Deck 2: Neuro Muscular and Pulmonary

Question 1

A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk, or perform any rehabilitative activities. The best initial nursing approach would be to:

A)Give him an explanation of why there is a need to quickly increase his activity
B)Emphasize repeatedly that with his prosthesis, he will be able to return to his normal lifestyle.
C)Appear cheerful and non-critical, regardless of his response to attempts at intervention.
D)Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving.

Answer 1

Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving.

Question 2

A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the:

A)Upper half of the sternum
B)Upper third of the sternum
C)Lower half of the sternum
D)Lower third of the sternum

Answer 2

Lower half of the sternum

Question 3

Which of the following statements concerning ARDS is true?

A)One of the causes of ARDS is CHF.
B)Pulmonary capillary wedge pressure is elevated in ARDS.
C)Surfactant production is reduced in ARDS.
D)ARDS has a low mortality rate.

Answer 3

Surfactant production is reduced in ARDS.

Question 4

A client, newly diagnosed with asthma, is started on theophylline (Theo-Dur, SloBid) and is going to be discharged. In the discharge teaching, the nurse instructs the client that this medication will cause which of the following?

A)Hemolytic anemia
B)Increased appetite
C)Increased ocular pressure
D)Tachycardia

Question 5

Which of the following physiologic effects of a pulmonary embolism would initially affect oxygenation?

A)A blood clot blocks ventilation; perfusion is unaffected.
B)A blood clot blocks ventilation, producing hypoxia despite normal perfusion.
C)A blood clot blocks perfusion and ventilation, producing profound hypoxia.
D)A blood clot blocks perfusion, producing hypoxia despite normal or supernormal ventilation.

Question 6

Dr) Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to:

A)Cause less irritation to the gastrointestinal tract
B)Destroy resistant organisms and promote proper blood levels of the drugs
C)Gain a more rapid systemic effect
D)Delay resistance and increase the tuberculostatic effect

Question 7

A thoracentesis is performed on a chest-injured client and no fluid or air is found. Blood and fluid is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?

A)Spontaneous pneumothorax
B)Ruptured diaphragm
C)Hemothorax
D)Pericardial tamponade

Question 8

To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:

A)Encourage bed rest with active and passive range of motion exercises.
B)Encourage frequent coughing and deep breathing.
C)Turn him from side to side at least every 2 hours.
D)Continue observing for dyspnea and crepitus.

Question 9

Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit, Mario is placed in Fowler's position on either his right side or on his back to:

A)Reduce incisional pain
B)Facilitate ventilation of the left lung
C)Equalize pressure in the pleural space
D)Increase venous return

Question 10

A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse's highest priority of information would be

A)Food and fluids will be withheld for at least 2 hours
B)Warm saline gargles will be done q2h
C)Coughing and deep-breathing exercises will be done q2h
D)Only ice chips and cold liquids will be allowed initially

Question 11

Which nursing goal would be appropriate for a client with sepsis who has developed acute respiratory distress syndrome?

A)To decrease the inflammatory response of the sepsis cascade
B)To prevent hypoxia associated with increased alveolar-capillary membrane permeability
C)To increase the intravascular volume, so as to maintain cardiac output and sustain blood pressure
D)To prepare the client and family members for anticipated surgery to remove the damaged lung tissue

Question 12

The nurse is assessing Mr. Guzman, a 40-year-old baker with no significant past medical history, who was admitted to the Emergency Department. The assessment findings include a decrease in level of consciousness; rapid, shallow respirations; nasal flaring; sterna and intercostals retractions; and cyanosis around the lips and oral mucosa. The ABG reveals pH - 7.24, pCO2 - 55, and PaO2 - 50. Which statement best describes these findings?

A)Acute respiratory distress with respiratory acidosis and hypoxemia
B)Mild respiratory distress with acidosis and hypoxemia
C)Acute respiratory distress with respiratory alkalosis and hypoxemia
D)No distress; ABG is normal

Question 13

A client had a respiratory arrest and required endotracheal intubation. Which auscultory findings would indicate correct placement of the tube?

A)Auscultate bilateral breath sounds and observe the chest wall rising and falling.
B)Auscultate stomach gurgling when ventilating the client and observe no rise or fall of the chest wall.
C)Auscultate breath sounds only on the right and observe rise and fall of the chest wall on the right.
D)Auscultate stomach gurgling when ventilating the client and observe chest rise only on the left side of the chest.

Question 14

While the nurse is caring for a client on a ventilator, the low-pressure ventilator alarm sounds. What should the nurse's first action be?

A)Suction the secretions from the endotracheal tube.
B)Check the client and ventilator connections.
C)Administer intravenous sedation and analgesia.
D)Reassure the client and instruct him or her not to bite on the tube.

Question 15

Mr) Kent, 42 years old, had a cuffed tracheostomy tube placed 4 weeks ago. This morning, his doctor made an order for him to begin eating by mouth, with the tracheostomy in place. To prevent aspiration, the nurse will: Select all that apply:

A)Raise the head of the bed to high Fowler's.
B)Increase Mr. Kent's FiO₂ .
C)Deflate the cuff on the tracheostomy tube.
D)Suction the client before eating.
E)Assess gag and swallow ability.

Question 16

A nurse is reading the results of a TB skin test on Ms. Dressler, a 72-year-old resident in a Nursing Home. Ms. Dressler has never had a TB skin test. There is no induration around the injection site. The nurse should document the test as negative and:

A)State that the client does not have TB
B)Have the client repeat the skin test in 2 weeks
C)Schedule the client repeat for a follow-up chest X-ray
D)Start the client on prophylactic TB medications because the client is in a high-risk group

Question 17

The nurse explains to a client's family that humidification is given with oxygen administration because:

A)Oxygen is highly permeable in water, thereby increasing gaseous diffusion.
B)Oxygen is very drying to the mucous membrane.
C)The partial pressures of oxygen are increased by water dilution, allowing more oxygen to reach the alveoli.
D)Water acts as a carrier substance, facilitating movement of oxygen across the respiratory membrane.