Ch37 Nursing Care Of Patients With Test Questions & Answers - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 37 Nursing Care of Patients with Gas Exchange Disorders
1) A patient with an acute exacerbation of emphysema is prescribed 60 mg of methylprednisolone per intravenous push. The medication is available from the pharmacy as 40 mg per 1 mL. How many milliliters of the medication should the nurse administer? Calculate to the nearest tenth decimal point.
Page Ref: 1349
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
2) A patient who nearly drowned is diagnosed with pulmonary edema and is prescribed furosemide 40 mg slow intravenous push. The medication available is a vial containing 100 mg/10 mL. How many milliliters of the medication should the nurse administer? Calculate the exact dose.
Page Ref: 1382
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
3) A patient who has been feeling more anxious since the recent and unexpected death of a spouse is experiencing an acute asthma attack. Rank the following events in the most likely order of occurrence. Place the five events in the correct order.
Choice 1. The patient states, "I feel like my throat is closing off and I can't breathe very well."
Choice 2. The patient is allergic to aspirin but unknowingly ingested a product with aspirin among its ingredients.
Choice 3. The patient's respiratory rate is 32 breaths per minute and his oxygen saturation level falls from 94% to 89%.
Choice 4. Inflammatory mediators are released and inflammatory cells are activated.
Choice 5. The patient is taken to the hospital via an ambulance and treated with medication.
Page Ref: 1336-1337
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
4) The nurse is providing medications to a patient with asthma. What does the nurse recognize about the use of corticosteroid inhalers for this patient?
1. They should be provided after the bronchodilator.
2. They are used only for acute asthma attacks.
3. They are used often with methylxanthines.
4. They are used to activate muscarinic receptors.
Page Ref: 1341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
5) The nurse is caring for a patient who is receiving neuromuscular blocking agents and is mechanically ventilated. For which reason should the alarms on the ventilator be activated?
1. The patient cannot breathe.
2. The patient will experience oxygen toxicity.
3. The patient might have arrhythmias.
4. The patient may have reduced intrapleural pressure.
Page Ref: 1373
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: 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: Quality & Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
6) A patient has a nasal endotracheal tube. For which complication should the nurse assess this patient? Select all that apply.
1. Tracheoesophageal fistula
2. Wound infection
3. Pressure necrosis of nares
4. Sinusitis
5. Obstruction of the tube
Page Ref: 1374
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
7) The nurse is preparing discharge instructions for a patient recovering from acute respiratory distress syndrome (ARDS). What should be included in this teaching? Select all that apply.
1. Avoid smoking and exposure to air pollution.
2. Practice lifestyle modifications to reduce oxygen demands.
3. Restrict fluids to prevent congestive heart failure (CHF).
4. Get the influenza immunization annually.
5. Avoid large crowds.
Page Ref: 1381
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
8) A patient is admitted with pulmonary edema. What is important for the nurse to assess first when completing the patient's history? Select all that apply.
1. Cardiac history
2. Pulmonary history
3. Renal and cardiac history
4. Pulmonary and renal history
5. Recent drug use and past vaccination record
Page Ref: 1371
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
9) A patient diagnosed with sepsis suddenly develops dyspnea, crackles, agitation, and confusion. Which health problem should the nurse suspect this patient is developing?
1. Noncardiogenic pulmonary edema
2. Right-sided heart failure
3. Left-sided heart failure
4. Constrictive pericarditis
Page Ref: 1382
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
10) A patient being mechanically ventilated develops hypotension after the respiratory therapist implements the most recent physician orders. Which ventilator mode should the nurse suspect has caused this change in the patient's status?
1. PEEP
2. SIMV mode
3. Assist-control mode
4. Pressure-control mode
Page Ref: 1378
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
11) A patient is being mechanically ventilated with SIMV at a rate of 25 breaths per minute. Why should the nurse question this setting?
1. The rate could be too high for this mode.
2. The patient would be more comfortable with a different mode.
3. The patient is not receiving enough sedation.
4. SIMV is always used in combination with PEEP.
Page Ref: 1375
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
12) A patient being mechanically ventilated requires increasing PEEP for worsening ARDS. The order for PEEP is now at 20 cm of H2O. For which finding should the nurse contact the healthcare provider?
1. Lung sounds greater on one side than the other
2. Lung sounds with crackles
3. Diminished peripheral pulses
4. High-pressure alarm
Page Ref: 1377
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
13) A patient being mechanically ventilated suddenly develops cardiac dysrhythmias from increasingly higher PEEP. What underlying issue should the nurse suspect in this patient?
1. Decreased cardiac output and acidosis
2. Increased cardiac output and alkalosis
3. Decreased cardiac output and renal failure
4. Increased cardiac output and electrolyte disturbance
Page Ref: 1378
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
14) A patient being mechanically ventilated has the following ventilator settings: SIMV 16, PEEP 20 cm of H2O, FiO2 45%, and tidal volume .450 L. What concern should the nurse have for this patient?
1. Barotrauma
2. Volutrauma
3. Sinusitis
4. Oxygen toxicity
Page Ref: 1377
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
15) The chest x-ray of a patient who was recently intubated shows the endotracheal tube located in the right mainstem bronchus. What action should be taken at this time?
1. The tube needs to be withdrawn slightly.
2. The tube needs to be inserted further.
3. The tube is correctly placed.
4. The tube is incorrectly attached to the ventilator.
Page Ref: 1380
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
16) A patient who is intubated is exhibiting rhonchi and has a pulse oximeter of 92%, soft abdomen, heart rate of 88 bpm, and blood pressure of 98/54 mmHg. Which should the nurse complete first?
1. Suction the patient.
2. Contact the healthcare provider.
3. Increase the oxygen.
4. Start dopamine.
Page Ref: 1380
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
17) The nurse is caring for a patient who is intubated and being mechanically ventilated. Which prescription should the nurse question for this patient?
1. Endotracheal suctioning every hour
2. Endotracheal suctioning as needed
3. NPO status while patient is ventilated
4. Intake and output every 4 hours
Page Ref: 1380
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
18) A patient being mechanically ventilated is exhibiting hypoxia, with a pulse oximeter reading of 88%. What should the nurse do if adventitious lung sounds are auscultated?
1. Suction the patient.
2. Contact the healthcare provider.
3. Turn the patient to one side.
4. Silence the alarm.
Page Ref: 1380
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
19) The family of a mechanically ventilated patient receiving a chest tube asks why the tube is necessary. How should the nurse respond?
1. "The chest tube helps to decompress the lung and prevents further complications."
2. "The chest tube helps the patient breathe more easily when on a ventilator."
3. "The chest tube is an elective procedure that many physicians like to perform."
4. "Placement of the chest tube requires surgery."
Page Ref: 1377
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
20) The nurse instructs a patient on the use of a metered-dose inhaler for asthma medications. To demonstrate understanding of the instructions, in which order should the patient self-administer this medication? Place in order the steps of the process.
Choice 1. Rinse the mouth.
Choice 2. Exhale slowly and completely.
Choice 3. Shake the canister vigorously for 3 to 5 seconds.
Choice 4. Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds.
Choice 5. Hold the breath for 10 seconds, release the pressure on the container, remove from the mouth, and exhale.
Page Ref: 1339
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
21) The nurse realizes that the medication tiotropium bromide (Spiriva) is contraindicated for a patient with chronic obstructive pulmonary disease (COPD). What information in the patient's medical history led to this clinical decision? Select all that apply.
1. The patient is being treated for glaucoma.
2. The patient uses a topical steroid for psoriasis.
3. The patient attends physical therapy three times a week.
4. The patient is taking medication for prostatic hypertrophy.
5. The patient limits the intake of dietary fats for weight loss.
Page Ref: 1341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
22) During an assessment the nurse suspects that a patient has chronic bronchitis. On what assessment finding is the nurse basing this clinical decision? Select all that apply.
1. Barrel chest
2. Smoking 1 ppd
3. Diminished breath sounds
4. Persistent productive cough
5. Wheezes and rhonchi lung sounds
Page Ref: 1347
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
23) A patient recovering from a lung transplant will have denervation of the lung tissue. What should the nurse include when planning this patient's care? Select all that apply.
1. Administering mucolytics every 2 hours.
2. Performing postural drainage twice a shift.
3. Ensuring oxygen delivery is below 2 L.
4. Scheduling deep breathing and coughing every 2 hours.
5. Positioning for chest vibration and percussion twice per shift.
Page Ref: 1351
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
24) The nurse instructs a patient with chronic obstructive pulmonary disease (COPD) on the huff cough technique. Which observation indicates that teaching has been effective? Select all that apply.
1. The patient coughs twice.
2. The patient leans forward.
3. The patient makes a huff sound when exhaling.
4. The patient inhales through the nose with the mouth closed.
5. The patient places one hand on the abdomen and the other on the chest.
Page Ref: 1356
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
25) The nurse is reviewing the results of laboratory and diagnostic tests conducted on a patient experiencing respiratory dysfunction. Which result confirms the nurse's suspicion that the patient has cystic fibrosis? Select all that apply.
1. Patchy infiltrates on chest x-ray
2. Mediastinal shift on chest CT scan
3. Oxygen saturation 82% on room air
4. Chloride concentration of sweat 85 mEq/L
5. Reduced total lung capacity from pulmonary function test
Page Ref: 1357
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
26) The nurse is caring for a patient experiencing atelectasis of the right lower lung lobe. What intervention should the nurse include in this patient's plan of care? Select all that apply.
1. Positioning on the left side
2. Applying oxygen as prescribed
3. Encouraging increased oral fluids
4. Coaching to deep-breathe and cough
5. Administering antibiotics as prescribed
Page Ref: 1361
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
27) A chest CT scan confirms that a patient has bronchiectasis. On which problem should the nurse focus when determining the care this patient will need? Select all that apply.
1. Airway clearance
2. Changes in fluid balance
3. Ineffective breathing pattern
4. Inability to provide self-care
5. Insufficient nutritional intake
Page Ref: 1361
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
28) A patient is diagnosed with subacute hypersensitivity pneumonitis. What should the nurse expect to assess in this patient? Select all that apply.
1. Weight loss
2. Chronic cough
3. Chills and fever
4. Loss of appetite
5. Shortness of breath
Page Ref: 1362
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.2 Describe the pathophysiology and manifestations of interstitial lung disease, and outline the interprofessional care and nursing care of patients with this disorder.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
29) After an assessment the nurse is concerned that a patient is experiencing cor pulmonale associated with right-heart failure. What finding led the nurse to make this clinical decision? Select all that apply.
1. Ankle edema
2. Ruddy cheeks
3. Nasal drainage
4. Cyanotic nail beds
5. Distended neck veins
Page Ref: 1370
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.3 Describe the pathophysiology and manifestations of pulmonary vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.
30) The nurse assists in the extubation of a patient recovering from injuries caused by a motor vehicle crash. Which observation indicates that the patient is able to independently maintain an airway? Select all that apply.
1. The patient is coughing.
2. The patient has a hoarse voice.
3. The patient has inspiratory stridor.
4. The patient's oxygen saturation is 75%.
5. The patient swallows small sips of water.
Page Ref: 1374
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
31) A patient being mechanically ventilated is diagnosed with barotrauma. Which assessment finding would lead the nurse to determine that the patient is experiencing subcutaneous emphysema? Select all that apply.
1. Blood-tinged sputum
2. Swollen neck and face
3. Reduced breath sounds
4. Sudden reduction of heart sounds
5. Crackling sound upon palpation of the skin of the upper chest
Page Ref: 1377
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.
32) The nurse is caring for a patient intubated for acute respiratory distress syndrome (ARDS). Which medication should the nurse expect to be prescribed for this patient? Select all that apply.
1. Surfactant
2. Antibiotics
3. Nitrous oxide
4. Anticoagulants
5. Cardiac glycosides
Page Ref: 1385
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
33) A patient who is intubated is having difficulty being weaned from the ventilator. What action should the nurse take to successfully wean this patient? Select all that apply.
1. Weaning in the morning
2. Placing in high-Fowler's position
3. Limiting activities during weaning
4. Coaching on coughing during weaning
5. Administering a sedative before weaning
Page Ref: 1386
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
34) A patient with sarcoidosis is being discharged. Which information should the nurse include when providing teaching to this patient? Select all that apply.
1. Reduce the intake of sodium.
2. Expect occasional painful joints.
3. Increase the intake of potassium.
4. Take corticosteroids as prescribed.
5. Report shortness of breath to the healthcare provider.
Page Ref: 1364
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 37.2 Describe the pathophysiology and manifestations of interstitial lung disease, and outline the interprofessional care and nursing care of patients with this disorder.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.
35) A patient is suspected of having a pulmonary embolism. Which diagnostic test should the nurse anticipate being prescribed for this patient? Select all that apply.
1. Coagulation studies
2. Plasma D-dimer level
3. Complete blood count
4. Pulmonary angiogram
5. Chest CT with contrast
Page Ref: 1365-1366
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: 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-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 37.3 Describe the pathophysiology and manifestations of pulmonary vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
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Chapter 35 Nursing Care Of Patients With Upper Respiratory Disorders
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Chapter 36 Nursing Care Of Patients With Ventilation Disorders
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Chapter 37 Nursing Care Of Patients With Gas Exchange Disorders
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Chapter 38 Assessing The Musculoskeletal System
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Chapter 39 Nursing Care Of Patients With Musculoskeletal Trauma
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