Question 5101)
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
A. Establish a means of communication.
B. Prepare the bowel by administering enemas until clear.
C. Teach the client to use an artificial larynx
D. Demonstrate the technique for suctioning a laryngectomy tube.
Answer: A
Explanation: Establishing a means of communication is the highest priority. Teaching the client to use an artificial larynx is a postoperative task. Because the laryngectomy tube will be temporary, the client will not need to learn to suction. That is a nursing function.
Question 5102)
A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to:
A. prevent excessive drying of secretions
B. facilitate oxygen diffusion of the blood
C. prevent depression of the respiratory drive.
D. compensate for increased airway resistance
Answer: C
Explanation: The stimulus to breathe in a person with COPD is a low oxygen level rather than a carbon dioxide level, as in normal persons. If high-flow oxygen were given, the oxygen level would increase, and the respiratory drive would cease.
Question 5103)
An adult is admitted with chronic obstructive pulmonary disease (COPD). The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
A. Pneumothorax
B. Cor pulmonale
C. Cardiogenic shock
D. Left-sided heart failure
Answer: B
Explanation: Distended neck veins and peripheral edema are signs of right-sided heart failure or cor pulmonale— heart failure due to pulmonary causes.
Question 5104)
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client’s temperature is 102°F., respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
A. promote thoracic expansion.
B. prevent the development of atelectasis
C. decrease metabolic needs.
D. prevent infection of others.
Answer: C
Explanation: Bed rest will reduce metabolic needs in this client who has pneumonia and is having difficulty meeting oxygenation needs. Semiupright position, not bed rest, will promote thoracic expansion. Isolation prevents infection of others. Deep breathing will help to prevent the development of atelectasis.
Question 5105)
An adult is to have a tracheostomy performed. What is the nursing priority?
A. Shave the neck
B. Establish a means of communication
C. Insert a Foley catheter
D. Start an IV
Answer: B
Explanation: The nursing priority is to establish a means of communication because she will not be able to speak after the tracheostomy is performed.
Question 5106)
Which nursing action is essential during tracheal suctioning?
A. Using a lubricant such as petroleum jelly
B. Administering 100% oxygen before and after suctioning
C. Making sure the suction catheter is open or on during insertion
D. Assisting the client to assume a supine position during suctioning
Answer: B
Explanation: One hundred percent oxygen is given before and after suctioning to help prevent hypoxia. Petroleumbased lubricants are not water-soluble and should never be used near an airway. Saline is used as a lubricant. The suction catheter is off during insertion to avoid traumatizing the tissues. The client should be in a semi-sitting position during suctioning. Supine predisposes to aspiration.
Question 5107)
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
A. The client’s lungs have re-expanded.
B. There is an obstruction in the tubing coming from the client.
C. There is a mechanical problem in the pump
D. Air is leaking into the drainage apparatus.
Answer: B
Explanation: Cessation of bubbling in the water seal bottle means either an obstruction in the tubing or reexpansion of the lung. This is the night of insertion of the tube. It takes at least 24 hours and often two to three days for the lung to reexpand.
Question 5108)
An adult has a chest drainage system. The client’s wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
A. go get petrolatum gauze and apply over the wound.
B. place her/his hand firmly over the wound.
C. apply a sterile 4 × 4 dressing.
D. reinsert the chest tube.
Answer: B
Explanation: The nurse’s primary goal has to be to stop air from entering the thoracic cavity and causing the lung to collapse again. Placing a hand firmly over the wound will accomplish this. Answer 1 is wrong, because the nurse should not leave the client. Petrolatum gauze would be ideal, but the nurse should not leave the client. Answer 3 is wrong because a sterile 4 × 4 dressing allows air to enter the thoracic cavity. The nurse should not reinsert the chest tube
Question 5109)
An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest xray. This indicated that at that time the client:
A. was less susceptible to a tuberculosis infection than the year before.
B. had acquired some degree of passive immunity to tuberculosis.
C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis.
D. was harboring a mild tuberculosis infection in an organ other than the lung.
Answer: C
Explanation: A positive PPD test indicates that the client has come in contact with the organism and fought it. A negative chest x-ray indicates that the client won the fight and does not at that time have active tuberculosis.
Question 5110)
An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which of the following symptoms would suggest a toxic effect of INH?
A. Paroxysmal tachycardia
B. Erythema multiforme
C. Peripheral neuritis
D. Tinnitus and deafness
Answer: C
Explanation: Peripheral neuritis is a toxic effect of INH. Tinnitus and deafness are side effects of streptomycin.
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