Practice Questions page 755 (652-674)
(652) 1. An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? * Diminished breath sounds
Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
(653) 2. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment for this client? * A hyperinflated chest noted on the x-ray
Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on excretion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
(654) 3. A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: * Promote carbon dioxide elimination
Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not purposes of this type of breathing.
(655) 4. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and take what initial action? * Ventilates the client manually
Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs cannot be the initial action. Although oxygen is helpful, it will not provide ventilation to the client.
(656) 5. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physician? * Bronchospasm
* Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. *
* (657) 6. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: * 10 seconds
* Rationale: Hypoxemia can be caused by prolonged suctioning, which simulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. *
* (658) 7. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart race is decreasing. Which of the following is the appropriate nursing intervention? * Stop the procedure and reoxygenate the client
* Rationale: During suctioning, the nurse should monitor the client closely for side effects, including...