Chapter 50 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 50

Question 1

Type: MCSA

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

1. The ability to cough

2. Filtration and humidification of inspired air

3. The sneeze reflex initiated by irritants in the nasal passages

4. Decrease in oxygen-carrying capacity of the trachea

Correct Answer: 2

Rationale 1: The client is able to cough.

Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed.

Rationale 3: The client can sneeze.

Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe the mechanisms for respiratory regulation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1242

Question 2

Type: MCSA

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?

1. The client with a nasal fracture

2. The client with impairment of vagus nerve conduction

3. The client with a sinus infection

4. The client with reduction in respiratory membrane conduction

Correct Answer: 2

Rationale 1: Nasal fracture does not depress the cough reflex.

Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.

Rationale 3: A sinus infection will not depress the cough reflex.

Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify factors influencing respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1243

Question 3

Type: MCSA

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint?

1. Use of accessory muscles

2. Increased respiratory depth

3. Increased respiratory rate

4. Decreased respiratory depth

5. Decreased respiratory rate

Correct Answer: 1, 2, 3, 4

Rationale 1: Use of accessory muscles often is an assessment finding indicating difficulty breathing.

Rationale 2: Depth is often assessed when determining difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present.

Rationale 3: Rate is assessed when determining difficulty breathing. Rate is generally increased.

Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present.

Rationale 5: Rate is generally increased.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1247

Question 4

Type: MCSA

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?

1. Increased hematocrit

2. Decreased BUN

3. Increased blood sugar

4. Increased sedimentation rate

Correct Answer: 1

Rationale 1: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the bodys attempt to increase oxygen-carrying capacity by increasing erythrocyte production.

Rationale 2: BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity.

Rationale 3: The blood glucose level is not used to measure oxygenation.

Rationale 4: The sedimentation rate is not a direct measure of oxygenation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function.

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1245

Question 5

Type: MCSA

A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take?

1. Increase the oxygen to 3 liters per minute via nasal cannula.

2. Lower the head of the clients bed to the semi-Fowlers position.

3. Have the client breathe through pursed lips.

4. Encourage the client to breathe more rapidly.

Correct Answer: 3

Rationale 1: In the client with chronic obstructive lung disease, the drive to breathe is often dependent upon low oxygen concentration. Increasing oxygen delivery by increasing the oxygen from 1.5 Lpm to 3 Lpm may be dangerous to this client.

Rationale 2: Lowering the head of the bed makes it more difficult to breathe. This client should have the head of the bed elevated to the Fowlers position or should be assisted to lean over the overbed table to increase chest excursion.

Rationale 3: The client should be taught to breathe out against pursed lips to increase the time it takes to exhale and to help keep airways open.

Rationale 4: Chronic obstructive lung disease makes it difficult for the client to breathe out, so increasing the rate of respiration will not be helpful.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1252

Question 6

Type: MCSA

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse?

1. Prepare to resuscitate the client.

2. Have the client concentrate on slowing down respirations.

3. Place the client in Trendelenburgs position and ask him to cough forcefully.

4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

Correct Answer: 2

Rationale 1: There is no indication that this client needs resuscitation.

Rationale 2: This client is hyperventilating and should be assisted to slow down respirations. Techniques to slow respirations include counting respirations or having the client match respirations with the nurse, who then slows down the respiratory rate.

Rationale 3: There is no need to place the client in Trendelenburgs position for coughing.

Rationale 4: Demerol may slow breathing, but is not necessary at this time.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1247

Question 7

Type: MCSA

The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon?

1. Blood sugar

2. Hemoglobin and hematocrit

3. Cardiac enzymes

4. Serum electrolytes

Correct Answer: 2

Rationale 1: Blood sugar is not used to evaluate respiratory function.

Rationale 2: In order to exhibit cyanosis, the clients blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit.

Rationale 3: Cardiac enzymes are not used to evaluate respiratory function.

Rationale 4: Serum electrolytes are not used to evaluate respiratory function.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function.

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1248

Question 8

Type: MCSA

A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?

1. Cheyne-Stokes

2. Biots

3. Cluster

4. Kussmauls

Correct Answer: 4

Rationale 1: Cheyne-Stokes respirations are commonly a result of chronic diseases, increased intracranial pressure, or drug overdose.

Rationale 2: Biots respirations are often the result of central nervous system disorders.

Rationale 3: Cluster respirations are often the result of central nervous system disorders.

Rationale 4: Kussmauls respirations are a type of hyperventilation that accompanies metabolic acidosis. They represent the bodys attempt to compensate for the acidosis by blowing off carbon dioxide.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1247

Question 9

Type: MCSA

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?

1. Ineffective Breathing Pattern

2. Anxiety

3. Ineffective Airway Clearance

4. Impaired Gas Exchange

Correct Answer: 3

Rationale 1: There are no data that support Ineffective Breathing Pattern as a diagnosis.

Rationale 2: There are no data that support Anxiety as a diagnosis.

Rationale 3: The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is crackles in both lung bases.

Rationale 4: There are no data that support Impaired Gas Exchange as a diagnosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1249

Question 10

Type: MCSA

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?

1. Sputum contains bacteria that should be expectorated.

2. Swallowing sputum is dangerous to the system.

3. The nurse should view the sputum for quality and quantity.

4. The client is likely to aspirate the sputum while attempting to swallow it.

Correct Answer: 3

Rationale 1: Sputum does contain bacteria, but they are killed by the acid environment of the gastrointestinal tract.

Rationale 2: There is no danger to swallowing sputum.

Rationale 3: There is no good rationale for having the client expectorate the sputum except for the nurse to view it for quality and quantity.

Rationale 4: The client is no more likely to aspirate sputum than any other fluid.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1249

Question 11

Type: MCSA

The nurse is planning a time schedule for a clients twice-daily postural drainage. Which time schedule would be best?

1. 0800 and 1100

2. 1200 and 1800

3. 0700 and 2000

4. 0900 and 2100

Correct Answer: 3

Rationale 1: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

Rationale 2: Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

Rationale 3: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 0700 and 2000.

Rationale 4: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1257

Question 12

Type: MCSA

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse?

1. Turn the client to the left side.

2. Increase the percentage of oxygen being delivered.

3. Check for an airtight seal between the clients face and the mask.

4. Increase the liter flow of oxygen being delivered.

Correct Answer: 4

Rationale 1: There is no need to turn the client to either side.

Rationale 2: All oxygen is delivered at 100%, so there is no method to increase the percentage of oxygen being delivered.

Rationale 3: The seal between the clients face and the mask should be snug, but will not be airtight.

Rationale 4: To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1260

Question 13

Type: MCSA

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

1. Tape the airway in place.

2. Suction the client.

3. Turn the clients head to the side.

4. Insert a nasal trumpet.

Correct Answer: 3

Rationale 1: The airway should not be taped in place, as it would then act as an airway obstruction if dislodged.

Rationale 2: Although suctioning the client is possible with the airway in place, the client should be suctioned only when it is necessary.

Rationale 3: The nurse should turn the clients head to the side to allow drainage of oral secretions.

Rationale 4: Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1265

Question 14

Type: MCSA

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?

1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.

2. Remove the tracheostomy ties and replace them with an elastic bandage.

3. Remove the tracheostomy inner cannula.

4. Tape the tracheostomy obturator to the head of the bed.

Correct Answer: 4

Rationale 1: The cuff should not be deflated if the client is being mechanically ventilated.

Rationale 2: The tracheostomy ties are only removed when they are soiled and need to be changed.

Rationale 3: The tracheostomy inner cannula is only removed for cleaning.

Rationale 4: The obturator should be taped to the head of the bed so that it will be readily available if the client tracheostomy tube should become dislodged.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1266

Question 15

Type: MCSA

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?

1. Turn the suction level up to 60 cm prior to inserting the catheter.

2. Increase the oxygen flow to the client by 20% prior to suctioning.

3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.

4. Instruct the client to cough forcefully from the abdomen prior to suction.

Correct Answer: 3

Rationale 1: Turning up the suction level will not hyperinflate the clients lungs.

Rationale 2: Increasing the oxygen flow rate will not hyperinflate the clients lungs.

Rationale 3: The nurse should provide 2 to 3 breaths at 1.5 times the clients normal tidal volume prior to and after insertion of the suction catheter.

Rationale 4: Coughing will not hyperinflate the clients lungs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1272

Question 16

Type: MCSA

The nurse who is assessing a clients chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?

1. Discontinue the chest tube suction.

2. Collaborate with the clients physician.

3. Mark the area involved and remove the tube.

4. Reinforce the chest tube dressing.

Correct Answer: 2

Rationale 1: Chest tube suction should not be discontinued.

Rationale 2: Subcutaneous emphysema, which is air in the subcutaneous tissues, can result from a poor seal at the chest tube insertion site. The nurse should collaborate with the clients physician regarding this finding.

Rationale 3: The tube should not be removed.

Rationale 4: Simply reinforcing the chest tube dressing will not prevent further air loss and does not allow for physician input.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1280

Question 17

Type: MCSA

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure?

1. An occlusive dressing

2. A 4 4 gauze

3. An adhesive gauze pad dressing

4. A non-adherent gauze dressing

Correct Answer: 1

Rationale 1: Because this chest tube was put in without a purse-string suture, there is nothing to pull the tissue together once the tube is removed. In order to prevent leakage of air into the chest cavity, an occlusive dressing must be used.

Rationale 2: This is not an occlusive dressing.

Rationale 3: This is not an occlusive dressing.

Rationale 4: This is not an occlusive dressing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1281

Question 18

Type: MCSA

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate that this client needs further instruction?

1. I will replace my cotton blankets with polyester ones.

2. My son will not be able to smoke when I am around.

3. I will have my electrical appliance checked for grounding.

4. I will buy a fire extinguisher for my bedroom.

Correct Answer: 1

Rationale 1: Polyester blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily.

Rationale 2: The client understands the hazards associated with home oxygen therapy.

Rationale 3: This statement reflects understanding of home oxygen therapy.

Rationale 4: This statement reflects understanding of home oxygen therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1259

Question 19

Type: MCSA

A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place?

1. Count the clients respirations.

2. Assess the depth of the clients respirations.

3. Auscultate for bilateral breath sounds.

4. Deflate the cuff and listen for minimal leak.

Correct Answer: 3

Rationale 1: Counting the respirations does not assess tube placement.

Rationale 2: This will not determine tube placement.

Rationale 3: The end of the endotracheal tube should sit just above the bifurcation of the trachea into the two mainstem bronchi. If the tube is in the correct position, the nurse should be able to hear equal bilateral breath sounds.

Rationale 4: Deflating the cuff and listening for minimal leak is a way to prevent damage to the trachea, not a way to assess placement.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1266

Question 20

Type: MCSA

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurses next action?

1. Fill the humidifier with normal saline.

2. Pad the tubing where it contacts the clients ears.

3. Set the oxygen delivery to 5 liters.

4. Secure the cannula with ties around the clients head.

Correct Answer: 2

Rationale 1: The humidifier should be filled with water prior to initiating therapy.

Rationale 2: It is necessary to pad the cannula where it contacts the clients ears, as pressure irritation may occur.

Rationale 3: Because this client has chronic obstructive pulmonary disease, the oxygen should be set at a lower delivery rate (generally no more than 1.5 to 2 Lpm).

Rationale 4: The cannula does not require ties to secure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: a. Administering oxygen by cannula, face mask, or face tent.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1263

Question 21

Type: MCSA

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?

1. Remove the old ties, clean the area well, and then put on new ties.

2. Attach the new tape and tie with a square knot behind the clients neck.

3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.

4. Remove the outer cannula, replace the soiled ties, and reinsert.

Correct Answer: 3

Rationale 1: Removing the ties without an assistant could allow the tracheostomy tube to become dislodged.

Rationale 2: The knot for securing the tracheostomy tube should be tied at the side of the neck to prevent an area of pressure development.

Rationale 3: Because these ties are soiled, it is likely that they must be removed before new ties are attached. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them.

Rationale 4: The outer cannula is not removed in a new tracheostomy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: d. Providing tracheostomy care.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1278

Question 22

Type: MCSA

The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to the UAP?

1. Both oral and tracheal suctioning

2. Only oral suctioning

3. Only tracheal suctioning

4. Neither oral nor tracheal suctioning

Correct Answer: 2

Rationale 1: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Rationale 2: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP.

Rationale 3: Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Rationale 4: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1269

Question 23

Type: MCSA

During tracheal suctioning, the nurse notes that the client heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?

1. Immediately discontinue suctioning.

2. Prepare to resuscitate the client.

3. Continue to suction until the airway is clear.

4. Complete the suction episode as quickly as possible.

Correct Answer: 4

Rationale 1: There is no need to immediately discontinue suctioning.

Rationale 2: There is no need to prepare to resuscitate the client.

Rationale 3: The client will likely not tolerate continuing the suction episode until the airway is clear.

Rationale 4: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1271

Question 24

Type: MCSA

A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should take which action?

1. Hyperventilate the client using the settings on the mechanical ventilator.

2. Hyperventilate the client using a manual resuscitator.

3. Avoid hyperventilation, but instill normal saline into the endotracheal tube.

4. Avoid hyperventilation and increase the oxygen to 100% for several breaths.

Correct Answer: 4

Rationale 1: Hyperventilating the client will likely serve to force secretions back into the respiratory tract.

Rationale 2: Hyperventilating the client will likely serve to force secretions back into the respiratory tract.

Rationale 3: There is no need to instill normal saline into the tube of a client with copious frothy secretions.

Rationale 4: The nurse should avoid hyperventilation and should increase the oxygen to 100% for several breaths prior to initiating suction. Hyperventilating a client who has copious secretions can force the secretions deeper into the respiratory tract.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1274

Question 25

Type: MCSA

A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?

1. The medications cannot be used on the same day.

2. The steroid inhaler should be used when immediate effects are necessary.

3. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler.

4. Both medications have the possible side effect of increased heart rate.

Correct Answer: 4

Rationale 1: The medications can be used on the same day.

Rationale 2: It is imperative for the client to understand that the steroid inhaler is not a rescue inhaler and should not be used for immediate relief.

Rationale 3: Although the client should be taught to use both inhalers as infrequently as possible, the client should be taught to use the inhaler when necessary. When the inhalers are used together, the bronchodilator is used first, followed by the steroid.

Rationale 4: Both of these medications have the possible side effect of increased heart rate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1253

Question 26

Type: MCMA

A client complains of difficulty breathing. What will the nurse most likely assess in this client?

Standard Text: Select all that apply.

1. Use of accessory muscles

2. Increased respiratory depth

3. Increased respiratory rate

4. Decreased respiratory depth

5. Decreased respiratory rate

Correct Answer: 1, 2, 3, 4

Rationale 1: Use of accessory muscles is an assessment finding associated with difficulty breathing.

Rationale 2: Increased respiratory depth is an assessment finding associated with difficulty breathing.

Rationale 3: Increased respiratory rate is an assessment finding associated with difficulty breathing.

Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Respiratory rate is generally increased.

Rationale 5: Respiratory rate is generally increased.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1245

Question 27

Type: MCSA

A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to

1. improve oxygenation.

2. remove irritants from the nasal passages.

3. remove irritants from the trachea or bronchi.

4. close the glottis.

Correct Answer: 3

Rationale 1: Coughing does not improve oxygenation.

Rationale 2: Sneezing removes irritants from the nasal passages.

Rationale 3: The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus that traps pathogens and microscopic particulate matter. These foreign particles are then swept upward toward the larynx and throat by cilia. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi.

Rationale 4: Swallowing closes the glottis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues.

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1243

Question 28

Type: MCSA

A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in

1. Ventilation.

2. Alveolar gas exchange.

3. Transportation of oxygen and carbon dioxide.

4. Systemic diffusion.

Correct Answer: 1

Rationale 1: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation.

Rationale 2: Alveolar gas exchange is the diffusion of oxygen from the alveoli and into the pulmonary blood vessels, and occurs after ventilation.

Rationale 3: Transportation of oxygen and carbon dioxide occurs in the blood.

Rationale 4: Systemic diffusion of oxygen and carbon dioxide occurs between the capillaries and the tissues and cells.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration).

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1245

Question 29

Type: MCSA

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the clients degree of effective gas exchange?

1. Blood glucose

2. Serum potassium

3. Serum sodium

4. Arterial blood gas

Correct Answer: 4

Rationale 1: The blood glucose level is not used to determine a clients degree of effective gas exchange.

Rationale 2: The serum potassium level is not used to determine a clients degree of effective gas exchange.

Rationale 3: The serum sodium level is not used to determine a clients degree of effective gas exchange.

Rationale 4: Blood for partial pressures or blood gases is usually obtained from arterial blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1245

Question 30

Type: MCMA

The nurse is determining a clients ability to transport oxygen from the lungs to body tissues. What factors will influence this ability?

Standard Text: Select all that apply.

1. Cardiac output

2. Exercise

3. Diet

4. Erythrocyte count

5. Hematocrit

Correct Answer: 1, 2, 4, 5

Rationale 1: Cardiac output is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 2: Exercise is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 3: Diet is not a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 4: Erythrocyte count is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 5: Hematocrit level is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify factors influencing respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1245

Question 31

Type: MCSA

A clients blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client?

1. Decreased respiration rate

2. Increased respiration rate

3. Increased blood pressure

4. Decreased bowel sounds

Correct Answer: 2

Rationale 1: An increase in carbon dioxide level will increase, not decrease, respirations.

Rationale 2: Of the three blood gaseshydrogen, oxygen, and carbon dioxidethat can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration.

Rationale 3: An increase in carbon dioxide level might not increase the clients blood pressure.

Rationale 4: An increase in carbon dioxide level has no effect on the clients bowel sounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1246

Question 32

Type: MCSA

A clients blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations?

1. Alveoli

2. Trachea

3. Bronchioles

4. Carotid bodies

Correct Answer: 4

Rationale 1: The alveoli do not respond to a low oxygen level.

Rationale 2: The trachea does not respond to a low oxygen level.

Rationale 3: The bronchioles do not respond to a low oxygen level.

Rationale 4: Special neural receptors sensitive to decreases in O2 concentration are located outside the central nervous system in the carotid bodies, just above the bifurcation of the common carotid arteries, and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration).

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1246

Question 33

Type: MCSA

An older client is prescribed diazepam (Valium). What should the nurse monitor in this client?

1. Respirations

2. Urine output

3. Muscle tone

4. Appetite

Correct Answer: 1

Rationale 1: Medications such as diazepam (Valium) can decrease the rate and depth of respirations. Older clients are at high risk of respiratory depression. The nurse must carefully monitor respiratory status in this client.

Rationale 2: Diazepam (Valium) does not affect urine output.

Rationale 3: Diazepam (Valium) does not affect muscle tone.

Rationale 4: Diazepam (Valium) does not affect appetite.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1247

Question 34

Type: MCMA

The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment?

Standard Text: Select all that apply.

1. Decreased cough reflex

2. Stiffening of blood vessels

3. Alteration in protein synthesis

4. Dry mucous membranes

5. Increased risk of aspiration

Correct Answer: 1, 4, 5

Rationale 1: The cough reflex decreases during aging.

Rationale 2: Stiffening of blood vessels is an effect of aging on the cardiovascular system.

Rationale 3: Alteration in protein synthesis is an effect of aging on the metabolic system.

Rationale 4: Mucous membranes are drier with aging.

Rationale 5: Increased risk of aspiration occurs in aging because of gastroesophageal reflux disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify factors influencing respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1246

Question 35

Type: MCSA

A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this clients respiratory function?

1. Conditions that affect the airway.

2. Conditions that affect transport.

3. Conditions that affect the movement of air.

4. Conditions that affect diffusion.

Correct Answer: 2

Rationale 1: Conditions that affect the airway are those that partially or totally occlude the respiratory passages.

Rationale 2: Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the oxygen to all body tissues, and transports CO2 from the cells back to the lungs, where it can be exhaled from the body. Conditions that decrease cardiac output, such as congestive heart failure or hypovolemia, affect tissue oxygenation and also the bodys ability to compensate for hypoxemia.

Rationale 3: Conditions that affect the movement of air would alter the clients breathing pattern.

Rationale 4: Impaired diffusion can affect levels of gases in the blood, particularly oxygen, which does not diffuse as readily as does carbon dioxide. Hypoxemia, or reduced oxygen levels in the blood, can be caused by conditions that impair diffusion at the alveolarcapillary level, such as pulmonary edema or atelectasis, or by low hemoglobin levels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify factors influencing respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1245

Question 36

Type: MCMA

The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment?

Standard Text: Select all that apply.

1. Lifestyle

2. Presence of cough

3. Sputum production

4. Pain

5. Diet

Correct Answer: 1, 2, 3, 4

Rationale 1: A comprehensive nursing history relevant to oxygenation status should include data about lifestyle.

Rationale 2: A comprehensive nursing history relevant to oxygenation status should include data about the presence of a cough.

Rationale 3: A comprehensive nursing history relevant to oxygenation status should include data about sputum production.

Rationale 4: A comprehensive nursing history relevant to oxygenation status should include data about pain.

Rationale 5: A comprehensive nursing history relevant to oxygenation status does not include data about diet.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1246

Question 37

Type: MCMA

A client is concerned about maintaining a healthy respiratory system. What should the nurse instruct the client to do to promote a healthy respiratory status?

Standard Text: Select all that apply.

1. Use pursed-lip breathing.

2. Exercise regularly.

3. Do not smoke.

4. Breathe through the nose.

5. Breathe through the mouth.

Correct Answer: 2, 3, 4

Rationale 1: Client teaching to promote healthy breathing does not include the use of pursed-lip breathing. This technique is for a client with a lung disorder such as chronic obstructive lung disease or emphysema.

Rationale 2: Client teaching to promote healthy breathing includes regular exercise.

Rationale 3: Client teaching to promote healthy breathing includes not smoking.

Rationale 4: Client teaching to promote healthy breathing includes breathing through the nose.

Rationale 5: Client teaching to promote healthy breathing does not include breathing through the mouth.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1252

Question 38

Type: MCSA

Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective?

1. A humidifier takes moisture out of the air.

2. A humidifier tightens secretions.

3. A humidifier prevents my lungs from getting too dry.

4. A humidifier replaces the use of oxygen.

Correct Answer: 3

Rationale 1: A humidifier adds moisture to the air.

Rationale 2: A humidifier loosens secretions.

Rationale 3: The purposes of humidifiers are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration.

Rationale 4: A humidifier does not replace the use of oxygen but is used with oxygen.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1252

Question 39

Type: MCSA

The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client?

1. Respiratory rate 24 and labored

2. Audible wheeze upon auscultation

3. High-pitched cough present

4. Presence of a productive cough

Correct Answer: 4

Rationale 1: Expectorants do not affect the respiratory rate.

Rationale 2: Expectorants should improve lung sounds.

Rationale 3: Expectorants should cause a more productive cough.

Rationale 4: Expectorants break up mucus, making it more liquid and easier to cough out.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1253

Question 40

Type: MCSA

The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client?

1. Apply suction for 510 seconds.

2. Plan to suction for 10 minutes.

3. Apply suction while inserting the catheter.

4. Apply suction for 2030 seconds.

Correct Answer: 1

Rationale 1: When conducting nasotracheal suctioning, the nurse should apply suction for 510 seconds.

Rationale 2: Suctioning should be done for no longer than 5 minutes.

Rationale 3: Suction should never be applied while inserting the catheter.

Rationale 4: Suction should only be applied for 510 seconds.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1270

Question 41

Type: MCSA

The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity?

1. How to apply suction during the insertion of the catheter

2. Not to apply suction during the insertion of the catheter

3. How to maintain sterile technique

4. How to listen for lung sounds

Correct Answer: 2

Rationale 1: The nurse would instruct not to apply suction during the insertion of the catheter.

Rationale 2: Oral suctioning using a Yankauer suction tube can be delegated to UAP, as this is not a sterile procedure. The nurse needs to review the procedure and important points, such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane.

Rationale 3: Oral suctioning uses clean, not sterile, technique.

Rationale 4: The nurse should not delegate the auscultation of lung sounds to UAP.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning; 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1269

Question 42

Type: MCMA

The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Amount, consistency, color, and odor of sputum

2. Amount of sterile solution used to flush the catheter

3. Lung sounds before the procedure

4. Lung sounds after the procedure

5. Oxygen saturation after the procedure

Correct Answer: 1, 3, 4, 5

Rationale 1: The nurse should document the amount, consistency, color, and odor of suctioned sputum.

Rationale 2: The nurse does not need to document the amount of sterile solution used to flush the catheter.

Rationale 3: The nurse should document the clients lung sounds before the procedure.

Rationale 4: The nurse should document the clients lung sounds after the procedure.

Rationale 5: The nurse should document the clients oxygen saturation after the procedure.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning; 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1271

Question 43

Type: MCMA

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a clients medical record. What should this documentation include?

Standard Text: Select all that apply.

1. Lung sounds before and after suctioning

2. Characteristics of suctioned sputum

3. Integrity of the skin around the stoma

4. Side on which the tracheostomy tie knot is located

5. Flow rate of oxygen

Correct Answer: 1, 2, 3, 5

Rationale 1: The nurse should document lung sounds before and after suctioning.

Rationale 2: The nurse should document the characteristics of the suctioned sputum.

Rationale 3: The nurse should document the integrity of the skin around the stoma.

Rationale 4: The nurse does not need to document the side on which the tracheostomy tie knot is located.

Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube.

d. Providing tracheostomy care. 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1275

Question 44

Type: MCSA

The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurses greatest concern is that this client might develop which health problem?

1. Chronic renal failure

2. A gastric ulcer

3. Hypoxemia

4. A cerebral vascular accident

Correct Answer: 3

Rationale 1: Injury to the heart muscle might affect renal function, but this is not the nurses greatest concern.

Rationale 2: Although an injury to the heart muscle can cause stress to the client and lead to a gastric ulcer, this is not the nurses greatest concern.

Rationale 3: Although injury to the heart muscle might affect any or all of the body systems, at this point the nurse is most concerned that the client will develop hypoxemia. The status of the respiratory system is closely linked to and dependent upon the cardiovascular system.

Rationale 4: Injury to the heart muscle may or may not cause a cerebral vascular accident. This is not the area of greatest concern to the nurse at this time.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Outline the structure and function of the respiratory system.

MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation.

Page Number: 1248

Question 45

Type: MCMA

Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the health care provider to question the order. What health problems did the client have that caused the nurse to question the medication order?

Standard Text: Select all that apply.

1. COPD

2. Asthma

3. Arthritis

4. Gastritis

5. Heart failure

Correct Answer: 1, 2

Rationale 1: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with COPD because they may constrict airways by blocking beta-2 adrenergic receptors.

Rationale 2: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with asthma because they may constrict airways by blocking beta-2 adrenergic receptors.

Rationale 3: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with arthritis.

Rationale 4: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with gastritis.

Rationale 5: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1254


Question 46

Type: MCMA

The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this clients plan of care?

Standard Text: Select all that apply.

1. Insert an oropharyngeal airway.

2. Provide nasal care every 2 to 4 hours.

3. Provide oral hygiene every 2 to 4 hours.

4. Adjust non-humidified airflow as prescribed.

5. Move the tube to opposite sides of the mouth every 8 hours.

Correct Answer: 1, 2, 3, 5

Rationale 1: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube.

Rationale 2: For an oral endotracheal tube, provide nasal care every 2 to 4 hours.

Rationale 3: For an oral endotracheal tube, provide oral hygiene every 2 to 4 hours.

Rationale 4: Provide humidified air or oxygen because the endotracheal tube bypasses the upper airways, which normally moisten the air.

Rationale 5: For an oral endotracheal tube, move the tube to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1266

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