Med Surg 1 Final #2 answered correct!!!
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest
wall. Which finding indicates the presence of a pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury
2
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary
disease. Which findings would the nurse expect to note on assessment of this client? Select all that
apply.
1. A low arterial PCo2 level
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5. Pulmonary function tests that demonstrate increased vital
2,3
The nurse is preparing a list of home care instructions for a client who has
been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the
list? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family
members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once
medication therapy is initiated.
4. Respiratory isolation is not necessary, because family
members already have been exposed.
5. Cover the mouth and nose when coughing or sneezing and
put used tissues in plastic bags.
6. When 1 sputum culture is negative, the client is no longer
considered infectious and usually can return to former
employment.
1,3,4,5
The nurse is caring for a client after a bronchoscopy and biopsy. Which
finding, if noted in the client, should be reported immediately to the primary health care provider?
1. Dry cough
2. Hematuria
,3. Bronchospasm
4. Blood-streaked sputum
3
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse
should expect to note which finding?
1. Slow, deep respirations
2. Rapid, deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration
4
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most
distinctive sign of flail chest?
1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
3
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory
distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress
syndrome?
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate
4
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been
receiving medication for 2 weeks. The nurse determines that the client has understood the
information if the client makes which statement?
1. "I need to continue medication therapy for 1 month."
2. "I can't shop at the mall for the next 6 months."
3. "I can return to work if a sputum culture comes back negative."
4. "I should not be contagious after 2 to 3 weeks of medication
therapy."
4
The nurse is preparing to give a bed bath to an immobilized client with
tuberculosis. The nurse should wear which items when performing this care?
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
,3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear
2
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
3
A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The
nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which
finding?
1. Positive
2. Negative
3. Inconclusive
4. Need for repeat testing
1
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should
assess the client for which expected finding?
1. Dyspnea
2. Headache
3. Weight gain
4. Hypothermia
1
The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes
that the client understands the information if the client indicates to report which early sign of
exacerbation?
1. Fever
2. Fatigue
3. Weight loss
4. Shortness of breath
4
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should
assess whether the client wears which item during periods of exposure to silica particles?
1. Mask
2. Gown
3. Gloves
4. Eye protection
, 1
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will
enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse
instruct the client to assume?
1. Sitting up in bed
2. Side-lying in bed
3. Sitting in a recliner chair
4. Sitting up and leaning on an overbed table
4
The community health nurse is conducting an educational session with community members
regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants
that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that
apply.
1. Dyspnea
2. Headache
3. Night sweats
4. A bloody, productive cough
5. A cough with the expectoration of mucoid sputum
1,3,4,5
The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse
should check the results of which diagnostic test that will confirm this diagnosis?
1. Chest x-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test
3
1. A nurse is completing the health history for a client who has been taking echinacea for a head cold.
The client asks, "Why isn't this helping me feel better?" Which of the following responses by the nurse
would be the most accurate?
1. "There is limited information as to the effectiveness of herbal products."
2. "Antibiotics are the agents needed to treat a head cold."
3. "The head cold should be gone within the month."
4. "Combining herbal products with prescription antiviral medications is sure to help you."
1
2A nurse is teaching a client about taking antihistamines. Which of the following instruc- tions should
the nurse include in the teaching plan? Select all that apply.
1. Operating machinery and driving may be dangerous while taking antihistamines.
2. Continue taking antihistamines even if nasal infection develops.
3. The effect of antihistamines is not felt until a day later.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest
wall. Which finding indicates the presence of a pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury
2
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary
disease. Which findings would the nurse expect to note on assessment of this client? Select all that
apply.
1. A low arterial PCo2 level
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5. Pulmonary function tests that demonstrate increased vital
2,3
The nurse is preparing a list of home care instructions for a client who has
been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the
list? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family
members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once
medication therapy is initiated.
4. Respiratory isolation is not necessary, because family
members already have been exposed.
5. Cover the mouth and nose when coughing or sneezing and
put used tissues in plastic bags.
6. When 1 sputum culture is negative, the client is no longer
considered infectious and usually can return to former
employment.
1,3,4,5
The nurse is caring for a client after a bronchoscopy and biopsy. Which
finding, if noted in the client, should be reported immediately to the primary health care provider?
1. Dry cough
2. Hematuria
,3. Bronchospasm
4. Blood-streaked sputum
3
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse
should expect to note which finding?
1. Slow, deep respirations
2. Rapid, deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration
4
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most
distinctive sign of flail chest?
1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
3
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory
distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress
syndrome?
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate
4
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been
receiving medication for 2 weeks. The nurse determines that the client has understood the
information if the client makes which statement?
1. "I need to continue medication therapy for 1 month."
2. "I can't shop at the mall for the next 6 months."
3. "I can return to work if a sputum culture comes back negative."
4. "I should not be contagious after 2 to 3 weeks of medication
therapy."
4
The nurse is preparing to give a bed bath to an immobilized client with
tuberculosis. The nurse should wear which items when performing this care?
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
,3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear
2
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
3
A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The
nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which
finding?
1. Positive
2. Negative
3. Inconclusive
4. Need for repeat testing
1
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should
assess the client for which expected finding?
1. Dyspnea
2. Headache
3. Weight gain
4. Hypothermia
1
The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes
that the client understands the information if the client indicates to report which early sign of
exacerbation?
1. Fever
2. Fatigue
3. Weight loss
4. Shortness of breath
4
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should
assess whether the client wears which item during periods of exposure to silica particles?
1. Mask
2. Gown
3. Gloves
4. Eye protection
, 1
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will
enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse
instruct the client to assume?
1. Sitting up in bed
2. Side-lying in bed
3. Sitting in a recliner chair
4. Sitting up and leaning on an overbed table
4
The community health nurse is conducting an educational session with community members
regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants
that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that
apply.
1. Dyspnea
2. Headache
3. Night sweats
4. A bloody, productive cough
5. A cough with the expectoration of mucoid sputum
1,3,4,5
The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse
should check the results of which diagnostic test that will confirm this diagnosis?
1. Chest x-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test
3
1. A nurse is completing the health history for a client who has been taking echinacea for a head cold.
The client asks, "Why isn't this helping me feel better?" Which of the following responses by the nurse
would be the most accurate?
1. "There is limited information as to the effectiveness of herbal products."
2. "Antibiotics are the agents needed to treat a head cold."
3. "The head cold should be gone within the month."
4. "Combining herbal products with prescription antiviral medications is sure to help you."
1
2A nurse is teaching a client about taking antihistamines. Which of the following instruc- tions should
the nurse include in the teaching plan? Select all that apply.
1. Operating machinery and driving may be dangerous while taking antihistamines.
2. Continue taking antihistamines even if nasal infection develops.
3. The effect of antihistamines is not felt until a day later.
