<P>

<Q>The
<TYPE>single</TYPE>
nurse is caring for a client with a diagnosis of pneumonia. Over the past
24 hours, the nurse observes that the client has been requiring increasing amou
nts of supplemental oxygen to maintain the same level of oxygenation. The best i
nterventiontheathealthcare
<MC1>Call this time provider
is to:</Q>requesting an order for an arterial blood gas
<MC2>Perform
(ABG).</MC1>
<MC3>Call
<MC4>Administer
<F>Rationale:
<CORRECT>2</CORRECT>
theaIncreased
physician
more
the standing
extensive
and ask
oxygendiuretic
pulmonary
requirements
for anorder
order
physical
two
can
forresult
hours
aassessment.</MC2>
bronchodilator.</MC3>
early.</MC4>
from fluid accumulation a
s in heart failure and require diuresis (option 4) or from bronchoconstriction,
which would require a bronchodilator (option 3). Additional data is needed befor
e a conclusion can be reached regarding the cause of the hypoxia and determine a
definitive treatment. The ABG (option 1) certainly provides additional data, bu
t prior to determining the need for the blood gas, a physical assessment needs t
o be performed
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
Physiological
Adult
cause
(option
Application
Nursing
Health:
of 2). Integrity:
this Process:isAssessment
Respiratory
problem Physiological
unidentified so Adaptation
eliminate any distracter
that treats a specific problem. Choose the distracter that gives you the most am
ount of information to report to the healthcare provider when called. Often when
a single piece of data is given in a question the correct option is one that al
lows for additional
Reference: Smith, S.assessment.
F., Duell, D. J., & Martin, B. C. (2008). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>Which
<TYPE>single</TYPE>
<P>
</P> of thepp.following
698-699.</F>
arterial blood gas (ABG) reports would the nurse expec
t in a client
<MC1>pH 7.55, PaCO₂
with advanced chronic 30 mmHg,
obstructive
PaO₂
pulmonary80disease
mmHg, HCO₃
(COPD)?</Q>
^-
<MC2>pH 7.40,24PaCO₂
mEq/L</MC1> 40 mmHg, PaO₂ 94 mmHg, HCO₃
^-
<MC3>pH 7. 38,22PaCO₂
mEq/L</MC2> 45 mmHg, PaO₂ 88 mmHg, HCO_{3</sub
>^-
<MC4>pH 7.30, PaCO₂
24 mEq/L</MC3> 60 mmHg, PaO₂ 70 mmHg, HCO₃
^- 30During
<F>Rationale:
<CORRECT>4</CORRECT>mEq/L</MC4>
the later stages of COPD, ABG findings indicate low pH, ele
vated pCO₂, low pO₂, and elevated HCO₃<sup>2</s
up>, which indicate the body's attempt to compensate for chronically low pH (opt
ion 4). Option 1 is indicative of respiratory alkalosis; options 2 and 3 are var
iationsNeed:
Cognitive
Client
Integrated
Content
Strategy:ofReview
Area:
Level:
normal
Process:
Physiological
AdultAnalysis
the
ABGHealth:
Nursing
pathophysiology
results.
Integrity:
Process: of
Respiratory Assessment
Reduction
COPD. Eliminate
of Risk any
Potential
distracters that do
not indicate an acidosis. Then eliminate distracters that do not indicate CO<sub
>2} retention.
References: Ignatavicius, D., & Workman, L. (2006). <i>Medical-surgical nursing:
Critical thinking for collaborative care</i> (5th ed.). Philadelphia, PA: W. B.
Saunders, pp. 276, 596; LeMone, P. & Burke, K. (2004). <i>Medical-surgical nurs
ing: Critical thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pea
rson Education,
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse considers
pp. 1114-1116.</F>
which of the following to be the priority item in dischar
ge teachingeffects
<MC1>Fluid
<MC2>Smoking
<MC3>Avoidance
<MC4>Side
<F>Rationale:
<CORRECT>2</CORRECT>
restriction</MC1>
for
cessation</MC2>
Cigarette
ofa of
client
crowds</MC3>
drugsmoking
who
therapy</MC4>
hasischronic
the primary
bronchitis?</Q>
etiology of chronic bronchitis so
cessation is the priority for the client (option 2). Avoidance of crowds to low
er the risk of pulmonary infections is a recommendation that is more individuali
zed and less common than the need for smoking cessation (option 3). Teaching the
client about potential side effects of any prescribed medications should be inc
luded in all discharge teaching (option 4). Fluids are often increased to liquef
y secretions
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
and
Health
Adult
core prevent
Application
issue
Promotion
Nursing
Health:
mucous
of Process:
Respiratory
the
andquestion
plugs
Maintenance
Planning
(option
is being
1). able to prioritize items neede
d in discharge teaching for a client with bronchitis. Recall that smoking is a k
ey ongoing LeMone,
Reference: risk factorP., &toBurke,
lung tissue
K. (2008).
to place
<i>Medical-surgical
this as highest nursing:
priority.Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1334.</F>
has returned to the clinic 72 hours following a tuberculin skin test
with an induration of about 5 to 6 mm at the administration site. The client is
visibly upset and states: "I can't believe I have TB!" Which statement by the n
urse is appropriate?</Q>
<MC1>"You'll need to put on a mask and wear it whenever you are around other peo
<MC2>"The doctor will prescribe Isoniazid for you to take for the next 3 months.
ple."</MC1>
<MC3>"This finding does not confirm TB; it may indicate a recent exposure to tub
"</MC2>
<MC4>"We'll need to do a chest x-ray. This may be falsely positive because of yo
erculosis."</MC3>
ur history of An
<F>Rationale:
<CORRECT>3</CORRECT>
diabetes."</MC4>
induration of 5 to 9 mm resulting from a tuberculin skin test i
s indicative of exposure to an individual infected with mycobacterium tuberculos
is. It does not necessarily mean there is active infection and there is not enou
gh information provided to tell whether a mask will be necessary (option 1). The
client with this finding will be prescribed isoniazid (INH) for 6 to 12 months
as prophylaxis against development of active TB (option 2). History of diabetes
is not related to false positive tuberculin skin test (option 4). The nurse shou
ld demonstrate
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Differentiate
Process:
Physiological
Adult
a Application
calm,
Communication
Health:
supportive,
exposure
Integrity:
Respiratory
toand
and
theDocumentation
Physiological
informing
TB bacillimanner
from
Adaptation
with this
active infection.
client. Elimin
ate items that
Reference: LeMone,
inferP.,that
& Burke,
the client
K. (2008).
is actively
<i>Medical-surgical
infected or isnursing:
unrelatedCritical
to TB.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1287.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is caring for a client with a tracheostomy tube. The nurse keeps wh
<MC3>Humidification
ich
<MC1>Client
<MC2>Tracheotomy
of the following
must tube
be ofsuctioned
concepts
must
inspired
be capped
inair
as mindwill
neededtowhile
using
allow
prevent
caring
clean
client
drying
for
technique.</MC1>
tothis
eatmucous
of client?</Q>
by mouth.</MC2>
membranes and
mucous plugging.</MC3>
<MC4>Saline can be inserted into tracheotomy tube prior to suctioning if secreti
ons are thick.</MC4>
<F>Rationale:
<CORRECT>3</CORRECT>
For any client with a tracheostomy, maintenance of the airway is c
learly the priority. Clients should be suctioned using sterile technique to prev
ent introduction of bacteria (option 1). Saline should not be inserted into the
trachea prior to suctioning for the same reason (option 4). Because the tracheos
tomy bypasses the normal airway's humidification, supplemental humidification is
needed to keep the airways moist and prevent mucous plugging and airway occlusi
on from occurring (option 3). The tracheotomy is capped and the balloon deflated
Cognitive
Client
Integrated
Content
Strategy:
to enable
Need:
Area:
Level:
Since
clients
Process:
Physiological
Fundamentals
the
Analysis
totracheostomy
Nursing
speakIntegrity:
(option
Process:
bypasses
2).
Planning
Physiological
the oropharynx,
Adaptation
select the distracter
that replaces
Reference: Smith,
the S.
functions
F., Duell,of theD. J.,
oropharynx.
& Martin, B. C. (2008). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>The
<TYPE>multi</TYPE>
<P>
</P> nurse ispp.caring
983-985.</F>
for a client who has recently had arterial blood gases (A
BG) drawn. The results of the ABGs are indicated below. Indicate the correct int
erpretations ofThe
<MC1>Respiratory
<MC2>Partially
<F>Rationale:
<CORRECT>[1,3,4,5]</CORRECT>
<MC5>Hypoxemia</MC5>
<MC4>Uncompensated</MC4>
<MC3>Hypercarbia</MC3>
compensated</MC2>
the
acidosis</MC1>
ABGsacid-base
indicatedisorder.
a respiratory
Selectacidosis
all thatbecause
apply.</Q>
of the acidotic p
H and the elevated PaCO₂ (hypercarbia). Because the HCO₃ i
s normal, there is no compensation. The low O₂ level indicates hypoxe
Cognitive
mia.
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Determine
Process:
Physiological
Adult
Analysis
Nursing
Health:
if eachIntegrity:
Process:
Respiratory
value is normal,
Assessment
Reduction increased
of RiskorPotential
decreased. Determine t
he pH first. Use the PaCO₂ and HCO₃ to determine if it is
respiratory Berman,
References: or metabolic
A., Snyder,
in origin S.,orKozier,
if it B.,
is compensated
& Erb, G. (2008).
or not.<i>Fundamental
s of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
<Q>A
<TYPE>single</TYPE>
<P>
</P>
NJ: client
Pearsonhas
Education,
a right chest
pp. 1449-1450.</F>
tube following a thoracotomy. When assisting the c
lient to ambulate, the nurse should use what measure to maintain functioning of
the closedchest
<MC1>Keep
<MC2>Clamp
<MC3>Milk
<MC4>Connect
<F>Rationale:
<CORRECT>1</CORRECT>
collection
chest
collection
Keeping
tube
drainage
tube device
when
before
the
device
system?</Q>
client
drainage
below
assisting
toreturns
athe
system
portable
level
thetobelow
client
ofsuction
bed the
toout
the chest.</MC1>
re-establish
level
machine.</MC4>
of bed.</MC2>
of thepatency.</MC3>
chest maintains
the water seal and prevents backflow of air and fluid into the chest (option 1)
. The chest tube should never be clamped as this may cause pneumothorax (option
2). The chest tube should not be milked unless ordered by the physician because
it increases negative pressure in the thorax and can cause lung injury (option 3
). When ordered, the chest drainage system is attached to wall suction rather th
an portable
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Recall
Process:
suction
Physiological
Adult
Application
principles
(optionIntegrity:
Nursing
Health: 4).chest tube
Process:
Respiratory
of Implementation
Physiological
management.Adaptation
Since the question is aski
ng what should be done, eliminate distracters that are not recommended. Eliminat
e options 2 and 3 first since they create pressure inside the tubing that could
be harmful to the client. Next, either eliminate option 4 as unnecessary or use
knowledge ofSmith,
Reference: gravity
S. F.,
in aiding
Duell,drainage
D. J., &toMartin,
chooseB.option
C. (2008).
1. <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>A
<TYPE>single</TYPE>
<P>
</P> client ispp.brought
994-996.</F>
to the Emergency Department following a motor vehicle col
lision with a tree. Which finding suggests to the nurse that the client has expe
rienced a tension
<MC3>Tracheal
<MC2>Hypotension</MC2>
<MC1>Tachypnea</MC1>
<MC4>Unilateral
<F>Rationale:
<CORRECT>3</CORRECT>
deviation</MC3>
Tension
wheezing</MC4>
pneumothorax?</Q>
pneumothorax is a life-threatening condition so the nurse
must recognize potential indicators. Deviation of the trachea toward the unaffec
ted side occurs due to increased pressure within the pleural cavity; this only o
ccurs with a tension pneumothorax (option 3). Increasing pressure on the great v
essels in the chest decreases cardiac output, which can be fatal. Hypotension (o
ption 2) and tachypnea (option 1) occur with pneumothorax but are also related t
o numerous other conditions and are therefore nonspecific. Unilateral wheezing i
s indicative
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Define
Process:
ofAdult
Physiological
narrowing
Application
tension
Nursing
Health:pneumothorax
ofIntegrity:
Process:
Respiratory
the airways Assessment
Physiological
and (option
recall that
4).Adaptation
the air that cannot be dis
placed creates pressure that puts the other structures in the thorax at risk. El
iminate distracters that are nonspecific findings. The distracter that is specif
ic for a tension
Reference: LeMone,pneumothorax
P., & Burke,remains.
K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1299.</F>
is doing an admission assessment on a client who reports a gradual
increase in shortness of breath over at least the past several months. The clien
t denies smoking and reports no history of smoking. The nurse asks about the cli
ent's occupationalishistory
<MC1>Sarcoidosis frequentlybecause:</Q>
the result of exposure to environmental and occup
ational hazards.</MC1>
<MC2>Repeated occupational exposure to an irritant may cause temporary airway ob
<MC3>Over 85% of all lung cancers result from repeated exposure to occupation ir
struction.</MC2>
<MC4>Exposure to occupational hazards may occur years before the onset of sympto
ritants.</MC3>
<F>Rationale: Exposure to an occupational irritant may occur years before the on
<CORRECT>4</CORRECT>
ms.</MC4>
set of respiratory symptoms (option 4). Sarcoidosis is an autoimmune disease cau
sing chronic inflammation and progressive fibrous tissue formation (option 1). R
epeated and frequent exposure to environmental irritants usually causes chronic
fibrotic changes in lung tissue (option 2). The most common cause of lung cancer
is cigarette smoking. In comparison, a very small percentage of lung cancers ar
e causedNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
byFirst,
Level:
Process:
occupational
Physiological
Adult
Comprehension
recall
Nursing
Health:
that
irritants
Integrity:
Process:
Respiratory
different
(option
Assessment
Physiological
disorders
3). haveAdaptation
a direct cause in contrast
to those that occur for some unknown reason. Then relate each of the individual
risk factors in the stem with the disease with which it is most commonly associ
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
ated.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 1346-1347.</F>
<Q>When
<TYPE>single</TYPE>
<P>
</P> auscultating breath sounds in the client with an acute asthma episode, t
he nurse uses which of the following to guide interpretation of severity of find
<MC1>Severity of airway obstruction is associated with intensity of wheezing.</M
ings?</Q>
<MC2>Wheezing maywheezing
C1>
<MC3>Unilateral be absentindicates
with severe
asthmaairway
as theobstruction.</MC2>
origin for respiratory distress
<MC4>Breath sounds
.</MC3>
<F>Rationale:
<CORRECT>2</CORRECT>
Wheezing
are is
prolonged
a commononfinding
expiration.</MC4>
during an acute asthma episode; howev
er, the wheezing is not a consistent predictor of the severity of the attack (op
tion 1). Airway obstruction may be so severe that the client is moving little or
no air and is experiencing severe respiratory distress (option 2). Breath sound
s are prolonged in expiration with asthma, but this factor does not alter the pl
an of care in any way (option 4). Asthmatic symptoms are produced by an inflamma
tion of airways bilaterally. If there is unilateral wheezing, this indicates an
airway Need:
Cognitive
Client
Integrated
Content
Strategy:
obstruction
Area:
Level:
To
Process:
Physiological
determine
Adult
Application
from
Nursing
Health:
the
another
Integrity:
correct
Process:
Respiratory
cause.
distracter,
Assessment
Physiological
recallAdaptation
the pathophysiology of ast
hma. Airway Ignatavicius,
References: inflammation can D.,be& Workman,
so severeL.that
(2006).
the client
<i>Medical-surgical
moves almost nonursing:
air.
Critical thinking for collaborative care</i> (5th ed.). Philadelphia, PA: W. B.
Saunders, pp. 585, 587. LeMone, P. & Burke, K. (2008). <i>Medical-surgical nurs
ing: Critical thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pea
rson Education, p. 1323.</F>
</P>