Med Surge Chapter 23 Exam
A perioperative nurse is caring for a postoperative patient. The patient has a shallow
respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should
address the patient's increased risk for what complication?
A)
Acute respiratory distress syndrome (ARDS)
B)
Atelectasis
C)
Aspiration
D)
Pulmonary embolism - ANSWER Ans: Atelectasis
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at
an increased risk of developing atelectasis.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical
complication. The nurse's assessment reveals that the patient has an increased work of
breathing due to copious tracheobronchial secretions. What should the nurse
encourage the patient to do?
A)
Increase oral fluids unless contraindicated.
B)
Call the nurse for oral suctioning, as needed.
C)
Lie in a low Fowler's or supine position.
D)
Increase activity. - ANSWER Ans: Increase oral fluids unless contraindicated.
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens
pulmonary secretions.
The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer this test?
A)
Administer intradermal injections into the children's inner forearms.
B)
Administer intramuscular injections into each child's vastus lateralis.
C)
Administer a subcutaneous injection into each child's umbilical area.
D)
,Med Surge Chapter 23 Exam
Administer a subcutaneous injection at a 45-degree angle into each child's deltoid -
ANSWER Ans: Administer intradermal injections into the children's inner forearms.
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the
inner aspect of the forearm.
The nurse is caring for a patient who has been in a motor vehicle accident and the care
team suspects that the patient has developed pleurisy. Which of the nurse's
assessment findings would best corroborate this diagnosis?
A)
The patient is experiencing painless hemoptysis.
B)
The patient's arterial blood gases (ABGs) are normal, but he demonstrates increased
work of breathing.
C)
The patient's oxygen saturation level is below 88%, but he denies shortness of breath.
D)
The patient's pain intensifies when he coughs or takes a deep breath. - ANSWER Ans:
The patient's pain intensifies when he coughs or takes a deep breath.
Feedback:
The key characteristic of pleuritic pain is its relationship to respiratory movement.
Taking a deep breath, coughing, or sneezing worsens the pain.
The nurse caring for a patient recently diagnosed with lung disease encourages the
patient not to smoke. What is the primary rationale behind this nursing action?
A)
Smoking decreases the amount of mucus production.
B)
Smoke particles compete for binding sites on hemoglobin.
C)
Smoking causes atrophy of the alveoli.
D)
Smoking damages the ciliary cleansing mechanism. - ANSWER Ans: Smoking
damages the ciliary cleansing mechanism.
Feedback:
In addition to irritating the mucous cells of the bronchi and inhibiting the function of
alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing
mechanism of the respiratory tract. Smoking also increases the amount of mucus
production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity
of hemoglobin, but not by directly competing for binding sites.
, Med Surge Chapter 23 Exam
A patient has been brought to the ED by the paramedics. The patient is suspected of
having ARDS. What intervention should the nurse first anticipate?
A)
Preparing to assist with intubating the patient
B)
Setting up oxygen at 5 L/minute by nasal cannula
C)
Performing deep suctioning
D)
Setting up a nebulizer to administer corticosteroids - ANSWER Ans: Preparing to assist
with intubating the patient
Feedback:
A patient who has ARDS usually requires intubation and mechanical ventilation.
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of
lung cancer. While assisting with a subclavian vein central line insertion, the nurse
notes the client's oxygen saturation rapidly dropping. The patient complains of
shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has
developed. Further assessment findings supporting the presence of a pneumothorax
include what?
A)
Diminished or absent breath sounds on the affected side
B)
Paradoxical chest wall movement with respirations
C)
Sudden loss of consciousness
D)
Muffled heart sounds - ANSWER Ans: Diminished or absent breath sounds on the
affected side
Feedback:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent
or diminished breath sounds on the affected side. Paradoxical chest wall movements
occur in flail chest conditions. Muffled or distant heart sounds occur in pericardial
tamponade.
The nurse is providing discharge teaching for a patient who developed a pulmonary
embolism after total knee surgery. The patient has been converted from heparin to
sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the
client?
A)
Coumadin will continue to break up the clot over a period of weeks
A perioperative nurse is caring for a postoperative patient. The patient has a shallow
respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should
address the patient's increased risk for what complication?
A)
Acute respiratory distress syndrome (ARDS)
B)
Atelectasis
C)
Aspiration
D)
Pulmonary embolism - ANSWER Ans: Atelectasis
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at
an increased risk of developing atelectasis.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical
complication. The nurse's assessment reveals that the patient has an increased work of
breathing due to copious tracheobronchial secretions. What should the nurse
encourage the patient to do?
A)
Increase oral fluids unless contraindicated.
B)
Call the nurse for oral suctioning, as needed.
C)
Lie in a low Fowler's or supine position.
D)
Increase activity. - ANSWER Ans: Increase oral fluids unless contraindicated.
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens
pulmonary secretions.
The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer this test?
A)
Administer intradermal injections into the children's inner forearms.
B)
Administer intramuscular injections into each child's vastus lateralis.
C)
Administer a subcutaneous injection into each child's umbilical area.
D)
,Med Surge Chapter 23 Exam
Administer a subcutaneous injection at a 45-degree angle into each child's deltoid -
ANSWER Ans: Administer intradermal injections into the children's inner forearms.
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the
inner aspect of the forearm.
The nurse is caring for a patient who has been in a motor vehicle accident and the care
team suspects that the patient has developed pleurisy. Which of the nurse's
assessment findings would best corroborate this diagnosis?
A)
The patient is experiencing painless hemoptysis.
B)
The patient's arterial blood gases (ABGs) are normal, but he demonstrates increased
work of breathing.
C)
The patient's oxygen saturation level is below 88%, but he denies shortness of breath.
D)
The patient's pain intensifies when he coughs or takes a deep breath. - ANSWER Ans:
The patient's pain intensifies when he coughs or takes a deep breath.
Feedback:
The key characteristic of pleuritic pain is its relationship to respiratory movement.
Taking a deep breath, coughing, or sneezing worsens the pain.
The nurse caring for a patient recently diagnosed with lung disease encourages the
patient not to smoke. What is the primary rationale behind this nursing action?
A)
Smoking decreases the amount of mucus production.
B)
Smoke particles compete for binding sites on hemoglobin.
C)
Smoking causes atrophy of the alveoli.
D)
Smoking damages the ciliary cleansing mechanism. - ANSWER Ans: Smoking
damages the ciliary cleansing mechanism.
Feedback:
In addition to irritating the mucous cells of the bronchi and inhibiting the function of
alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing
mechanism of the respiratory tract. Smoking also increases the amount of mucus
production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity
of hemoglobin, but not by directly competing for binding sites.
, Med Surge Chapter 23 Exam
A patient has been brought to the ED by the paramedics. The patient is suspected of
having ARDS. What intervention should the nurse first anticipate?
A)
Preparing to assist with intubating the patient
B)
Setting up oxygen at 5 L/minute by nasal cannula
C)
Performing deep suctioning
D)
Setting up a nebulizer to administer corticosteroids - ANSWER Ans: Preparing to assist
with intubating the patient
Feedback:
A patient who has ARDS usually requires intubation and mechanical ventilation.
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of
lung cancer. While assisting with a subclavian vein central line insertion, the nurse
notes the client's oxygen saturation rapidly dropping. The patient complains of
shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has
developed. Further assessment findings supporting the presence of a pneumothorax
include what?
A)
Diminished or absent breath sounds on the affected side
B)
Paradoxical chest wall movement with respirations
C)
Sudden loss of consciousness
D)
Muffled heart sounds - ANSWER Ans: Diminished or absent breath sounds on the
affected side
Feedback:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent
or diminished breath sounds on the affected side. Paradoxical chest wall movements
occur in flail chest conditions. Muffled or distant heart sounds occur in pericardial
tamponade.
The nurse is providing discharge teaching for a patient who developed a pulmonary
embolism after total knee surgery. The patient has been converted from heparin to
sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the
client?
A)
Coumadin will continue to break up the clot over a period of weeks
