Verified Test Bank | Nursing Care Of Patients With – Ch.36 - 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 36 Nursing Care of Patients with Ventilation Disorders
1) The nurse is caring for a patient with bacterial pneumonia. Which classification of medications should the nurse expect to be prescribed for this patient? Select all that apply.
1. Antibiotics
2. Steroids
3. Bronchodilators
4. Antiemetics
5. Antihistamines
Page Ref: 1285
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.
2) A clinic is being conducted to provide influenza (flu) and pneumonia vaccines for adults. Prior to administration of a flu vaccine, for what should the nurse assess the patients?
1. Current antibiotic therapy
2. Pulse oximeter saturation level
3. Allergy to mercury
4. Allergy to eggs
Page Ref: 1285
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
3) A patient with pneumonia is having difficulty maintaining a clear airway. Which action should the nurse take to ensure this patient is adequately ventilated? Select all that apply.
1. Assess skin color at least every four hours.
2. Assess breath sounds at least every four hours.
3. Assess oxygen saturation level at least every four hours.
4. Assess vital signs daily.
5. Assess respiratory rates every shift.
Page Ref: 1288
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
4) The nurse is caring for a patient diagnosed with severe acute respiratory syndrome (SARS). What should the nurse expect to assess in this patient? Select all that apply.
1. Nasal flaring
2. Restlessness
3. Anxiety
4. Decreased level of consciousness
5. Sputum production
Page Ref: 1290
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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
5) A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effect should the nurse instruct the patient to report to the healthcare provider? Select all that apply.
1. Fever
2. Yellow tint to the skin
3. Episodic pain in the upper-left quadrant
4. Diarrhea
5. Change in stool color
Page Ref: 1299-1300
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.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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
6) A patient diagnosed with tuberculosis is prescribed ethambutol (EMB). Prior to initiating this medication, what should the nurse instruct the patient?
1. Avoid this medication if allergic to eggs.
2. Have a baseline visual examination.
3. Have an influenza (flu) vaccination.
4. Have a baseline ECG (electrocardiogram).
Page Ref: 1300
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.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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
7) A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation?
1. Until sputum specimens for acid-fast bacilli are negative
2. Until the Mantoux test (PPD) converts from positive to negative
3. Until the patient has orders for discharge
4. Until the chest x-ray is normal
Page Ref: 1301
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: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
8) The nurse is teaching a patient prescribed isoniazid (INH). Which patient statement indicates that additional patient teaching is required?
1. "I will take the INH immediately after eating breakfast."
2. "I will make sure I tell all my healthcare providers that I am taking INH."
3. "Although I love beer, I will give it up while taking this medication."
4. "I will make sure I get my laboratory tests drawn to monitor my liver function."
Page Ref: 1300
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.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: Evaluation/Teaching/Learning
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
9) A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system?
1. Periodic bubbling in the water seal chamber immediately after insertion
2. No evidence of tidaling
3. Vigorous bubbling in the suction control chamber
4. Large amount of bloody drainage in the drainage collection chamber
Page Ref: 1312
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.
10) The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax?
1. New onset of absent breath sounds over the right lung
2. Blood pressure of 170/80 mmHg
3. Pulse oximetry readings ranging from 94% to 96%
4. Crackles and wheezing heard in both lungs
Page Ref: 1311
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
11) The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax?
1. Hyperresonance to percussion at the apex of the left lung
2. Dullness to percussion at the base of the left lung
3. Crackles throughout the left lung
4. Shallow breathing
Page Ref: 1310
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
12) The nurse caring for a patient diagnosed with lung cancer determines that the patient might be experiencing superior vena cava syndrome. What did the nurse assess to make this clinical decision?
1. Face and neck swelling
2. Hourly urine outputs 250 to 500 mL
3. Calcium level of 14.0 mg/dL
4. Flat jugular veins
Page Ref: 1323
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: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.
13) A patient states, "I've been sick for days, and all the doctor does is take a chest x-ray, hand me prescriptions, and tell me I have bronchitis." What should the nurse consider about this patient's treatment?
1. Appropriate for the diagnosis
2. Should include more diagnostic tests
3. Inadequate for the diagnosis of bronchitis
4. Should include hospitalization
Page Ref: 1280
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
14) A patient who is diagnosed with primary atypical pneumonia reports not feeling "sick." What would be the nurse's best response?
1. "Give it a few days and you will."
2. "You're lucky."
3. "You must be recovering from the illness."
4. "This type of pneumonia is usually mild in its effects."
Page Ref: 1283
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.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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
15) A patient who was admitted with symptoms of hypoxia is changed from a face mask to a nasal cannula for oxygen delivery. How should the nurse classify this patient's health status?
1. Deteriorating
2. Improving
3. Stabilizing
4. Compounded with another health issue
Page Ref: 1286
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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
16) A hospitalized patient is diagnosed with severe acute respiratory syndrome (SARS). What action should the nurse implement immediately?
1. Standard precautions
2. Standard precautions and droplet precautions
3. Standard precautions and contact precautions
4. Standard, contact, and airborne precautions
Page Ref: 1292
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: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
17) A patient with a lung abscess is being discharged from the hospital. What should be included in this patient's discharge instructions?
1. Complete the entire prescription of antibiotics.
2. Expect symptoms to become worse.
3. Return to routine activities of daily living.
4. Lung abscesses rarely cause other problems once treatment is started.
Page Ref: 1293
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
18) A patient who is on isoniazid (INH) for pulmonary tuberculosis reports not wanting to take the medication because it makes the fingers burn. Which side effect is this patient experiencing?
1. A common side effect of isoniazid (INH) that will go away after completing the medication
2. A common side effect of isoniazid (INH) that can be treated with pyridoxine
3. A long-term complication of isoniazid (INH) that has no treatment
4. A common complication of isoniazid (INH) that can be treated with vitamin B12 injections
Page Ref: 1300
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.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: Evaluation
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
19) A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. How should this finding be identified?
1. Negative
2. Positive for tuberculosis
3. Follow up with a tine test
4. Unable to be determined
Page Ref: 1298
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
20) A patient reports receiving the bacilli Calmette-Guérin (BCG) vaccination as a child. How should the nurse expect this patient to be screened for tuberculosis?
1. Tine test
2. Mantoux test
3. Tine and Mantoux tests
4. Chest x-ray
Page Ref: 1299
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.
21) A patient who is taking rifampin (Rifadin) as part of treatment for tuberculosis asks about making an appointment for a urologist because the urine is "bright orange." What should the nurse realize this patient is experiencing?
1. A secondary urinary tract infection
2. A common side effect of rifampin therapy
3. The onset of a kidney stone
4. Early renal failure
Page Ref: 1300
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
22) The nurse is providing care to a patient with pulmonary tuberculosis. What should the nurse do to ensure personal protection while caring for this patient?
1. Wear a gown and eye goggles.
2. Wear a gown and surgical mask.
3. Wear a gown and HEPA mask.
4. Wear a gown and sterile gloves.
Page Ref: 1303
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
23) A patient is diagnosed with histoplasmosis. What element of this patient's history would help explain the reason for the disease?
1. Lives in a city with chemical plants
2. Drives a vehicle that uses diesel fuel
3. Is an electrical engineer
4. Works on a chicken farm
Page Ref: 1306
Cognitive Level: Analyzing
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.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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
24) A patient with lung cancer is demonstrating signs of complete tumor response after two courses of chemotherapy. What should the nurse conclude that this response indicates?
1. A long-term survival from the disease
2. An indication that radiation therapy is needed
3. An indication that surgery can be performed
4. A contraindication for further chemotherapy
Page Ref: 1325
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: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.
25) A patient who is receiving radiation therapy for lung cancer complains of ongoing fatigue. What should be included in the teaching for this patient?
1. This is a complication of radiation therapy and will continue for years.
2. There is nothing that can help the fatigue.
3. Frequent rest periods and good nutrition can help with the fatigue.
4. Restricting caloric intake often helps with the fatigue.
Page Ref: 1327
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: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.
26) A patient is diagnosed with pleurisy. What should the nurse suggest to the patient to alleviate the associated chest pain from this disorder?
1. Instructing the patient to take the prescribed analgesic only when the pain is severe
2. Teaching the patient how to splint the affected area when coughing
3. Advising the patient to maintain bed rest
4. Warning the patient to expect a fever to develop
Page Ref: 1307
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.
27) A young adult patient who is asking questions about smoking cessation plans to take a scuba diving class. Which health problem is this patient at risk for developing?
1. Pleural effusion
2. Pleurisy
3. Pneumothorax
4. Hemothorax
Page Ref: 1309
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
28) The nurse observes air bubbles in a patient's chest tube water seal chamber. How should the nurse interpret this finding?
1. Normal
2. An emergency
3. An indication that the pneumothorax is worsening
4. An indication to remove the chest tube
Page Ref: 1312
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: Evaluation
Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
29) During the assessment of a patient's respiratory status, the nurse notes paradoxical lung movements. Which health problem should the nurse suspect is occurring with this patient?
1. Flail chest
2. Pleurisy
3. Pneumothorax
4. Pneumonia
Page Ref: 1315
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: 36.3 Describe the pathophysiology and manifestations of trauma of the chest or lung, and outline the interprofessional care and nursing care of patients with these injuries.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.
30) The nurse is providing care to a patient with a differential diagnosis of carbon monoxide poisoning. Which assessment finding would be consistent with this diagnosis? Select all that apply.
1. Cherry-red mucous membranes
2. Circumoral pallor
3. Diarrhea
4. Nausea
5. Dizziness
Page Ref: 1319
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: 36.3 Describe the pathophysiology and manifestations of trauma of the chest or lung, and outline the interprofessional care and nursing care of patients with these injuries.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.
31) A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply.
1. Hypertension
2. Distended neck veins
3. Bradycardia
4. Absent breath sounds on the affected side
5. Tracheal deviation toward unaffected side
Page Ref: 1311
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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
32) A child diagnosed with pneumonia has been prescribed erythromycin, 45 mg per day for every 1 kilogram of body weight. The patient weighs 46 pounds. The physician asks that the patient receive the medication in three equal doses throughout the day. Calculate how much medication the patient should receive per each dose. ________ mg
Record your answer rounding to the nearest whole number.
Page Ref: 1285
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.
33) The nurse is caring for victims of bioterrorism who were exposed to inhalation anthrax. After assessment, it is determined that 350 people were exposed to the potentially deadly spore. Knowing that this disease has a 45% mortality rate, how many patients should the nurse expect to recover from this illness? Record your answer rounding to the nearest whole number.
Page Ref: 1306
Cognitive Level: Analyzing
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.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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
34) A patient has developed pulmonary tuberculosis. Rank the findings in order of occurrence based on the normal progression of this disease. Place the findings in the order in which they occur.
Choice 1. The patient begins to feel better.
Choice 2. The patient is admitted to the hospital for treatment of pulmonary tuberculosis.
Choice 3. The patient does not complain of any symptoms associated with pulmonary tuberculosis.
Choice 4. The patient visits the physician's office with complaints of fatigue, night sweats, and has lost 10 pounds over the last 3 months.
Choice 5. The patient's purified protein derivative test is positive. The patient develops a cough with blood-tinged sputum. A chest x-ray indicates the presence of a cavitary lesion.
Page Ref: 1297
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; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
35) A patient is recovering from surgery for lung cancer. Which action should the nurse take when caring for this patient? Select all that apply.
1. Assess respiratory system at least every four hours.
2. Restrict the use of pain medication.
3. Provide frequent small meals.
4. Use strict aseptic technique.
5. Assist with early ambulation.
Page Ref: 1326
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: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.
36) After reviewing the medical history, the nurse suspects that an older patient would benefit from another dose of the pneumococcus vaccination. What information did the nurse use to make this clinical decision? Select all that apply.
1. Initial vaccination at age 55
2. Taking medications for hypertension
3. Ongoing treatment for prostate cancer
4. History of two hip replacement surgeries
5. Beginning dialysis for chronic renal failure
Page Ref: 1285
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
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: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation 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 ventilation disorders.
37) The nurse is preparing to assess a patient admitted for treatment of bilateral pleural effusions. On what should the nurse focus when assessing this patient? Select all that apply.
1. Urine output
2. Cardiac rate and rhythm
3. Joint function and mobility
4. Muscle tone and movement
5. Peripheral pulses and edema
Page Ref: 1307-1308
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, 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 ventilation disorders.
38) The nurse is preparing a patient for a thoracentesis to drain an empyema. What should the nurse instruct the patient about this procedure? Select all that apply.
1. You will have a chest x-ray after the procedure.
2. You will lie on the unaffected side for 1 hour after the procedure.
3. You will have general anesthesia for pain control during the procedure.
4. You will be seated, learning forward with arms and head supported with an overbed table.
5. You will be permitted to resume normal activities after 1 hour if no evidence of adverse effects occurs.
Page Ref: 1309
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: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.
39) A patient is diagnosed with Legionella pneumophila. Which antibiotic should the nurse expect to be prescribed for this patient? Select all that apply.
1. Rifampin
2. Macrolide
3. Prednisone
4. Erythromycin
5. Fluoroquinolone
Page Ref: 1285
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: Planning
Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
Explore recommendations drawn directly from what you're reading
Chapter 34 Assessing The Respiratory System
DOCX Ch. 34
Chapter 35 Nursing Care Of Patients With Upper Respiratory Disorders
DOCX Ch. 35
Chapter 36 Nursing Care Of Patients With Ventilation Disorders
DOCX Ch. 36 Current
Chapter 37 Nursing Care Of Patients With Gas Exchange Disorders
DOCX Ch. 37
Chapter 38 Assessing The Musculoskeletal System
DOCX Ch. 38