/minute

3. Bronchodilator therapy

4. Mucolytic therapy

Correct Answer: 4

Rationale 1: The nurse would not question an order for antibiotic therapy because the fever and increase in WBC bands indicate potential infection.

Rationale 2: Oxygen is indicated for a COPD patient whose oxygen saturations are below 88%.

Rationale 3: Bronchodilators will open up the alveoli and increase the exchange of oxygen and carbon dioxide more effectively.

Rationale 4: No mucolytics have been shown to demonstrate clinical efficacy in treating the symptoms of COPD.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 23

Type: MCMA

The nurse would identify which nursing diagnoses as appropriate for a 10-year-old patient just diagnosed with cystic fibrosis?

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

Standard Text: Select all that apply.

1. Ineffective Airway Clearance

2. Anticipatory Grieving

3. Imbalanced Nutrition: Less than Body Requirements

4. Mobility, Altered

5. Infection, Risk for

Correct Answer: 1,2,3,5

Rationale 1: Ineffective Airway Clearance is related to the thickened mucus production of the respiratory tract that makes it difficult to expectorate.

Rationale 2: The life span and lifestyle of a patient with cystic fibrosis are limited. The child may grieve for losses at his or her own levelfor example the loss of the ability to play with other children.

Rationale 3: Due to the pancreatic enzyme deficiency and impaired digestion, nutrition is altered even with medication to improve the process. If the patient does not comply with the medical regimen, death from respiratory failure and nutrition deficit is likely.

Rationale 4: The patient may experience decreased oxygenation, which would result in Fatigue or Activity Intolerance as nursing diagnoses. There is no indication that mobility is altered.

Rationale 5: The patient with CF has chronic pulmonary disease and is at risk for infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27-3

Question 24

Type: MCMA

Which topics would be appropriate to instruct a patient diagnosed with occupational lung disease?

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

Standard Text: Select all that apply.

1. Methods to conserve energy and increase rest

2. Restricting fluids due to increased edema

3. Counseling for caregiver role strain from chronic disease management

4. Avoiding air pollutants and cigarette smoke

5. Importance of wearing personal protective equipment against occupational exposure

Correct Answer: 1,3,4,5

Rationale 1: With progressive lung damage from asbestos, chemicals, coal, or other irritants, the patient would have less tissue available to exchange air. Energy conservation would decrease oxygen demand in the body when at rest by decreasing the basal metabolic requirements of the cells.

Rationale 2: Restricting fluids due to increased edema is contraindicated for patients with lung disease.

Rationale 3: Caregiver role strain is a common problem and should be discussed, especially because of expected role changes due to the patients progressive decline and increasing activity intolerance as more lung tissue is damaged by the onset of the complication of COPD.

Rationale 4: Avoidance of air pollution and smoking will reduce additional damage and maximize airflow for a greater period of time.

Rationale 5: Personal protective equipment is designed to reduce occupational exposure to hazardous materials.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-5

Question 25

Type: MCSA

A patient diagnosed with a femur fracture is experiencing sudden dyspnea, pleuritic chest pain, syncope with movement, cyanosis, tachycardia, and tachypnea. What should be the nurses first action?

1. Raise the head of the bed (HOB).

2. Administer oxygen per nasal cannula for the cyanosis and dyspnea.

3. Provide reassurance and keep the patient calm by staying with the patient.

4. Evaluate urinary output to assess cardiac output.

Correct Answer: 1

Rationale 1: Raising the HOB to a high Fowlers position facilitates maximum lung expansion and reduces venous return to the right side of the heart, lowering pressure on the vascular system. This intervention should be done first.

Rationale 2: Oxygen therapy will increase the availability of air to the patient, but another intervention should be performed first.

Rationale 3: Staying with the patient will minimize the stress of the situation and reduce oxygen demand. However, another intervention should be performed first.

Rationale 4: Cardiac output will be helpful to assess, but urinary output must be measured by hourly volumes, and unless a catheter is in place, this action is the least important approach to managing cardiac and pulmonary status from possible emboli.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 26

Type: MCSA

During pulmonary function tests, a patient with asthma is found to have approximately 500 mL of air moving in and out of the lungs during normal, quiet breathing. How would the nurse document this result?

1. Tidal volume

2. Expiratory reserve volume

3. Residual volume

4. Vital capacity

Correct Answer: 1

Rationale 1: Tidal volume (TV) is the amount of air (approximately 500 mL) that is moved in and out of the lungs with each normal, quiet breath.

Rationale 2: Expiratory reserve volume (ERV) is the approximately 1,000 mL of air that can be forced out over the tidal volume.

Rationale 3: The residual volume is the volume of air (approximately 1,100 mL) that remains in the lungs after a forced expiration.

Rationale 4: Vital capacity (VC) is the sum of TV + IRV + ERV and is approximately 4,500 mL in the healthy patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27-3

Question 27

Type: MCSA

When preparing a patient for a pulmonary function test, which instruction should the nurse provide?

1. Expect to be sedated for the test.

2. Antinausea medication will be provided prior to the test.

3. You will wear a nose clip during the test.

4. You will be given oxygen for a while after the test.

Correct Answer: 3

Rationale 1: Patients are not sedated for pulmonary function testing.

Rationale 2: Nausea is not a common issue with the tests.

Rationale 3: A nose clip is placed on a nonsedated patient during pulmonary function testing.

Rationale 4: Oxygen is typically not needed after the test.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 28

Type: FIB

The nurse would anticipate alpha-1 antitrypsin (ATT) levels to be drawn on all patients ______ years of age or younger who demonstrate assessment findings of chronic obstructive pulmonary disease.

Standard Text:

Correct Answer: 40

Rationale : Tests to determine ATT levels are done when patients younger than 40 years of age exhibit assessment findings of COPD. This deficiency accounts for less than 1% of the COPD cases in the United States.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-3

Question 29

Type: MCMA

Which health promotion information should the nurse provide to the patient newly diagnosed with chronic obstructive pulmonary disease (COPD)?

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

Standard Text: Select all that apply.

1. Here is some information about a smoking cessation clinic you should investigate.

2. I will give you a flu shot before you leave the clinic today.

3. High pollen counts should not bother you, but stay inside on windy, dusty days.

4. You should avoid being in enclosed areas with large groups of people.

5. Avoid spending time outside if it is very hot or very cold.

Correct Answer: 1,2,4,5

Rationale 1: Smoking cessation is the primary health promotion need for patients with COPD.

Rationale 2: Patients with COPD should have annual immunizations against influenza.

Rationale 3: High pollen counts often result in worsening of COPD symptoms.

Rationale 4: People with COPD are at risk of contracting illness from others.

Rationale 5: Persons with COPD should avoid extremes of temperature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 30

Type: FIB

A child with recurrent respiratory infection is being evaluated for cystic fibrosis. The nurse explains to the parents that diagnosis is based on history and two sweat chloride tests equal to or over ______ mEq/L.

Standard Text:

Correct Answer: 60

Rationale : Cystic fibrosis results in alteration of salt and water transport. It is diagnosed by history and sweat chloride testing. Because of possible false-positive readings, the disorder is not diagnosed until two sweat chloride tests equal to or over 60 mEq/L are obtained.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 31

Type: MCMA

The nurse is discussing the long-term care of a child with cystic fibrosis (CF) with the parents. Which goals should the nurse include in this plan?

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

Standard Text: Select all that apply.

1. Prevention of infection

2. Improvement of nutrition

3. Making the childs life as normal as possible

4. Maintaining antibiotic therapy to cure the disease

5. Preventing common neurologic complications

Correct Answer: 1,2,3

Rationale 1: CF predisposes patients to the development of serious respiratory infection.

Rationale 2: CF causes changes in the gastrointestinal tract that interfere with absorption of nutrients.

Rationale 3: The child will need physiological and psychological support to maintain as normal a life as possible.

Rationale 4: CF is not a curable disease.

Rationale 5: CF affects the respiratory and gastrointestinal systems. Neurologic complications are not common.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-3

Question 32

Type: MCMA

A nurse is discussing cystic fibrosis (CF) with a group of young adults who have the disease. What information should the nurse provide about sexuality and reproduction?

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

Standard Text: Select all that apply.

1. Men with CF are generally not able to have biologic children.

2. Women with CF do not have problems becoming pregnant but have difficult labor and delivery experiences.

3. People with CF have reduced sexuality.

4. Children of a parent with CF will have the disease or be carriers.

5. Some women with CF are infertile.

Correct Answer: 1,4,5

Rationale 1: Men with CF are almost always sterile.

Rationale 2: Women with CF often do have difficulty becoming pregnant.

Rationale 3: There is no evidence that people with CF have reduced sexuality.

Rationale 4: Children of a parent with CF will either manifest the disease or be carriers.

Rationale 5: Some women with CF are infertile.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 33

Type: MCSA

A patient diagnosed with a pulmonary embolism has been started on heparin therapy. The patient asks, How long before the medicine dissolves my clot? How should the nurse respond?

1. It will be at least 3 days before your blood levels are high enough to start dissolving the clot.

2. Your body will dissolve and resorb the clot. The heparin is to help prevent additional clots.

3. As soon as you are given intravenous heparin, the clot will begin to dissolve.

4. The clot will never dissolve. The heparin is to help prevent other clots from forming.

Correct Answer: 2

Rationale 1: Heparin does not dissolve clots.

Rationale 2: Heparin is administered to help prevent additional clots from forming.

Rationale 3: Heparin does not have clot-lysing ability.

Rationale 4: The body will dissolve and resorb the clot. The heparin helps prevent additional clot formation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 34

Type: MCMA

The nurse is developing handouts for a community educational session about lung cancer. Which information should the nurse include in this material?

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

Standard Text: Select all that apply.

1. The majority of lung cancers are detected when the patient has an X-ray for an unrelated complaint.

2. Coughing is a common symptom of lung cancer.

3. Hoarseness is a symptom that should be evaluated.

4. Small-cell lung cancer is almost always found in smokers.

5. Lung cancer associated with smoking is almost always treated with radiation and chemotherapy.

Correct Answer: 2,3,4

Rationale 1: Only about 15% of lung cancers are detected in this manner.

Rationale 2: Coughing is a very common symptom of lung cancer that frequently is the reason the patient seeks medical care.

Rationale 3: Hoarseness is sometimes a symptom of lung cancer.

Rationale 4: Small-cell lung cancer is a highly aggressive disseminated cancer that is almost always found in smokers.

Rationale 5: The methods used to treat lung cancer vary from case to case.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-4

Question 35

Type: MCSA

A patient presents with findings suggestive of pulmonary embolism. The D-dimer test is negative. How does the nurse interpret this finding?

1. The patient has a pulmonary embolism.

2. Additional testing is necessary, but a pulmonary embolism is unlikely.

3. There is 4% likelihood that the test is incorrect.

4. The test should be repeated in 48 hours.

Correct Answer: 2

Rationale 1: A negative D-dimer does not support the diagnosis of pulmonary embolism.

Rationale 2: A negative D-dimer indicates that a pulmonary embolism is unlikely. Additional tests to discover the etiology of the symptoms are necessary.

Rationale 3: There is no indication that the test is incorrect.

Rationale 4: There is no indication that the test should be repeated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-3

 

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