41 Questions
What is the most appropriate action by the nurse if the connection between the chest tube and the water seal dislodges while the client is ambulating?
Reconnect the tube to the water seal.
Which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues?
A client with a tumor of the medulla.
What term should the nurse document to best describe a client experiencing shortness of breath when lying down but finding relief in an upright position?
Orthopnea
How will corticosteroids prescribed for a client with emphysema help during acute bronchitis?
Decrease inflammation in the airways.
What is an important aspect to consider when planning percussion and postural drainage for a client?
The order should be coughing, percussion, positioning, and then suctioning.
What is the purpose of SCDs?
They promote venous return from the legs.
In a client with severe mitral stenosis having surgery, which valve is typically replaced?
Mitral valve
Why are the elderly at increased risk of fluid imbalances?
Decreased kidney function and reduced thirst sensation.
What are the priority nursing assessments for Hyperkalemia?
Monitoring ECG changes and assessing muscle weakness.
What does a bounding pulse indicate?
Increased stroke volume and decreased peripheral resistance.
What is the best way to prevent postoperative complications related to respiratory function?
Diaphragmatic and pursed-lip breathing 5 to 10 times, 4 times a day
What should the nurse do prior to performing tracheostomy care?
Checks the tightness of the ties and knot
What represents proper nasopharyngeal and nasotracheal suction technique?
Rotate the catheter while applying suction
Which client conditions can alter respiratory function?
A client who has increasing thick secretions and A client with heart failure
How can corticosteroid therapy affect bronchitis?
It can reduce airway inflammation
What is the best time to perform percussion and postural drainage?
In the morning after breakfast when the client is well rested.
What should always precede percussion and postural drainage?
3 minutes of 100% oxygen.
What topic does the teaching guide for a client with cardiovascular risk factors focus on?
Effective breathing and airway clearance.
In which sequence does the electrical impulse travel through the heart's conduction system?
Sinoatrial node, Atrioventricular node, Bundle of His, Bundle branches, Purkinje fibers.
What would be included in the evaluation of the client goal 'Demonstrate adequate tissue perfusion'?
Brisk capillary refill.
What blood tests would be expected for a client admitted with acute crushing chest pain that radiates down the left arm?
Troponin, Creatine Kinase (CK-MB), Myoglobin.
What pattern of behavior is most likely to be exhibited by the child during a nurse's assessment of breath sounds?
c. Fusses, cries, and pushes the nurse away during assessment of the breath sounds
Which nursing intervention will be most helpful for a 14-year-old adolescent hospitalized for surgical repair of scoliosis?
b. Instruct parents to room-in with her
What comment from a 65-year-old man recently retired should the nurse be concerned about?
b. 'Every day, when I wake up, it’s hard to find a reason to get out of bed.'
What is a possible cardiovascular risk factor for the 65-year-old man who is a retired independent contractor?
c. 'I often take ibuprofen for the pain in my knees.'
What is the purpose of percussion and postural drainage in nursing care?
To help mobilize and clear secretions from the lungs
What ABG results indicate respiratory acidosis?
pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L
What is the first action the nurse should take when a client experiences chest pain and shortness of breath?
Administer oxygen
How does corticosteroid therapy help a client with emphysema during acute bronchitis?
Reduces inflammation in the airways
What are the signs of cardiovascular risk factors during physical activity?
Elevated blood pressure, Weak, rapid pulse, Jugular vein distention
What is the purpose of percussion and postural drainage in nursing care?
To help mobilize and remove secretions from the lungs
Which nursing diagnosis is most appropriate for the 88-year-old woman in the skilled nursing facility who is a Sunday school teacher and volunteers for church projects?
c.Spiritual health enhancement
Which nurse's thought exemplifies a 'wounded healer'?
d.“I felt scared when I had surgery; maybe this client feels similarly.”
What is the most accurate nursing diagnosis for the mother of a pediatric client questioning why God would allow her child's illness?
a.Spiritual disruption related to search for meaning of child’s illness
Which learning activity reflects Bloom’s affective domain?
Existing questions.
Explain the concept of 'wounded healer' in nursing practice.
The 'wounded healer' refers to a healthcare provider who uses their own experiences of pain or suffering to empathize and connect with patients.
Describe the nursing intervention for a client with impaired oxygen transport from the lungs to the tissues.
Administering oxygen therapy to improve oxygenation.
How does corticosteroid therapy benefit a client with acute bronchitis?
Corticosteroids help reduce airway inflammation and swelling, promoting easier breathing.
What are the key components of percussion and postural drainage in nursing care?
Percussion involves rhythmic clapping to loosen secretions, while postural drainage uses positioning to help drain mucus from the lungs.
How can physical activity reduce cardiovascular risk factors?
Physical activity helps lower blood pressure, improve cholesterol levels, and maintain a healthy weight.
Explain the importance of therapeutic communication in assessing risk factors for a disease.
Therapeutic communication fosters trust, enabling clients to disclose relevant information about their health history and behaviors.
Test your nursing knowledge with scenarios involving chest tubes and oxygen transport. Identify the most appropriate actions for a dislodged chest tube connection and assess the client at greatest risk for oxygen transport problems.
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