Question 1

A client has been diagnosed with emphysema and has dyspnea with minimal exertion. The nurse understands that this client is at risk for developing which of the following?

Accepted Answer

Decreased ventilation causes carbon dioxide retention, resulting in an increase in carbonic acid and respiratory acidosis. Hypoxemia (especially with activity) may be present. The other choices are incorrect because respiratory alkalosis occurs with increased exhalation of carbon dioxide; metabolic acidosis and metabolic alkalosis both have metabolic etiologies.

Question 2

An HIV-positive client presents with a CD4 count of <200/Î¼l and invasive cervical cancer. How would the nurse evaluate these findings in terms of current CDC guidelines?

Accepted Answer

The CDC case definition of AIDS for adults states that the two factors described in the question are diagnostic of progression of AIDS. Seroconversion and positive HIV status have already occurred. The latent period is considered to be one in which the individual is asymptomatic.

Question 3

One potential complication of an abdominal hysterectomy is abdominal distention. Postoperative nursing measures designed to avoid abdominal distention are:

Accepted Answer

Insertion of nasogastric and rectal tubes and ambulation, as ordered. Manipulation of abdominal contents during surgery produce inhibition of peristalsis for 24 to 48 hours. Measures to avoid potential distention could include insertion of a nasogastric tube before surgery and continuous postsurgical suction until peristalsis returns; rectal tubes can be inserted to remove excess air in the lower colon; and early ambulation promotes return of bowel sounds.

Question 4

In a client with new rib fractures, which assessment finding would best alert the nurse to the possible development of a pneumothorax?

Accepted Answer

Clients with rib fractures should be assessed periodically for the possible complication of pneumothorax. Decreased or absent breath sounds are related to pneumothorax because pneumothorax compresses functional lung tissue. Pink, frothy sputum is a possible (but unlikely) finding in clients with pneumothorax (Choice A). Hoarseness is indicative of an airway obstruction or laryngeal nerve paralysis (Choice B). Percussion sounds are hyperresonant in the area of a pneumothorax, caused by the collection of air in the pleural space (Choice D).

Question 5

Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:

Accepted Answer

Assess his response to the equipment. It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding.

Question 6

A client with myasthenia gravis is given a Tensilon test. Forty minutes after the test, the client develops severe weakness and ptosis. The nurse should be prepared to:

Accepted Answer

Developing severe weakness within 1 hour of the administration of Tensilon indicates a cholinergic crisis, or overdose of anticholinesterase drugs. The antidote for cholinergic crisis is atropine. Choice B is incorrect because it would be inappropriate to administer an anticholinesterase drug, such as pyridostigmine, to a client in cholinergic crisis. Choice C is incorrect because checking for constricted pupils does not provide useful information. Pupil constriction does not occur during a cholinergic crisis. Choice D is incorrect because intubation is not the first action. Atropine should be used first to counteract the toxic effects of the anticholinesterase drug.

Question 7

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in:

Accepted Answer

Crutches are measured so that the tops are two to three finger-widths from the axilla. This ensures that the client's axilla are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus.

Question 8

A client with fat embolism is receiving 100% FiO₂ on a mechanical ventilator and continues to be hypoxic. Which of the following measures can improve his oxygenation?

Accepted Answer

PEEP can be added to open up alveoli and keep them open. There is no reason to give the client beta blockers. He may benefit from diuresis, but in the meantime, PEEP should be added to improve oxygenation. The highest amount of oxygen that can be delivered is 100% FiO2.

Question 9

Two hours ago the client had a left thoracotomy with a lobe resection. The sanguineous drainage in the chest tube collection chamber is 325 mL. The nurse recognizes that this is:

Accepted Answer

Sanguineous drainage of greater than 100 mL/hr in the client who is in the immediate postoperative period following a thoracotomy indicates hemorrhage. The physician should be notified immediately. Normal chest tube drainage should be less than 100 mL/hr. A pneumothorax occurs when there is air between the visceral and the parietal pleura, which causes compression of the lung and results in acute respiratory distress. Chyle drainage is a milky color that results from disruption of the lymphatic drainage system.

Question 10

In a client with right lung pneumonia, the nurse should encourage which position to facilitate optimal oxygenation?

Accepted Answer

Positioned with the left side dependent. With unilateral lung disease, the example to remember is "good lung down." Since ventilation and perfusion are gravity dependent, enhancing ventilation and perfusion to healthy lung tissue and alveoli will enhance oxygenation. Supine positioning would provide near equal ventilation and perfusion to both lungs. In the diseased lung, excess fluid and fibrosis inhibit gas exchange at the pulmonary capillary membrane, thereby diminishing oxygenation.

Question 11

What is a normal tidal volume for a client on a ventilator?

Accepted Answer

Normal tidal volume is 7-9 ml/kg or about 500 ml for an average-sized man (approximately 75 kg).

Question 12

A client with a left leg fracture is to be taught the three-point gait before discharge. Which instruction should the nurse give to this client?

Accepted Answer

In the three-point gait, both crutches and the affected "badâ" leg and foot move together, with the unaffected "good"leg and foot following. Choices A and B are incorrect because the crutches are moved simultaneously, not independently. Choice C is incorrect because the client should not bear weight on the fractured leg when using the three-point gait.

Question 13

Which assessment finding by the nurse has the most serious implication for a 70-year-old client with emphysema?

Accepted Answer

Bilateral crackles throughout the lung fields indicate excessive pulmonary fluid requiring acute intervention. Increased anterior-posterior diameter of the chest, pursed-lip breathing, and circumoral cyanosis are chronic findings in clients with emphysema. They do not indicate acute changes in the client's condition.

Question 14

The nurse is encouraging a client who has undergone an amputation to immediately fit a prosthesis. The advantage for this immediate action is:

Accepted Answer

When the prosthesis is in place immediately following surgery, the client can stand up several hours postoperatively and walk the next day. The operative site is closed to outside contamination and benefits from improved circulation due to ambulation.

Quiz 1: Medical Surgical