1|Page
FUNDAMENTALS OF NURSING 10TH EDITION LIPPINCOTT - TEST
BANK CHAPTER 40 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+||NEWEST VERSION
THE NURSE CARING FOR A CLIENT WITH EMPHYSEMA HAS DETERMINED THAT A PRIORITY
NURSING DIAGNOSIS FOR THIS CLIENT IS "IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENTS RELATED TO DIFFICULTY BREATHING WHILE EATING." BASED UPON THIS
DIAGNOSIS, WHICH OF THE FOLLOWING IS AN APPROPRIATE NURSING INTERVENTION TO
INCLUDE IN THE CLIENT'S CARE PLAN?
A) PROVIDE SIX SMALL MEALS DAILY.
B) PROVIDE THREE LARGE MEALS DAILY.
C) ENCOURAGE THE CLIENT TO EAT IMMEDIATELY BEFORE BREATHING TREATMENTS.
D) ENCOURAGE THE CLIENT TO ALTERNATE EATING AND USING A NEBULIZER DURING MEAL
TIME. - ANSWER-A) Provide six small meals daily.
THE NURSE SHOULD CONSIDER PROVIDING SIX SMALL MEALS DISTRIBUTED OVER THE COURSE
OF THE DAY INSTEAD OF THREE LARGE MEALS. MEALS SHOULD BE EATEN ONE TO TWO HOURS
AFTER BREATHING TREATMENTS AND EXERCISES.
THE NURSE IS DEVELOPING A PLAN OF CARE FOR A CLIENT ADMITTED WITH PNEUMONIA. THE
NURSE HAS DETERMINED THAT A PRIORITY NURSING DIAGNOSIS FOR THIS CLIENT IS
"INEFFECTIVE AIRWAY CLEARANCE RELATED TO COPIOUS AND TENACIOUS SECRETIONS." BASED
UPON THIS NURSING DIAGNOSIS, WHAT IS AN APPROPRIATE NURSING INTERVENTION TO
INCLUDE IN THE CLIENT'S CARE PLAN?
A) ENCOURAGING THE CLIENT TO CONSUME TWO TO THREE QUARTS OF CLEAR FLUIDS DAILY
B) CREATING AN ENVIRONMENT THAT IS LIKELY TO REDUCE ANXIETY
C) POSITIONING THE CLIENT SUPINE
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D) ENCOURAGING THE CLIENT TO DECREASE THE NUMBER OF CIGARETTES SMOKED DAILY. -
ANSWER-A) Encouraging the client to consume two to three quarts of clear fluids daily.
CLIENTS CAN HELP KEEP THEIR SECRETIONS THIN BY DRINKING TWO TO THREE QUARTS (1.9 L
TO 2.9 L) OF CLEAR FLUIDS DAILY. ALTHOUGH IT IS IMPORTANT TO CREATE AN ENVIRONMENT
THAT IS LIKELY TO REDUCE A CLIENT'S ANXIETY, DOING SO WILL NOT ASSIST IN PROMOTING
AIRWAY CLEARANCE. THE NURSE SHOULD NOT ENCOURAGE THE CLIENT TO DECREASE THE
NUMBER OF CIGARETTES SMOKED DAILY, BUT SHOULD ENCOURAGE THE CLIENT TO STOP
SMOKING. PROPER POSITIONING TO EASE RESPIRATIONS INCLUDES PLACING THE CLIENT IN A
HIGH FOWLER'S POSITION.
WHILE THE NURSE IS PROVIDING MORNING HYGIENE FOR A CLIENT WHO HAS A CHEST TUBE,
THE CLIENT HAS ROLLED OVER QUICKLY AND THE CHEST TUBE HAS BECOME DISCONNECTED
FROM THE DRAINAGE UNIT. HOW SHOULD THE NURSE FIRST RESPOND TO THIS EVENT?
A) SUBMERGE THE END OF THE TUBE IN STERILE WATER.
B) CLAMP THE TUBE NEAR THE END AND ALSO NEAR THE INSERTION POINT.
C) PLACE THE END OF THE TUBE ON A STERILE SURFACE AND SEEK HELP PROMPTLY.
D) CLEAN THE END OF THE TUBE WITH AN ALCOHOL SWAB AND RECONNECT IT TO THE
DRAINAGE UNIT. - ANSWER-A) Submerge the end of the tube in sterile water.
IF A CHEST TUBE BECOMES DISCONNECTED FROM THE DRAINAGE UNIT, THE NURSE SHOULD
SUBMERGE THE END OF THE TUBE IN A BOTTLE OF STERILE WATER, THUS PREVENTING A
PNEUMOTHORAX BUT STILL ALLOWING AIR TO ESCAPE.
A CLIENT HAS HAD A HEAD INJURY AFFECTING THE BRAIN STEM. WHAT IS LOCATED IN THE
BRAIN STEM THAT MAY AFFECT RESPIRATORY FUNCTION?
A) CHEMORECEPTORS
B) STRETCH RECEPTORS
C) MEDULLA
D) OXYGEN CENTER - ANSWER-C) Medulla
, 3|Page
THE MEDULLA IN THE BRAIN STEM, IMMEDIATELY ABOVE THE SPINAL CORD, IS THE
RESPIRATORY CENTER. STRETCH RECEPTORS ARE LOCATED IN MUSCLES. CHEMORECEPTORS
THAT AFFECT RESPIRATIONS ARE LOCATED IN THE AORTIC ARCH AND THE CAROTID BODIES.
WHICH OF THE FOLLOWING DISEASES MAY RESULT IN DECREASED LUNG COMPLIANCE?
A) EMPHYSEMA
B) APPENDICITIS
C) ACNE
D) CHRONIC DIARRHEA - ANSWER-A) Emphysema
LUNG COMPLIANCE REFERS TO THE STRETCHABILITY OF THE LUNGS, OR THE EASE WITH WHICH
LUNGS CAN BE INFLATED. EMPHYSEMA, A CHRONIC LUNG DISEASE, AND THE NORMAL
CHANGES ASSOCIATED WITH AGING ARE EXAMPLES OF CONDITIONS THAT RESULT IN
DECREASED ELASTICITY OF LUNG TISSUE, WHICH IN TURN DECREASES LUNG COMPLIANCE.
A NURSE IS CARING FOR A CLIENT WITH PNEUMONIA. THE CLIENT'S OXYGEN SATURATION IS
BELOW NORMAL. WHAT ABNORMAL RESPIRATORY PROCESS DOES THIS DEMONSTRATE?
A) CHANGES IN THE ALVEOLAR-CAPILLARY MEMBRANE AND DIFFUSION
B) ALTERATIONS IN THE STRUCTURES OF THE RIBS AND DIAPHRAGM
C) RAPID DECREASES IN ATMOSPHERIC AND INTRAPULMONIC PRESSURES
D) LOWER-THAN-NORMAL CONCENTRATIONS OF ENVIRONMENTAL OXYGEN - ANSWER-A)
Changes in alveolar-capillary membrane diffusion.
ANY CHANGE IN THE SURFACE AREA OF THE LUNGS HINDERS DIFFUSION OF GAS EXCHANGE.
ANY DISEASE OR CONDITION THAT RESULTS IN CHANGES IN THE ALVEOLAR-CAPILLARY
MEMBRANE, SUCH AS PNEUMONIA OR PULMONARY EDEMA, MAKES DIFFUSION MORE
DIFFICULT, ASSESSED BY DECREASED OXYGEN SATURATION MEASUREMENT.
FUNDAMENTALS OF NURSING 10TH EDITION LIPPINCOTT - TEST
BANK CHAPTER 40 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+||NEWEST VERSION
THE NURSE CARING FOR A CLIENT WITH EMPHYSEMA HAS DETERMINED THAT A PRIORITY
NURSING DIAGNOSIS FOR THIS CLIENT IS "IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENTS RELATED TO DIFFICULTY BREATHING WHILE EATING." BASED UPON THIS
DIAGNOSIS, WHICH OF THE FOLLOWING IS AN APPROPRIATE NURSING INTERVENTION TO
INCLUDE IN THE CLIENT'S CARE PLAN?
A) PROVIDE SIX SMALL MEALS DAILY.
B) PROVIDE THREE LARGE MEALS DAILY.
C) ENCOURAGE THE CLIENT TO EAT IMMEDIATELY BEFORE BREATHING TREATMENTS.
D) ENCOURAGE THE CLIENT TO ALTERNATE EATING AND USING A NEBULIZER DURING MEAL
TIME. - ANSWER-A) Provide six small meals daily.
THE NURSE SHOULD CONSIDER PROVIDING SIX SMALL MEALS DISTRIBUTED OVER THE COURSE
OF THE DAY INSTEAD OF THREE LARGE MEALS. MEALS SHOULD BE EATEN ONE TO TWO HOURS
AFTER BREATHING TREATMENTS AND EXERCISES.
THE NURSE IS DEVELOPING A PLAN OF CARE FOR A CLIENT ADMITTED WITH PNEUMONIA. THE
NURSE HAS DETERMINED THAT A PRIORITY NURSING DIAGNOSIS FOR THIS CLIENT IS
"INEFFECTIVE AIRWAY CLEARANCE RELATED TO COPIOUS AND TENACIOUS SECRETIONS." BASED
UPON THIS NURSING DIAGNOSIS, WHAT IS AN APPROPRIATE NURSING INTERVENTION TO
INCLUDE IN THE CLIENT'S CARE PLAN?
A) ENCOURAGING THE CLIENT TO CONSUME TWO TO THREE QUARTS OF CLEAR FLUIDS DAILY
B) CREATING AN ENVIRONMENT THAT IS LIKELY TO REDUCE ANXIETY
C) POSITIONING THE CLIENT SUPINE
,2|Page
D) ENCOURAGING THE CLIENT TO DECREASE THE NUMBER OF CIGARETTES SMOKED DAILY. -
ANSWER-A) Encouraging the client to consume two to three quarts of clear fluids daily.
CLIENTS CAN HELP KEEP THEIR SECRETIONS THIN BY DRINKING TWO TO THREE QUARTS (1.9 L
TO 2.9 L) OF CLEAR FLUIDS DAILY. ALTHOUGH IT IS IMPORTANT TO CREATE AN ENVIRONMENT
THAT IS LIKELY TO REDUCE A CLIENT'S ANXIETY, DOING SO WILL NOT ASSIST IN PROMOTING
AIRWAY CLEARANCE. THE NURSE SHOULD NOT ENCOURAGE THE CLIENT TO DECREASE THE
NUMBER OF CIGARETTES SMOKED DAILY, BUT SHOULD ENCOURAGE THE CLIENT TO STOP
SMOKING. PROPER POSITIONING TO EASE RESPIRATIONS INCLUDES PLACING THE CLIENT IN A
HIGH FOWLER'S POSITION.
WHILE THE NURSE IS PROVIDING MORNING HYGIENE FOR A CLIENT WHO HAS A CHEST TUBE,
THE CLIENT HAS ROLLED OVER QUICKLY AND THE CHEST TUBE HAS BECOME DISCONNECTED
FROM THE DRAINAGE UNIT. HOW SHOULD THE NURSE FIRST RESPOND TO THIS EVENT?
A) SUBMERGE THE END OF THE TUBE IN STERILE WATER.
B) CLAMP THE TUBE NEAR THE END AND ALSO NEAR THE INSERTION POINT.
C) PLACE THE END OF THE TUBE ON A STERILE SURFACE AND SEEK HELP PROMPTLY.
D) CLEAN THE END OF THE TUBE WITH AN ALCOHOL SWAB AND RECONNECT IT TO THE
DRAINAGE UNIT. - ANSWER-A) Submerge the end of the tube in sterile water.
IF A CHEST TUBE BECOMES DISCONNECTED FROM THE DRAINAGE UNIT, THE NURSE SHOULD
SUBMERGE THE END OF THE TUBE IN A BOTTLE OF STERILE WATER, THUS PREVENTING A
PNEUMOTHORAX BUT STILL ALLOWING AIR TO ESCAPE.
A CLIENT HAS HAD A HEAD INJURY AFFECTING THE BRAIN STEM. WHAT IS LOCATED IN THE
BRAIN STEM THAT MAY AFFECT RESPIRATORY FUNCTION?
A) CHEMORECEPTORS
B) STRETCH RECEPTORS
C) MEDULLA
D) OXYGEN CENTER - ANSWER-C) Medulla
, 3|Page
THE MEDULLA IN THE BRAIN STEM, IMMEDIATELY ABOVE THE SPINAL CORD, IS THE
RESPIRATORY CENTER. STRETCH RECEPTORS ARE LOCATED IN MUSCLES. CHEMORECEPTORS
THAT AFFECT RESPIRATIONS ARE LOCATED IN THE AORTIC ARCH AND THE CAROTID BODIES.
WHICH OF THE FOLLOWING DISEASES MAY RESULT IN DECREASED LUNG COMPLIANCE?
A) EMPHYSEMA
B) APPENDICITIS
C) ACNE
D) CHRONIC DIARRHEA - ANSWER-A) Emphysema
LUNG COMPLIANCE REFERS TO THE STRETCHABILITY OF THE LUNGS, OR THE EASE WITH WHICH
LUNGS CAN BE INFLATED. EMPHYSEMA, A CHRONIC LUNG DISEASE, AND THE NORMAL
CHANGES ASSOCIATED WITH AGING ARE EXAMPLES OF CONDITIONS THAT RESULT IN
DECREASED ELASTICITY OF LUNG TISSUE, WHICH IN TURN DECREASES LUNG COMPLIANCE.
A NURSE IS CARING FOR A CLIENT WITH PNEUMONIA. THE CLIENT'S OXYGEN SATURATION IS
BELOW NORMAL. WHAT ABNORMAL RESPIRATORY PROCESS DOES THIS DEMONSTRATE?
A) CHANGES IN THE ALVEOLAR-CAPILLARY MEMBRANE AND DIFFUSION
B) ALTERATIONS IN THE STRUCTURES OF THE RIBS AND DIAPHRAGM
C) RAPID DECREASES IN ATMOSPHERIC AND INTRAPULMONIC PRESSURES
D) LOWER-THAN-NORMAL CONCENTRATIONS OF ENVIRONMENTAL OXYGEN - ANSWER-A)
Changes in alveolar-capillary membrane diffusion.
ANY CHANGE IN THE SURFACE AREA OF THE LUNGS HINDERS DIFFUSION OF GAS EXCHANGE.
ANY DISEASE OR CONDITION THAT RESULTS IN CHANGES IN THE ALVEOLAR-CAPILLARY
MEMBRANE, SUCH AS PNEUMONIA OR PULMONARY EDEMA, MAKES DIFFUSION MORE
DIFFICULT, ASSESSED BY DECREASED OXYGEN SATURATION MEASUREMENT.
