Thenurserecognizesthaturinaryeliminationchangesmayoccurevenin

healthyolderadultsbecauseofwhichofthefollowing?
Thebladderdistendsanditscapacityincreases.
Olderadultsignoretheneedtovoid.
Urinebecomesmoreconcentrated.
Theamountofurineretainedaftervoidingincreases.
Theamountofurineretainedaftervoidingincreases.
Rationale:Thecapacityofthebladdermaydecreasewithagebutthemuscleisweakerandcancauseurine
toberetained(option4).Olderadultsdonotignoretheurgetovoidandmayhavedifficultyingettingto
thetoiletintime(option2).Thekidneybecomeslessabletoconcentrateurinewithage(option3).

Duringassessmentoftheclientwithurinaryincontinence,thenurseis
mostlikelytoassessforwhichofthefollowing?Selectallthatapply.
Perinealskinirritation
Fluidintakeoflessthan1,500mL/day
Historyofantihistamineintake
Historyoffrequenturinarytractinfections
Afecalimpaction
Perinealskinirritation
Fluidintakeoflessthan1,500mL/day
Historyoffrequenturinarytractinfections
Afecalimpaction
Rationale:Theperineummaybecomeirritatedbythefrequentcontactwithurine(option1).Normalfluid
intakeisatleast1,500mL/dayandclientsoftendecreasetheirintaketotrytominimizeurineleakage
(option2).UTIscancontributetoincontinence(option4).Afecalimpactioncancompresstheurethra,
whichcanresultinsmallamountsofurineleakage(option5).Antihistaminescancauseurinaryretention
ratherthanincontinence(option3).

Whichactionrepresentstheappropriatenursingmanagementofaclient
wearingacondomcatheter?
Ensurethatthetipofthepenisfitssnuglyagainsttheendofthecondom.
Checkthepenisforadequatecirculation30minutesafterapplying.

Changethecondomevery8hours.
Tapethecollectingtubingtothelowerabdomen.
Checkthepenisforadequatecirculation30minutesafterapplying.
Rationale:Thepenisandcondomshouldbecheckedonehalfhourafterapplicationtoensurethatitisnot
tootight.A1in.spaceshouldbeleftbetweenthepenisandtheendofthecondom(option1).Thecondom
ischangedevery24hours(option3),andthetubingistapedtothelegorattachedtoalegbag(option4).
Anindwellingcatheteristapedtothelowerabdomenorupperthigh.

Thecatheterslipsintothevaginaduringastraightcatheterizationofa
femaleclient.Thenursedoeswhichaction?
Leavesthecatheterinplaceandgetsanewsterilecatheter.
Leavesthecatheterinplaceandasksanothernursetoattemptthe
procedure.
Removesthecatheterandredirectsittotheurinarymeatus.
Removesthecatheter,wipesitwithasterilegauze,andredirectsittothe
urinarymeatus.
Leavesthecatheterinplaceandgetsanewsterilecatheter.
Rationale:Thecatheterinthevaginaiscontaminatedandcannotbereused.Ifleftinplace,itmayhelp
avoidmistakingthevaginalopeningfortheurinarymeatus.Asinglefailuretocatheterizethemeatusdoes
notindicatethatanothernurseisneededalthoughsometimesasecondnursecanassistinvisualizingthe
meatus(option2).

Whichstatementindicatesaneedforfurtherteachingofthehomecare
clientwithalongtermindwellingcatheter?
"Iwillkeepthecollectingbagbelowthelevelofthebladderatalltimes."
"Intakeofcranberryjuicemayhelpdecreasetheriskofinfection."
"Soakinginawarmtubbathmayeasetheirritationassociatedwiththe
catheter."
"Ishouldusecleantechniquewhenemptyingthecollectingbag."
"Soakinginawarmtubbathmayeasetheirritationassociatedwiththecatheter."
Rationale:Soakinginabathtubcanincreasetheriskofexposuretobacteria.Thebagshouldbebelowthe
levelofthebladdertopromoteproperdrainage(option1).Intakeofcranberryjuicecreatesanenvironment
nonconducivetoinfection(option2).Cleantechniqueisappropriatefortouchingtheexteriorportionsof
thesystem(option4).

Duringshiftreport,thenurselearnsthatanolderfemaleclientisunable
tomaintaincontinenceaftershesensestheurgetovoidandbecomes

incontinentonthewaytothebathroom.Whichnursingdiagnosisismost
appropriate?
StressUrinaryIncontinence
ReflexUrinaryIncontinence
FunctionalUrinaryIncontinence
UrgeUrinaryIncontinence
UrgeUrinaryIncontinence
Rationale:Thekeyphraseis"theurgetovoid."Option1occurswhentheclientcoughs,sneezes,orjarsthe
body,resultinginaccidentallossofurine.Option2occurswithinvoluntarylossofurineatsomewhat
predictableintervalswhenaspecificbladdervolumeisreached.Option3isinvoluntarylossofurine
relatedtoimpairedfunction.

Afemaleclienthasaurinarytractinfection(UTI).Whichteachingpoints
bythenursewouldbehelpfultotheclient?Selectallthatapply.
Limitfluidstoavoidtheburningsensationonurination.
ReviewsymptomsofUTIwiththeclient.
Wipetheperinealareafrombacktofront.
Wearcottonunderclothes.
Takebathsratherthanshowers.
ReviewsymptomsofUTIwiththeclient.
Wearcottonunderclothes.
Rationale:Option2validatesthediagnosis.Cottonunderwearpromotesappropriateexposuretoair,
resultingindecreasedbacterialgrowth(option4).Increasedfluidsdecreaseconcentrationandirritation
(option1).Theclientshouldwipetheperinealareafromfronttobacktopreventspreadofbacteriafrom
therectalareatotheurethra(option3).Showersreduceexposureofareatobacteria(option5).

Thenursewillneedtoassesstheclient'sperformanceofcleanintermittent
selfcatheterization(CISC)foraclientwithwhichurinarydiversion?
Ilealconduit
Kockpouch
Neobladder
Vesicostomy
Kockpouch
Rationale:Theilealconduitandvesicostomy(options1and4)areincontinenturinarydiversions,and

clientsarerequiredtouseanexternalostomyappliancetocontaintheurine.Clientswithaneobladdercan
controltheirvoiding(option3).

Whichfocusisthenursemostlikelytoteachforaclientwithaflaccid
bladder?
Habittraining:attemptvoidingatspecifictimeperiods.
Bladdertraining:delayvoidingaccordingtoaprescheduletimetable.
Cred'smaneuver:applygentlemanualpressuretothelowerabdomen.
Kegelexercises:contractthepelvicmuscles.
Cred'smaneuver:applygentlemanualpressuretothelowerabdomen.
Rationale:Becausethebladdermuscleswillnotcontracttoincreasetheintrabladderpressuretopromote
urination,theprocessisinitiatedmanually.Options1,2,and4:Topromotecontinence,bladder
contractionsarerequiredforhabittraining,bladdertraining,andincreasingthetoneofthepelvicmuscles.

Whichofthefollowingbehaviorsindicatesthattheclientonabladder
trainingprogramhasmettheexpectedoutcomes?Selectallthatapply.
Voidseachtimethereisanurge.
Practicesslow,deepbreathinguntiltheurgedecreases.
Usesadultdiapers,for"justincase."
Drinkscitrusjuicesandcarbonatedbeverages.
Performspelvicmuscleexercises.
Practicesslow,deepbreathinguntiltheurgedecreases.
Performspelvicmuscleexercises.
Rationale:Itisimportantfortheclienttoinhibittheurgetovoidsensationwhenaprematureurgeis
experienced.Someclientsmayneeddiapers;thisisnottheBESTindicatorofasuccessfulprogram(option
3).Citrusjuicesmayirritatethebladder(option4).Carbonatedbeveragesincreasediuresisandtheriskof
incontinence(option4).

Aclientcomestotheprimarycareprovider'sofficewiththecomplaintsof
urinatingallthetime,painonurination,smallamountsofurinebeing
passedwhenvoiding,andafoulsmelltotheurine.Aurinespecimenhas
beensentforanalysis.Basedonthesignsandsymptomsexpressedbythe
client,whichofthefollowinghealthproblemswouldbeanticipated?
Acuterenalfailure
Renalstone

Urinarytractinfection
Chronicrenalfailure
Urinarytractinfection
Objective:Identifycommoncausesofselectedurinaryproblems.
Rationale:Thenotedsignsandsymptomshelptoidentifytheproblemofurinarytractinfection.Thesigns
andsymptomsnotedarenotcommonwiththeotherdiseaseslisted.

Anappropriatehealthgoalforclientswithurinaryeliminationproblems
wouldinclude:
Ignoringnormalizationofvoidingpattern.Thatthepatienthastheability
tovoidisthemostimportantaspectofcare.
Encouragingtheclienttofollowmeasurestoshowalargerthannormal
urineoutputtoflushtokidneys
Alwaysassistingtheclientwithtoiletingactivitiesinordertomonitor
amount
Preventingassociatedrisks,suchasinfectionsandfluidandelectrolyte
imbalances.
Preventingassociatedrisks,suchasinfectionsandfluidandelectrolyteimbalances.
Objective:Developnursingdiagnoses,desiredoutcomes,andinterventionsrelatedtourinaryelimination.
Rationale:Preventingassociatedrisksrelatedtourinarydiseaseistheonlyappropriategoalnoted.

Whichnursingassessmentinthehomecareenvironmentforclientswith
urinaryeliminationproblemsisinappropriate?
Clientselfcareabilities
Distanceandbarrierstoaccessingthebathroom
Need/useofambulatoryaidsasrequired
Nodietaryrestrictionsneeded
Nodietaryrestrictionsneeded
Objective:Describenursingassessmentofurinaryfunctionincludingsubjectiveandobjectivedata.
Rationale:Dietaryguidesrelatedtofiberandfluidbalancearegiventoclientswiththisproblem.The
remainingactionsarenotedintheassessmentguide,andareappropriatemeasurestousewithclients.

ThenurseisrequestedtoperformteachingtoaclientintheEmergency
Departmentrelatedtothediagnosisofaurinarytractinfection.An

interventiontobefollowedbytheclientincludes:
Avoidtightfittingpantsorclothing
Drinksixglassesofwaterperday
Typeofsoapwhenbathinghasnosignificanceinthisarea.
Voidingpatterninthecourseofthedayhasnosignificancewiththis
problem.
Avoidtightfittingpantsorclothing
Objective:Delineatewaystopreventurinaryinfection.
Rationale:Tightfittingclothingcreatesirritationtotheurethraandpreventsventilationoftheperineal
area.Itisrecommendedthateightglassesofwaterbedrunktoflushouttheurinarysystem.Avoidharsh
soaps,bubblebath,powders,andspraysintheperinealarea,becausetheycanhaveanirritatingeffecton
theurethra,encouraginginflammationandabacterialinfection.Practicefrequentvoiding(q23hours)to
flushbacteriaoutothertheurethraandpreventorganismsfromascendingintothebladder.

Urinaryincontinenceisnotanormalpartofaging.Aninterventionused
bynursestoassistclientstoregainormaintaincontinencewithindividuals
sufferingfromthisproblemwouldnotinclude:
Bladdertraining
Habittraining
Promptedvoiding
Fluidrestriction
Fluidrestriction
Objective:Developnursingdiagnoses,desiredoutcomes,andinterventionsrelatedtourinaryelimination.
Rationale:Fluidswouldbeencouraged,toallowthekidneystobeflushedandurinetobeformed.Bladder
trainingrequiresthattheclientpostponevoiding,resistorinhinbitthesensationofurgency,andvoid
accordingtoatimetable,ratherthanaccordingtoanurge.Habittrainingisalsoreferredtotimedor
scheduledvoiding.Thereisnoattempttomotivatetheclienttodelayvoidingiftheurgeoccurs.Prompted
voidingsupplementshabittrainingbyencouragingtheclienttotrytousethetoiletandremindingtheclient
whentovoid.

Urinarycatheterizationiscarriedoutforclientsonlywhenabsolutely
necessary.Whichofthefollowingcandidates/situationswouldnotwarrant
theneedforthisprocedure?
Aclienthavingabdominalsurgery
Aclientwhoiscompletelyparalyzed

Aclientinneedofdecompressionofthebladder
Tocollectarandomurinespecimenforevaluation
Tocollectarandomurinespecimenforevaluation
.Objective:Explainthecareofclientswithretentioncathetersorurinarydiversions.
Rationale:Collectionofarandomurinespecimenisnotroutinelyobtainedbyuseoftheprocessof
catheterization.Theothercandidates/situationsareappropriateusesofthistechnique.

Thegoalofnursingcareoftheclientwithanindwellingcatheterand
continuousdrainageislargelydirectedatpreventinginfectionofthe
urinarytractandencouragingurinaryflowthroughthedrainagesystem.
Whichofthefollowinginterventionsencouragedbynursesworkingwith
theseclientswouldnotbeappropriateinmeetingthisgoal?
Havingtheclientdrinkupto3000mLperday
Encouragingtheclienttoeatfoodsthatincreasetheacidintheurine
Routinehygieniccare
Changingindwellingcathetersevery72hours.
Changingindwellingcathetersevery72hours.
Objective:Explainthecareofclientswithretentioncathetersorurinarydiversions.
Rationale:Retentioncathetersareremovedaftertheirpurposeisachieved;routinechangingofthecatheter
ordrainagesystemisnotrecommended.Largeamountsoffluidensurealargeurineoutput,whichkeeps
thebladderflushedoutanddecreasesthelikelihoodofurinarystasisandsubsequentinfection.Eatingfoods
thatincreasetheacidinurinehelpstoreducetheriskofurinarytractinfectionsandstoneformation.
Hygienecarerelatedtocathetersissetbyhospitalpolicy.

Aurinarydiversionisthesurgicalreroutingofurinefromthekidneystoa
siteotherthanthebladder.Whichtypeofclientwouldthistypeof
procedurewouldbenefitfromthisprocedure?
Anabdominaltraumavictim
Arenalfailureclient
Aclientwithkidneystones
Anindividualsufferingfromaurinarytractinfection
Anabdominaltraumavictim
Objective:Explainthecareofclientswithretentioncathetersorurinarydiversions.
Rationale:Theabdominaltraumavictimistheonlyappropriateanswerhere.Theremainingproblemscan
betreatedwithlesstraumaticcaremeasures.

Apracticeguidelinefornursestouseinpreventingcatheterassociated
urinaryinfectionincludeswhichoftheinstructionslistedbelow?
Maintaincleantechniquewheninsertingthecatheterintotheclient.
Disconnectthecatheteranddrainagetubingonceashifttorinsetheunit
incleaningthedevice.
Sinceyouarewearinggloves,itisnotnecessarytowashyourhands.
Preventcontaminationofthecatheterwithfecesintheincontinentclient.
Preventcontaminationofthecatheterwithfecesintheincontinentclient.
Objective:Explainthecareofclientswithretentioncathetersorurinarydiversions.
Rationale:Keepingtheperinealareafreeoffeceseliminatesthepossiblespreadofanybacteriathatmay
colonizeinthefecesandtravelupthecathetertothebladder.Sterileoraseptictechniqueisusedwhen
insertingFoleycathetersintoclientstopreventthespreadofinfectionwiththeprocess.Cathetertubing
shouldnotbedisconnectedonceputintouse.Connectionsareusuallytapedtohelpsecuretheirseal.
WearinggloveswiththisprocedureispartofthepracticeofUniversalPrecautionsutilizedwhenhealth
careworkerscomeincontactwithmosttubesandbodyfluids.

Thenurseiscounselingayoungmotherwhocomplainsofhavingstress
incontinencecontinuingforthreemonthsafterherpregnancy.Ithasbeen
recommendedthatshepracticepelvicmuscleexercisestostrengthenher
bladdermuscles.Whatactionwouldthenurserecommendtothisclientin
ordertoperformthisactivitycorrectly?
Stoppingurinationmidstream
Standingtallandstretchingoutherarmsandtouchinghertoes
Emptyingherbladdercompletely
Movingherbowels
Stoppingurinationmidstream
Objective:Developnursingdiagnoses,desiredoutcomes,andinterventionsrelatedtourinaryelimination
Rationale:Stoppingtheflowofurinationmidstreamfocusesonthemuscleusedtocontrolthisactivity.
Theremaininganswersdonotaffectthismuscleinthesamemanner.

Youaskaclienttoprovideacleancatchurinespecimen,explainingthe
procedurethatwillfollow.Whentheclienthandsyouthespecimen,you
noticethattheurinehasaslightlyreddishcolor.Whichofthefollowing
actionsshouldyoutake?[Hint]
Notifythephysicianimmediatelyoftheurinecolor.

Asktheclienthowlongtheirurinehasbeenbloody.
Askthenursingsupervisorwhattodo.
Assesstheclient'srecentdietandmedicationintake.
Assesstheclient'srecentdietandmedicationintake.

Duringtheshiftreport,youlearnthatyourassignedclienthas"nocturia."
Whichofthefollowingquestionsshouldyouaskthisclient?[Hint]
"Howoftendoyouwetthebedatnight?"
"Areyoueatingsaltysnacksintheevening?"
"Howmanytimesdoyougetuptovoidatnight?"
"Whendidthesebladderspasmsatnightbegin?"
"Howmanytimesdoyougetuptovoidatnight?"

Whenteachingolderadultsaboutincontinence,youmostneedtoinform
olderadultsthat:[Hint]
incontinenceisnotanormalconsequenceofagingandoftencanbe
treated.
thebladderlosesitsmuscletonewithaging,soKegelexercisesaretheonly
help.
itisnecessarytogotothebathroommoreofteninordertoprevent
incontinence.
99percentofincontinenceintheelderlyiscausedbyaformofurinary
retention.
incontinenceisnotanormalconsequenceofagingandoftencanbetreated.

Whenassessingaclientwhohasadiagnosisofneurogenicbladder,what
wouldyoumostlikelyfindtheclienttosay?[Hint]
"Mybladderalwaysfeelsfull."
"Iamoftenunabletocontrolmyurination."
"Ihaveanervousbladder."
"Iurinateabout5to7timeseach24hourday."

"Iamoftenunabletocontrolmyurination."
Theclientwithaneurogenicbladderdoesnotperceivebladderfullnessandisunabletocontroltheurinary
sphincters.Theremaybefrequentinvoluntaryurination.

Thephysicianordersaclienttobecatheterizedforresidualurineafterthe
nextvoiding.Thenurseresponsibleforcatheterizingthisclientwillmost
needto:[Hint]
instructtheclienttoputontheircalllightaftervoiding.
catheterizetheclientwithin30minutesofvoiding.
catheterizetheclientimmediatelyaftertheclientvoids.
charttheresidualamountobtainedifitismorethan30mL/hour.
catheterizetheclientimmediatelyaftertheclientvoids.

Whencollectingacleancatchormidstreamspecimenfromaclient,itis
mostimportantthatthenurse:[Hint]
providetheclientwithasterilespecimencontainerandalid.
instructtheclienttosquatorstandwhilevoidingintothecontainer.
havetheclientwearapairofcleanorsterilegloves.
givetheclientanantibacterialsoaptouseincleansingtheurethralarea.
providetheclientwithasterilespecimencontainerandalid.

Thephysicianhaswrittenanorderforyourassignedclienttohavea24
hoururinecollectionsenttothelaboratoryforspecifictesting.Yourealize
thatyoumust:[Hint]
informtheclientthattheymustsaveallurinefor24hoursbeginningat
12:01a.m.
starttheurinecollectionateither12:01a.m.or12:01p.m.
atthestartofthecollectionperiod,havetheclientvoidanddiscardthis
urine.
provideenoughsterilereceptaclesfortheurinecollection.
atthestartofthecollectionperiod,havetheclientvoidanddiscardthisurine.
Atthestartofthecollectionperiod,havetheclientvoidanddiscardthisurine.

Yournursinginstructorcomesintoyourassignedclient'sroomandhands
youaurinometerorahydrometer.Yourealizethattheinstructorwants
youtodowhichofthefollowingthings?[Hint]
Measuretheclient'surinespecificgravity.
Findoutiftheclienthasproteinintheurine.
Measuretheforceoftheurinestream.
DeterminetheurinepH.
Measuretheclient'surinespecificgravity.

Whenreadingthelabreportsofyourassignedclients,youfindthatoneof
yourclientshasaurinepHof6.YoudeterminethatthisurinepHis:
[Hint]
stronglyalkalinic.
slightlyacidic.
abnormal.
neutral.
slightlyacidic.

Whichofthefollowingstatementsbyaclientwithrecurrenturinary
infectionswouldindicatetheclientunderstoodyourteachingaboutthe
bestfluidstodrinktopreventurinaryinfections?[Hint]
"Mydailydietincludestwotothreeglassesofvegetablejuice."
"EachdayIdrinktwoglassesofablendoffruitandyogurt."
"Idrinktwotothreeglassesofcranberryjuiceeveryday."
"EachmorningandeveningIhaveaglassoforangejuice."
"Idrinktwotothreeglassesofcranberryjuiceeveryday."

The nurse makes the assessment that which client has the greatest
risk for a problem with the transport of oxygen from the lungs to the
tissues? A client who has
Anemia.
Rationale:Anemiaisaconditionofdecreasedredbloodcellsanddecreasedhemoglobin.Hemoglobinis
howtheoxygenmoleculesaretransportedtothetissues.

Option3:Afracturedribwouldinterrupttransportofoxygenfromtheatmospheretotheairways.
Option4:Damagetothemedullawouldinterferewithneuralstimulationoftherespiratorysystem.

The nurse is caring for a client with a tracheostomy. For what

protective mechanism will the nurse monitor in the client?
Filtrationandhumidificationofinspiredair
Whenthenasalpassagesarebypassedastheywouldbeinthecaseofaclientwithatracheostomy,the
filtration,humidification,andwarmingofthenasalpassagesisalsobypassed.

The nurse is planning to perform percussion and postural drainage.

Which is an important aspect of planning the client's care?
Percussionandposturaldrainageshouldbedonebeforelunch.
Rationale:Posturaldrainageresultsinexpectorationoflargeamountsofmucus.Clientssometimesingest
partofthesecretions.Thesecretionsmayalsoproduceanunpleasanttasteintheoralcavity,whichcould
resultinnausea/vomiting.Thisprocedureshouldbedoneonanemptystomachtodecreaseclient
discomfort.

A client with emphysema is prescribed corticosteroid therapy on a

short-term basis for acute bronchitis. The client asks the nurse how the
steroids will help him. The nurse responds by saying that the
corticosteroids will do which of the following?
Decreaseinflammationintheairways.
Rationale:Glucocorticoidsareprescribedbecauseoftheirantiinflammatoryeffect.

Which term does the nurse document to best describe a client

experiencing shortness of breath when lying down who must assume
an upright or sitting position to breathe more comfortably and
effectively?
Orthopnea
Rationale:Respiratorydifficultyrelatedtoarecliningpositionwithoutotherphysicalalterationsisdefined
asorthopnea.

While a client with chest tubes is ambulating, the connection between

the tube and the water seal dislodges. Which action by the nurse is
most appropriate?
Reconnectthetubetothewaterseal.
Rationale:Thetubeshouldbereconnectedtothewatersealasquicklyaspossible.
Assistingtheclientbacktobed(option1)andassessingtheclient'slung(option3)arepossibleactions
afterthesystemisreconnected.

Which client statement informs the nurse that his teaching about the
proper use of an incentive spirometer was effective?
"Ishouldinhaleslowlyandsteadilytokeeptheballsup."
Rationale:ProperuseofanSMIrequirestheclienttotakeslow,steadyinhalations,everyhourortwo,5to
10breathseachtime.Onlythemouthpiececanbesuccessfullyrinsedorwipedclean.Thedeviceshould
notbesubmergedinwater(option4).

Which action by the nurse represents proper

nasopharyngeal/nasotracheal suction technique?
Rotatethecatheterwhileapplyingsuction.
Rationale:Rotatingthecatheterpreventspullingoftissueintotheopeningonthecathetertipandside.
Suctioncathetersmayonlybelubricatedwithwaterorwatersolublelubricant(petroleumjelly,e.g.,
Vaseline,hasanoilbase)(option1).Nosuctionshouldeverbeappliedwhilethecatheterisbeinginserted
becausethiscantraumatizetissues(option2).Theclientshouldbehyperoxygenatedforonlyafewminutes
beforeandaftersuctioningandthisisgenerallylimitedtoclientswhoareintubatedorhaveatracheostomy
(option4).

The nurse is preparing to perform tracheostomy care. Prior to

beginning the procedure the nurse performs which action?
Tellstheclienttoraisetwofingerstoindicatepainordistress.
Rationale:Priortostartingtheprocedure,itisimportanttodevelopameansofcommunicationbywhich
theclientcanexpresspainordiscomfort.Thetwilltapeisnotchangeduntilafterperformingtracheostomy
care(option2).Cleaningtheincisionshouldbedoneaftercleaningtheinnercannula(option3).Checking
thetightnessofthetiesandknotisdoneafterapplyingnewtwilltape(option4).

To prevent postoperative complications, the nurse assists the client

with coughing and deep-breathing exercises. This is best accomplished
by implementing which of the following?
YourAnswer:Huffcoughingevery2hoursorasneeded.
Rationale:Huffcoughinghelpskeeptheairwaysopenandsecretionsmobilized.Huffcoughingisan
alternativeforclientswhoareunabletoperformanormalforcefulcough(e.g.,postoperatively).Deep
breathingandcoughingshouldbeperformedatthesametime.Onlyatmealtimesisnotsufficient(option
1).Extendedforcefulcoughingfatiguestheclient,especiallypostoperatively(option2).Diaphragmaticand
pursedlipbreathingaretechniquesusedforclientswithobstructiveairwaydisease(option4).

A client with chronic pulmonary disease has a bluish tinge around the
lips. The nurse charts which term to most accurately describe the
client's condition?
YourAnswer:Cyanosis
Rationale:Abluishtingetomucousmembranesiscalledcyanosis.Thisismostaccuratebecauseitiswhat
thenurseobserves.Thenursecanonlyobservesigns/symptomsofhypoxia(option1).Moreinformationis
neededtovalidatethisconclusion.Hypoxemiarequiresbloodoxygensaturationdatatobeconfirmed
(option2),anddyspneaisdifficultbreathing(option3).

What suggestions could be given to Mr. Calloway about coping with his
emphysema?
Teachclientrelaxationtechniques,properuseofoxygen,positioningtechniques,assesssputumcolorand
consistency,fluidintakeadequatetomaintainhydration,promoteairwayclearance.

What oxygen safety precautions should be discussed with Mr.

Calloway?
Nosmokinginthehomeorneartheoxygen,cautionarysignspostedneartheroom,makesurethat
electricaldevicesareingoodworkingordertopreventsparks,avoidmaterialsthatgeneratestatic

electricity,avoiduseofflammablematerialsinrangeofthetank,groundelectricalequipment,havefire
extinguishersaccessible.

Mr. Calloway states that when he is short of breath, he likes to turn his
oxygen up. What should be said to Mr. Calloway about this practice?
ForclientswithCOPD,alowflowoxygensystemisessential.Toomuchoxygenmayinhibitbreathing

_____________ or clapping is forceful striking of the skin with cupped

hands to dislodge tenacious secretions.
CorrectAnswer:Timeofday
Objective:Identifyanddescribenursingmeasurestopromoterespiratoryfunctionandoxygenation.
Rationale:Percussionisforcefulstrikingwithcuppedhandsandusedtodislodgetenacioussecretions.The
nurseshouldcovertheareawithatowelorblanket,asktheclienttobreatheslowly,alternatelyflexand
extendthewristsrapidlytoslapthechestfor1to2minutes.

Which clinical signs are indicative of hypoxia? (Select all that apply.)
CorrectAnswers:
1.Flaringofnostrils
2.Cyanosis
3.Rapidpulse
4.Substernalorintercostalsretractions
Objective:Describenursingmeasurestopromoterespiratoryfunctionandoxygenation.
Rationale:Signsofhypoxiainclude:rapidpulse,rapid,shallowrespirationsanddyspnea,increased
restlessnessandlightheadedness,flaringofthenares,substernalorintercostalsretractionsandcynaosis.

Which client is most at risk for developing an upper respiratory

infection?
YourAnswer:A3yearoldinpreschool
Objective:Identifyfactorsinfluencingrespiratoryfunction.
Rationale:Duringinfancyandchildhood,upperrespiratoryinfectionsarecommonduetochangesin
developingrespiratorysystems.Adolescentsandyoungandmiddleadultindividualswouldsufferthis
problemonlyiftheirimmunesystemswerecompromisedinanymanner,oriftheysufferedfromchronic
illness.

An appropriate nursing responsibility in caring for clients with chest

drainage systems would be:
YourAnswer:Monitoringthepatencyandintegrityofthedrainagesystem
Objective:Stateoutcomecriteriaforevaluatingclientresponsestomeasuresthatpromoteadequate
oxygenation.
Rationale:Actionstakendirectlyfromthetextinbook.Notubecandraineffectivelyifitiscloggedor
damagedinanymanner.Thewaterseallevelismarkedformosteffectivelevelofuse.Overfillingitadds
noadditionaleffectiveness.Clampsarereadilyavailableatthebedsideforemergencypurposes,suchas
dislodgementofthetube.Monitoringofclientstatusaftertubeinsertionincludesallvitalsigns,andisset
accordingtoclientneedandhospitalguidelines.

While suctioning a client in ICU, the nurse notices that the activity
brings about deep breathing and coughing maneuvers by the client.
This is considered a good action because
Deepbreathingoxygenatesthelungs,andcoughingloosensandmovessecretionsinthelungs.
Objective:Explaintheuseoftherapeuticmeasuressuchasmedications,inhalationtherapy,oxygen
therapy,artificialairways,airwaysuctioning,andchesttubestopromoterespiratoryfunction.
Rationale:Themovementallowsforexpansionofthelungs,andtheforceandpressuresexertedin
coughingloosenthesecretions.Theotherstatementsarenotaccurate.

Appropriate follow-up evaluation of a client after suctioning does not

include which of the following assessments?
Onlydocumentfindingsabnormalintheclientrecord;thedoctorwillseetheresultswhenroundsonthe
clientaredone.
Objective:Explaintheuseoftherapeuticmeasuressuchasmedications,inhalationtherapy,oxygen
therapy,artificialairways,airwaysuctioning,andchesttubestopromoterespiratoryfunction.
Rationale:Allfindingsaftersuctioningclientsaredocumentedintherecord.Abnormalfindingsarenot
onlydocumented,butcalledtothephysician'sattentionaswell.Allotheractionsareappropriate.

Which is the appropriate method to use when a client is suffering

respiratory difficulty and in need of suctioning?
Portableorwallsuctionmachinewithtubingandcollectionreceptacle
Objective:Explaintheuseoftherapeuticmeasuressuchasmedications,inhalationtherapy,oxygen
therapy,artificialairways,airwaysuctioning,andchesttubestopromoterespiratoryfunction.
Rationale:Adextroseandwatersolutionisnotusedhere.Controversyexistswithusingnormalsalineto
assistinlooseningsecretions.Thenasalcannulaisnotusedinthistechnique.Gogglesarewornfor
protectionfromanysecretionssplashedduringthesuctioningprocess.

The nursing intervention that is appropriate for use with clients having
an endotracheal tube is:
Providingroomair
Objective:Explaintheuseoftherapeuticmeasuressuchasmedications,inhalationtherapy,oxygen
therapy,artificialairways,airwaysuctioning,andchesttubestopromoterespiratoryfunction.
Rationale:Humidifiedairoroxygenshouldbegiven,becausetheendotrachealtubebypassestheupper
airways,whichnormallymoistensair.Notepadsandpictureboardshelptogivetheclientsomecontrolin
communicationwithothers.Frequentassessmentsofnasalandoralmucosamonitorforskinbreakdown
andinfection.Placingtheclientinasidelyingpositionpreventsaspirationoffluids,whichcanleadto
infection.

The nurse is to teach a client with Chronic Obstructed Pulmonary

Disease safety precautions for using oxygen at home. The nurse knows
that the client understands the safety principles discussed when he
says the following:
YourAnswer:"Avoidmaterialsthatgeneratestaticelectricity."
Objective:Explaintheuseoftherapeuticmeasuressuchasmedications,inhalationtherapy,oxygen
therapy,artificialairways,airwaysuctioning,andchesttubestopromoterespiratoryfunction.

Rationale:Oxygenisahighlycombustiblesubstance.Whennearaclientusingoxygen,smokeonlyoutside
orinaroomprovidedforsmoking,awayfromtheclient.Inappropriatesubstancesforusearenotedin
answer3.Fireextinguishersshouldbereadilyavailable,andthereshouldbeanindividual/familymember
withknowledgeofitsuse.

Vibration
aseriesofvigorousquiveringsproducedbyhandsthatareplacedflatagainstthechestwalltoloosenthick
secretions

Torr (t.o.r.r.)
millimetersofmercury

Surfactant
asurfaceactiveagent(eg,soaporasyntheticdetergent).Inpulmonaryphysiology,amixtureof
phosopholipidssecretedbyalveolarcellsintothealveoliandrespiratoryairpassagesthatreducesthe
surfacetensionofpulmonaryfluidsandthuscontributestotheelasticpropertiesofpulmonarytissue.

Suctioning
theaspirationofsecretionsbyacatheterconnectedtoasuctionmachineorwalloutlet

Stridor
aharsh,crowingsoundmadeoninhalationcausedbyconstrictionoftheupperairway

Respiratory membrane
wheregasexchangeoccursbetweentheaironthealveolarsideandthebloodonthecapillaryside;the
alveolarandcapillarywallsformtherespiratorymembrane

Postural drainage
thedrainage,bygravity,ofsecretionsfromvariouslungsegments

Pneumothorax
whenaircollectsinthepleuralspace

Partial pressure
thepressureexertedbyeachindividualgasinamixtureaccordingtoitspercentageconcentrationinthe
mixture

Orthopnea
abilitytobreatheonlywheninanuprightposition(sittingorstanding)

Lung scan
alsoknownasaV/Q(ventilation/perfusion)scan,recordstheemissionsfromradioisotopesthatindicate
howwellgasandbloodaretravelingthroughthelungs

Lung recoil
thetendencyoflungstocollapseawayfromthechestwall

Lung compliance

expansibilityofthelung

Laryngoscopy
visualexaminationofthelarynxwithalaryngoscope

Kussmaul's breathing
hyperventilationthataccompaniesmetabolicacidosisinwhichthebodyattemptstocompensate(giveoff
excessbodyacids)byblowingoffcarbondioxidethroughdeepandrapidbreathing

Intrapulmonary pressure
pressurewithinthelungs

Intrapleural pressure
pressureinthepleuralcavitysurroundingthelungs

Incentive spirometers
devicesthatmeasuretheflowofairinhaledthroughthemouthpiece

Hypoxia
insufficientoxygenanywhereinthebody

Hypoxemia
...

Hyperoxygenation
donewithamanualresuscitationbagorthroughaventilator,increasesoxygenflow(usuallyto100
percent)beforesuctioningandbetweensuctionattempts

Hyperinflation
givingtheclientbreathsthatare1to1.5timesthetidalvolumethroughtheventilatorcircuitorviaa
manualresuscitationbag

Hypercarbia---- Hypercapnia
aconditioninwhichcarbondioxideaccumulatesintheblood

Humidifiers
devicesthataddwatervaportoinspiredair

Hemothorax
acollectionofbloodinthepleuralcavity

Expectorate
tocoughandspitupmucusorothermaterials

Emphysema
achronicpulmonaryconditioninwhichthealveoliaredilatedanddistended

Dyspnea

difficultorlaboredbreathing

Diffusion
themixingofmoleculesorionsoftwoormoresubstancesasaresultofrandommotion

Cheyne-Stokes respiration
respirationsrhythmicwaxingandwaningofrespirationsfromverydeepbreathingtoveryshallow
breathingwithperiodsoftemporaryapnea,oftenassociatedwithcardiacfailure,increasedintracranial
pressure,orbraindamage

Bronchoscopy
visualexaminationofthebronchiusingabronchoscope

Biot's respirations
shallowbreathsinterruptedbyapnea

When planning care, for which client would the nurse include close
observation for a decreased or absent cough reflex?
2.Theclientwithimpairmentofvagusnerveconduction
Thecoughreflexdependsuponnerveimpulsetransmissionviathevagusnervetothemedulla.Thenurse
mustmonitorclientswithvagusnerveimpairment(throughspinalcordinjury,trauma,CNSdepression,or
othermeans)foradecreasedorabsentcoughreflex.Thisdecreasedorabsentreflexplacestheclientat
highriskforaspirationordevelopmentofpneumoniaorotherrespiratoryinfections.

The client complains of difficulty breathing. Which of the following

assessment findings would the nurse commonly associate with that
complaint? (Select all that apply.)
1.Useofaccessorymuscles
2.Increasedrespiratorydepth
3.Increasedrespiratoryrate
4.Decreasedrespiratorydepth
:Rate,depth,anduseofaccessorymusclesoftenareassessmentfindingsindicatingdifficultybreathing.
Thedepthofrespirationscanbedeeper(tidalvolumegreaterthan500mLofair)ormoreshallowifpartial
obstructionispresentinconditionssuchasasthma.Rateisgenerallyincreased.

The client has been admitted with complaints of shortness of breath of

2 weeks duration and has received the nursing diagnosis Impaired Gas
Exchange. Which admission laboratory result would support the choice
of this diagnosis?
1.Increasedhematocrit
Hematocritisthepercentageofthebloodthatiserythrocytes,whichcontainthehemoglobinthatcarries
oxygen.Longtermhypoxiamayresultinthebody'sattempttoincreaseoxygencarryingcapacityby
increasingerythrocyteproduction.

BUN
measureofbloodureanitrogen,notoxygencarryingcapacity

The sedimentation rate

notadirectmeasureofoxygenation.

A client, diagnosed with chronic obstructive lung disease receiving

oxygen at 1.5 liters per minute via nasal cannula, is complaining of
shortness of breath. What action should the nurse take?
3.Havetheclientbreathethroughpursedlips.
Theclientshouldbetaughttobreatheoutagainstpursedlipstoincreasethetimeittakestoexhaleandto
helpkeepairwaysopen.
ThisclientshouldhavetheheadofthebedelevatedtoFowler'spositionorshouldbeassistedtoleanover
theoverbedtabletoincreasechestexcursion.
Chronicobstructivelungdiseasemakesitdifficultfortheclienttobreatheout,soincreasingrateof
respirationswillnotbehelpful.

After learning of a terminal illness and life expectancy, the client

begins to hyperventilate and complains of being light-headed with the
fingers, toes, and mouth tingling. What action should be taken by the
nurse?
2.Havetheclientconcentrateonslowingdownrespirations.
Thisclientishyperventilatingandshouldbeassistedtoslowdownrespirations.Techniquestoslow
respirationsincludecountingrespirationsorhavingtheclientmatchrespirationswiththenursewhothen
slowsdowntherespiratoryrate.
Demerolmayslowbreathing,butisnotnecessaryatthistime.

The client is experiencing severe shortness of breath, but is not

cyanotic. What lab value would the nurse review in an attempt to
understand this phenomenon?
2.Hemoglobinandhematocrit
Inordertoexhibitcyanosis,theclient'sbloodmustcontainabout5gormoreofunoxygenatedhemoglobin
per100mLofbloodandthesurfacebloodcapillariesmustbedilated.Severeanemiawillinterferewiththe
developmentofcyanosis,sothenurseshouldreviewthehemoglobinandhematocrit.

The client has a 20-year history of asthma with chronic hypoxia. Which
change in the client's fingers would the nurse expect?
Clubbing
Rationale:Clubbingistheincreaseintheanglebetweenthenailandthebaseofthenailtomorethan180
degrees.Thebaseofthenailbecomesswollenandtheendsofthefingersincreaseinsize.Clubbingisa
classicsignofchronichypoxia.

The client has a medical condition that often results in the

development of metabolic acidosis. The nurse should observe this
client for the development of which breathing pattern as a result of this
condition?

4.Kussmaul's
Kussmaul'srespirationsareatypeofhyperventilationthataccompaniesmetabolicacidosis.Theyrepresent
thebody'sattempttocompensatefortheacidosisby"blowingoff"carbondioxide.

Cheyne-Stokes respirations are commonly a result of

congestiveheartfailure,
increasedintracranialpressure,
drugoverdose.

Biot's respirations are often the result of

centralnervoussystemdisorders

Cluster respirations are often the result of

centralnervoussystemdisorders.

Upon assessment, the nurse notes that the client is dyspneic, has
bibasilar crackles, and tires easily upon exertion. Which nursing
diagnosis is best supported by these assessment details?
3.IneffectiveAirwayClearance
ThedatagivenforthisclientbestsupportthenursingdiagnosisofIneffectiveAirwayClearance.Themost
supportivefindingforthisdiagnosisisbibasilarcrackles.

The client is hypoxic according to arterial blood gas measurement.

What nursing diagnosis problem statement is most appropriate for this
client?
ImpairedGasExchange
Rationale:TheonlynursingdiagnosissupportedbyhypoxiaastheonlyfindingisImpairedGasExchange.
TheclientmayhaveothernursingdiagnosessuchasIneffectiveBreathingPatternorIneffectiveAirway
Clearance,butthosediagnosesarenotsupportedbythefindingsinthisscenario.

The nurse encourages the client to expectorate sputum rather than

swallowing it. What is the rationale for this direction?
3.Thenurseshouldviewthesputumforqualityandquantity.

The nurse is planning a time schedule for a client's twice-daily postural

drainage. Which time schedule would be best?
3.0700and2000
Posturaldrainageshouldbescheduledtoavoidhoursshortlyaftermealsbecausethetreatmentmayinduce
vomitingandcanbeverytiringfortheclient.Oftheoptionsoffered,theonethattakesintoconsideration
themealscheduleandismostwidelydistributedis0700and2000.

The client is receiving oxygen by nonrebreather mask, but the bag is

not deflating on inspiration. What action should be taken by the nurse?
Increasetheliterflowofoxygenbeingdelivered.

Acidosis Respiratory
pHPaCO2

The pH is a measurement of the

acidityoralkalinityoftheblood.
Itisinverselyproportionaltothenumberofhydrogenions(H+)intheblood.ThemoreH+present,the
lowerthepHwillbe.
Likewise,thefewerH+present,thehigherthepHwillbe.ThepHofasolutionismeasuredonascale
from
1(veryacidic)to14(veryalkalotic).AliquidwithapHof7,suchaswater,is
neutral(neitheracidicnoralkalotic).

Medications that can decrease rate and depth of respirations

Benzodiazepinesedativehypnotics
antianxietydrugs:
diazepam,(Valium)
lorazepam(Ativan)
midazolam(Versed)
Barbituatiates(phenobarbital)
narcoticsmorphine&meperidinehydrochloride(Demerol)
Whenadministeringthese,thenursemustmonitorrespiratorystatus,especiallywhenbeginningthemedor
increasingdose.
Olderclients=highriskfordepressionofrespiratoryrequirereduceddosages.

The nurse is documenting the completion of tracheostomy suctioning

and tracheostomy care in a client's medical record. What should this
documentation include?
1.Lungsoundsbeforeandaftersuctioning.
2.Characteristicsofsuctionedsputum.
3.Integrityoftheskinaroundthestoma.
4.Typeoftracheostomytiesused.
5.Flowrateofoxygen.

The nurse has completed nasopharyngeal suctioning of a client. What

should the nurse document about this procedure?
1.Amount,consistency,color,andodorofsputum.
3.Lungsoundsbeforetheprocedure.
4.Lungsoundsaftertheprocedure.
5.Oxygensaturationaftertheprocedure.

The nurse wants to delegate the Yankauer suctioning of a client to UAP.

What will the nurse ensure that UAP know before delegating this
activity?
2.Nottoapplysuctionduringtheinsertionofthecatheter.
OralsuctioningusingaYankauersuctiontubecanbedelegatedtoUAP,sincethisisnotasterile
procedure.Thenurseneedstoreviewtheprocedureandimportantpoints,suchasnotapplyingsuction
duringinsertionofthetubetoavoidtraumatothemucousmembrane.

When conducting nasotracheal suctioning of a client, what will the

nurse do?
1.Applysuctionfor510seconds.

The nurse documents that a prescribed expectorant has been effective

for a client. What did the nurse evaluate in this client?
4.Presenceofaproductivecough.

Which client statement indicates to the nurse that instruction about

the use of a humidifier has been effective?
3."Ahumidifierpreventsmylungsfromgettingtoodry."
Thepurposesofhumidifiersaretopreventmucousmembranesfromdryingandbecomingirritatedandto
loosensecretionsforeasierexpectoration.

What will the nurse instruct a client to do to promote a healthy

respiratory status?
2.Exerciseregularly.
3.Donotsmoke.
4.Breathethroughthenose.

pursed-lip breathing.
Thistechniqueisforaclientwithalungdisordersuchaschronicobstructivelungdiseaseoremphysema.

The nurse is conducting a health history for a client with a respiratory

disorder. What will be included in this assessment?
1.Lifestyle.
2.Presenceofcough.
3.Sputumproduction.
4.Pain.

A client is diagnosed with congestive heart failure. The nurse will

assess the client for which condition that can alter this client's
respiratory function?
2.Conditionthataffectstransport.
:Onceoxygenmovesintothelungsanddiffusesintothecapillaries,thecardiovascularsystemtransports
theoxygentoallbodytissues,andtransportsCO2fromthecellsbacktothelungs,whereitcanbeexhaled
fromthebody.Conditionsthatdecreasecardiacoutput,suchascongestiveheartfailureorhypovolemia,
affecttissueoxygenationandalsothebody'sabilitytocompensateforhypoxemia.

While assessing an older client, the nurse will keep in mind what
effects that aging has on respiratory function?
1.Decreasedcoughreflex.
4.Drymucousmembranes.
5.Increasedriskofaspiration.
Thecoughreflexdecreasesduringaging.
Increasedriskofaspirationoccursinagingbecauseofgastroesophagealrefluxdisease.
:Mucousmembranesaredrierwithaging.

An older client is prescribed diazepam (Valium). What will the nurse

assess in this client?
Respirations.
Medicationssuchasdiazepam(Valium)candecreasetherateanddepthofrespirations.Olderclientsareat
highriskofrespiratorydepression.Thenursemustcarefullymonitorrespiratorystatusinthisclient.

A client's blood gas results reveal a low oxygen level. The nurse
realizes that which area of the body will respond to this level and
influence respirations?
Carotidbodies.
SpecialneuralreceptorssensitivetodecreasesinO2concentrationarelocatedoutsidethecentralnervous
systeminthecarotidbodies,justabovethebifurcationofthecommoncarotidarteries,andaorticbodies
locatedaboveandbelowtheaorticarch.Decreasesinarterialoxygenconcentrationsstimulatethese
chemoreceptors,andtheyinturnstimulatetherespiratorycentertoincreaseventilation.

A client's blood gas analysis results show an increase in carbon dioxide

level. What will the nurse most likely assess in this client?
Increasedrespirationrate.
Ofthethreebloodgaseshydrogen,oxygen,andcarbondioxidethatcantriggerchemoreceptors,
increasedcarbondioxideconcentrationnormallyhasthestrongesteffectonstimulatingrespiration.

An increase in carbon dioxide level

willincreaserespirations.

The nurse is determining a client's ability to transport oxygen from the

lungs to body tissues. What factors will influence this ability?
1.Cardiacoutput.
2.Exercise
3.Erythrocytecount.
4.Hematocrit.

1.
2.
3.
4.

Cardiac output.
Exercise
Erythrocyte count.
Hematocrit.

affectstherateofoxygentransportfromthelungstothetissues.

A client is demonstrating signs of hypoxia. What laboratory value will

help the nurse determine the client's degree of effective gas
exchange?
Arterialbloodgas
Bloodforpartialpressuresorbloodgasesareusuallyobtainedfromarterialblood.

A client is experiencing atelectasis. The nurse anticipates that this

client will have an alteration in:

Ventilation.
Atelectasisaffectslungcompliance,whichisaconditionthatneedstobepresentforadequateventilation.

Alveolar gas exchange

isthediffusionofoxygenfromthealveoliandintothepulmonarybloodvessels,andoccursafter
ventilation.

: Systemic diffusion of oxygen and carbon dioxide

occursbetweenthecapillariesandthetissuesandcells.

A client who was a victim of a house fire is coughing. The nurse

realizes that the purpose of the cough is to:
Removeirritantsfromthetracheaorbronchi
Thetracheaandbronchiarelinedwithmucosalepithelium.Thesecellsproduceathinlayerofmucusthat
trapspathogensandmicroscopicparticulatematter.Theseforeignparticlesarethensweptupwardtoward
thelarynxandthroatbycilia.Thecoughreflexistriggeredbyirritantsinthelarynx,trachea,orbronchi.

The client complains of difficulty breathing. What will the nurse most
likely assess in this client?
1.Useofaccessorymuscles.
2.Increasedrespiratorydepth.
3.Increasedrespiratoryrate.
4.Decreasedrespiratorydepth.

The depth of respirations can be deeper (tidal volume greater than 500
mL of air) or more shallow
ifpartialobstructionispresentinconditionssuchasasthma.Respiratoryrateisgenerallyincreased.

The client has been prescribed both a bronchodilator and a steroid

medication that is delivered by inhaler. What information is essential to
teach this client in regard to these medications?
Bothmedicationshavethepossiblesideeffectofincreasedheartrate.

It is imperative for the client to understand that the steroid inhaler

isnota"rescue"inhalerandshouldnotbeusedforimmediaterelief.

When the inhalers are used together : bronchodilator and a steroid

medication
thebronchodilatorisusedfirst,followedbythesteroid.

As a part of preoperative teaching, the nurse is instructing the client on

the use of a volume-oriented incentive spirometer. Which instruction
should be included in this teaching? (Select all that apply.)
Closeyourlipstightlyaroundthemouthpiece.
Useanosecliptooccludenasalpassagesifnecessary.

Coughafterusingthedevice.
Thevolumeorientedincentivespirometerworksbestwhentheclientclosesthelipsaroundthemouthpiece
tightly,inhalesslowlyanddeeplytoachieveriseintheenclosedcylinder,andkeepsthedevicelevel.A
noseclipmaybeusedtooccludenasalpassagesiftheclienthasdifficultybreathingonlythroughthenose.
Theclientshouldalsobetaughttocoughafterusingthedevice.

The client who is being mechanically ventilated has copious amounts

of secretions ranging from thick and tenacious to frothy. In preparing to
suction this client the nurse should:
Avoidhyperventilationandincreasetheoxygento100%forseveralbreaths.

During tracheal suctioning, the nurse notes that the client' heart rate
has increased from 80 to 100 bpm. Based upon this assessment, what
action should the nurse take?
Completethesuctionepisodeasquicklyaspossible
Anincreaseinheartratefrom80to100isnotanunusualfindingduringsuctioning,butdoesindicate
increasedstressontheclient.Thenurseshouldcompletethesuctioningepisodeasquicklyaspossible.

The nurse is planning the care of a client who has need for frequent
suctioning. Which of the following should the nurse delegate to the
UAP?
Onlyoralsuctioning
ThesuctioningoftheoralcavityisanonsterileprocedureandcanbedelegatedtotheUAP.

The nurse who is performing care for a client with a new tracheostomy
needs to change the ties. What is the best method for changing these
ties?
Haveanassistantholdthetracheostomytubeinplace,removethesoiledties,andreplacetheties.

The nurse has just initiated oxygen by nasal cannula for a client with
the medical diagnosis of chronic obstructive pulmonary disease. What
is the nurse's next action?
Padthetubingwhereitcontactstheclient'sears.
Thehumidifiershouldbefilledwithwaterpriortoinitiatingtherapy
Itisnecessarytopadthecannulawhereitcontactstheclient'searsaspressureirritationmayoccur.
Sincethisclienthaschronicobstructivepulmonarydisease,theoxygenshouldbesetatalowerdelivery
rate(generallynomorethan1.5to2Lpm).
Thecannuladoesnotrequiretiestosecure.

The client who has a nasotracheal tube in place has been restless and
pulling at the tube. How would the nurse assess if the tube is still in
place?
Auscultateforbilateralbreathsounds.
Theendoftheendotrachealtubeshouldsitjustabovethebifurcationofthetracheaintothetwomainstem
bronchi.Ifthetubeisincorrectposition,thenurseshouldbeabletohearequalbilateralbreathsounds.

Deflating the cuff and listening for minimal leak is a way to

preventdamagetothetrachea,notawaytoassessplacement.

The nurse has completed discharge teaching for a client who will be
going home on oxygen therapy. What statement, made by the client,
would indicate that this client needs further instruction?
"Iwillreplacemycottonblanketswithpolyesterones."
Polyesterblanketsandfabricstendtoproducestaticelectricity,whichcancausesparksandcancause
oxygensaturatedfabricstoburnmorereadily.

The nurse is preparing to assist with the removal of a chest tube that is
a simple insertion without a purse-string suture. What materials should
the nurse gather for this procedure?
Anocclusivedressing
Sincethischesttubewasputinwithoutapursestringsuture,thereisnothingtopullthetissuetogether
oncethetubeisremoved.Inordertopreventleakageofairintothechestcavity,anocclusivedressingmust
beused.

The nurse who is assessing a client's chest tube insertion site notices a
fine crackling sound and feeling upon palpating the area. What action
should the nurse take?
Collaboratewiththeclient'sphysician

The nurse needs to hyperinflate a client prior to suctioning. How should

the nurse proceed with this requirement?
Provide2to3breathsat1.5timesthetidalvolumepriortosuction.
Thenurseshouldprovide2to3breathsat1.5timestheclient'snormaltidalvolumepriortoandafter
insertionofthesuctioncatheter.

A client has a newly created tracheostomy for mechanical ventilation

after a surgical procedure. What action should the nurse plan for this
client?
Tapethetracheostomyobturatortotheheadofthebed.
Theobturatorshouldbetapedtotheheadofthebedsothatitwillbereadilyavailableiftheclient
tracheostomytubeshouldbecomedislodged.

The nurse has placed an oropharyngeal airway in a client. What action

should the nurse take at this time?
Turntheclient'sheadtotheside
Thenurseshouldturntheclient'sheadtothesidetoallowdrainageoforalsecretions.

The client is receiving oxygen by nonrebreather mask, but the bag is

not deflating on inspiration. What action should be taken by the nurse?
Increasetheliterflowofoxygenbeingdelivered.

Rationale4:Ifthebagattachedtothenonrebreathermaskisnotdeflatingoninspiration,thenurseshould
increasetheliterflowoftheoxygenbeingdelivered.

Normal Values of ABG's

pH:7.357.45
PaO2:80100mmHg
PaCO2:3545mmHg
HCO3:2226mEq/L
Baseexcess2to+2mEq/L
O2saturation:9598%

pH less tha
...

Ventilation
Movementofairintoandoutofthelungs
Deliveryoffreshairtothelung'saveoli
Regulatedbythemedulla(respiratorycontrolcenter)

Alveolar Gas Exchange

Oxygenuptake(externalrespiration)istheexchangeofoxygenfromthealveolarspaceintothe
pulmonarycapillaryblood.
Carbondioxidediffusesfromthebloodtothealveolarspace.

Cellular Respiration (internal respiration)

Oxygendiffusesfromthebloodtothetissues
CO2diffusesmovesfromthetissuestotheblood
Thebloodisthenreoxygenated.

Oxygen transport and delivery

Oxygentransportintheblood
PaO2O2dissolvedintheplasma,normalPaO2ofarterialbloodis80100mmHg
SaO2amountofO2boundtothehgb.AlsocalledO2saturation(92%to100%)
O2isdeliveredtothecellsbyprocessofcirculationtheheartpumpsoxygenatedbloodtothecells

Factors Affecting Oxygenation

Age
Environmentalandlifestylefactors
DiseaseProcesses
Obstructivepulmonarydisease
Restrictivepulmonarydisease:pneumonia,pulmonaryfibrosis(scarring),traumaticinjurytothethorax.
Diffusiondefects:decreaseintheefficiencyofgasdiffusionfromthealveolarspaceintothepulmonary
capillaryblood.
Ventilationperfusionmismatching
Atherosclerosis
HeartFailure
AnemiaAlterationsinoxygenuptake(cyanidepoisoningandseveresepsis)

Assessment

HealthHistory
Thehealthhistoryshouldbeginwithathoroughexplorationofthepresentingproblem;askhowlonghasit
beenpresentandifithasgottenworse
Explorethemedicalhistory,impactofillnessonactivitiesofdailyliving,client'sknowledgeleveland
copingabilities
PhysicalExamination
Generalobservationofclient'seffortsatventilation
Countrespiratoryrate,notetherhythm
Signsofhypoxiacyanosis,clubbingoffingers
Adventitiousbreathsoundscrackles,rhonchi,wheezes,pleuralfrictionrub,stridor
DiagnosticandLaboratoryData
Pulseoximetry
Arterialbloodgases(ABGs)
Lacticacid,H&H
Sputumcollection
Ventilatoryfunctiontests
Chestxray
Computerizedtomography,MRI
Bronchoscopy,thoracentesis
Ekg,echo,stresstest

Signs of Hypoxia
Mentalstatuschangesareoftenthefirstsignsofrespiratoryproblemsandmayincluderestlessnessand
irritability.
Cyanosisisalatesignofhypoxia.Centralcyanosisisthemostseriousfindingbecauseitindicates
hypoxemia
Centralcyanosisisobservedinthetongue,softpalate,andconjunctivaoftheeye,wherebloodflowishigh

Nursing Diagnosis
PrimaryNursingDiagnoses:
IneffectiveAirwayClearance
IneffectiveBreathingPatterns
ImpairedGasExchange
DecreasedCardiacOutput
AlteredTissuePerfusion
SecondaryNursingDiagnoses:
KnowledgeDeficit
ActivityIntolerance
SleepPatternDisturbance
AlteredNutrition
Pain
Anxiety

Goals
Thegoalsshouldbeindividualizedtoreflecttheclient'scapabilitiesandlimitations.
Outcomesmaybebasedonphysiologicalparameterssuchasrespiratoryrateorarterialbloodgasvalues
Theoutcomesshouldbebasedupontheassessmentfindingsthatledtothenursingdiagnosesathand

Nursing interventions

Interventionstopromoteairwayclearance
Teacheffectivecoughing
Initiateposturaldrainageandchestphysiotherapy
Monitorhydration
Administermedications
Monitorenvironmentalandlifestyleconditions
Suctiontheairway
Teachcontrolledbreathingexercises
InterventionstoimproveO2uptakeanddelivery
Administeroxygen
Administerbloodcomponents
Interventionstoincreasecardiacoutputandtissueperfusion
Managefluidbalance
Suggestactivityrestrictionsandassistancewithactivitiesofdailyliving
Positionclientproperly
Administermedications
RestorationofcardiopulmonaryfunctioningCPR(rememberABC!!)

The nurse caring for the client with a nasal cannula should plan to
assess the client's
naresandsuperiorsurfaceofbothearsforskinbreakdownevery6hours.

Implementation: Health Promotion

Bodyweight
Diet
Exercise
Stressreduction
Occupationalsafety
Smokefree
Regularphysicalexams
Vaccinations/immunizations
Influenza
pneumonia

Implementation: Restorative Care

Hydration
Coughingtechniques
Respiratorymuscletraining
Breathingexercises

Evaluation
Inmanyinstances,theevaluationofthesuccessofthespecificinterventionswillbebasedonthedegreeto
whichtheclientisorcanbereturnedtoasatisfactorystateofrespiratoryfunction

A person who starts smoking in adolescence and continues to smoke

into middle age:
Hasanincreasedriskforcardiopulmonarydiseaseandlungcancer

Carbon monoxide (CO) is a toxic inhalant that decreases the oxygencarrying capacity of blood by:
Formingastrongbondwithhemoglobin

Conditions such as shock and severe dehydration resulting from

extracellular fluid loss cause:
Hypovolemia

Fever increases the tissues' need for oxygen, and as a result:

Carbondioxideproductionincreases

Left-sided heart failure is characterized by:

Decreasedfunctioningoftheleftventricle

Cyanosis, the blue discoloration of the skin and mucous membranes

caused by the presence of desaturated hemoglobin in capillaries, is:
Alatesignofhypoxia

A simple and cost-effective method for reducing the risks of stasis of

pulmonary secretions and decreased chest wall expansion is:
Frequentchangeofposition

The nurse is concerned when a client's heart rate, which is normally 95

beats per minute, rises to 220 beats per minute, because a rate this
high will:
Reducecoronaryarteryperfusion

A client is admitted to the emergency department with a suspected

cervical spine fracture at the C3 level. The nurse is most concerned
about the client's ability to:
Breathe

When suctioning secretions that are collecting in an endotracheal tube,

the nurse does not apply suction for longer than:
15seconds

The nurse is caring for a client with a chest tube in the right thorax. On
first assessment the nurse notes that there is bubbling in the waterseal chamber. This client is scheduled to undergo a chest x-ray
examination, and the transporters have arrived to take him by
wheelchair to the radiology department. The nurse considers whether
the chest tube should be clamped or not during the trip to the
radiology department. The nurse makes the which correct decision?
Donotclampthechesttubeanddisconnectitfromthewallsuction.

A client is receiving oxygen via a nonrebreathing mask. A crucial

nursing assessment the nurse performs is to be sure that:

Thebagattachedtothemaskisinflatedatalltimes

A client with known chronic obstructive pulmonary disease (COPD) is

admitted to the emergency department with multiple minor injuries
following an automobile accident. To ensure adequate ventilation the
nurse applies a nasal cannula providing oxygen at what rate and for
what reason?
2L/mintopreventelevatingthearterialoxygentension(PaO2),whichwouldsuppressthehypoxicdrive

The nurse is caring for a client who has undergone cardiac

catheterization. The client says to the nurse, "The doctor said my
cardiac output was 5.5 L/min. What is normal cardiac output?" Which of
the following is the nurse's best response?
"Thenormalcardiacoutputforanadultis4to6L/min."

Which of these statements is true regarding the vertebra prominens?

The vertebra prominens is:
thespinousprocessofC7

When performing a respiratory assessment on a patient, the nurse

notices a costal angle of approximately 90 degrees. This characteristic
is:
anormalfindinginahealthyadult

When assessing a patient's lungs, the nurse recalls that the left lung:
consistsoftwolobes

Which statement about the apices of the lungs is true? The apices of
the lungs:
extend3to4cmabovetheinnerthirdoftheclavicles

During an examination of the anterior thorax, the nurse keeps in mind

that the trachea bifurcates anteriorly at the:
sternalangle

During an assessment, the nurse knows that expected assessment

findings in the normal adult lung include the presence of:
muffledvoicesoundsandsymmetricaltactilefremitus

The primary muscles of respiration include the:

diaphragmandintercostals

A 65-year-old patient with a history of heart failure comes to the clinic

with complaints of "being awakened from sleep with shortness of
breath." Which action by the nurse is most appropriate?
Assessforothersignsandsymptomsofparoxysmalnocturnaldyspea.

When assessing tactile fremitus, the nurse recalls that it is normal to

feel tactile fremitus most intensely over which locations?
betweenthescapulae

The nurse is reviewing the technique of palpating for tactile fremitus

with a new graduate. Which statement by the graduate nurse reflects a
correct understanding of tactile fremitus? "Tactile fremitus:
iscausedbysoundsgeneratedfromthelarynx.

During precussion, the nurse knows that a dull percussion note elicited
over a lung lobe most likely results from:
increaseddensityoflungtissue

The nurse is observing the auscultation technique of another nurse.

The correct method to use when progressing from one auscultatory site
on the thorax to another is _____ comparison.
sidetoside

When auscultating the lungs of an adult patient, the nurse notes that
over the posterior lower lobes low-pitched, soft breath sounds are
heard, with inspiration being longer than expiration. The nurse
interprets that these are:
vesicularbreathsoundsandarenormalinthatlocation.

The nurse is auscultating the chest in an adult. Which technique is

correct?
Usethediaphragmofthestethoscopeheldfirmlyagainstthechest.

The nurse is percussing over the lungs of a patient with pneumonia.

The nurse knows that percussion over an area of atelectasis in the
lungs would reveal:
dullness

During auscultation of the lungs, the nurse expects decreased breath

sounds to be heard in which situation?
Whenthebronchialtreeisobstructed

The nurse notes hyperresonant percussion tones when percussing the

thorax of an infant. The nurse's best action would be to:
considerthisanormalfinding

The nurse knows that a normal finding when assessing the respiratory
system of an elderly adult is:
decreasedmobilityofthethorax

A mother brings her 3-month-old infant to the clinic for evaluation of a

cold. She tells the nurse that he had "a runny nose for a week." When

performing the physical assessment, the nurse notes that the child has
nasal flaring and sternal and intercostal retractions. The nurses next
action should be to:
recognizethattheseareserioussignsandcontactthephysician

When assessing the respiratory system of a 4-year-old child, which of

these findings would the nurse expect?
Thepresenceofbronchovesicularbreathsoundsintheperipherallungfields

When inspecting the anterior chest of an adult, the nurse should

include which assessment?
Theshapeandconfigurationofthechestwall.

The nurse knows that auscultation of fine crackles would most likely be
noticed in:
theimmediatenewbornperiod

During an assessment of an adult, the nurse has noted unequal chest

expansion and recongnizes that this occurs in which situation?
Whenpartofthelungisobstructedorcollapsed

During auscultation of the lungs of an adult patient, the nurse notices

the presence of bronchophony. The nurse should assess for signs of
which conditions?
Pulmonaryconsolidation

The nurse is reviewing the characteristics of breath sounds. Which

statement about bronchovesicular breath sounds is true? They are:
expectednearthemajorairways

The nurse is listening to the breath sounds of a patient with severe

asthma. Air passing through narrowed bronchioles would produce
which of these adventitious soudns?
Wheezes

A patient has a long history of chronic obstructive pulmonary disease.

During the assessment, the nurse is most likely to observe which of
these?
Ananteroposteriortotransversediameterratioof1:1

A teenage patient comes to the emergency department with

complaints of an inability to breathe and a sharp pain in the left side of
his chest. The assessment findings include cyanosis, tachypnea,
tracheal deviation to the right, decreased tactile fremitus on the left,
hyperresonance on the left, and decreased breath sounds on the left.
The nurse interprets that these assessment findings are consistent
with:

apneumothorax

An adult patient with a history of allergies comes to the clinic

complaining of wheezing and difficulty in breathing when working in his
yard. The assessment findings include tachypnea, use of accessory
neck muscles, prolonged expiration, intercostal retractions, decreased
breath sounds, and expiratory wheezes. The nurse interprets that
these assessment findings are consistent with:
asthma

The nurse is assessing the lungs of an older adult. Which of these

describes normal changes in the respiratory system of the older adult?
Thelungsarelesselasticanddistensible,whichdecreasestheirabilitytocollapseandrecoil.

A woman in her 26th week of pregnancy states that she is "not really
short of breath" but feels that she is aware ofher breathing and the
need to breathe. What is the nurse's best reply?
"Whatyouareexperiencingisnormal.Somewomenmayinterpretthisasshortnessofbreath,butitisa
normalfindingandnothingiswrong."

When considering the biocultural differences in the respiratory

systems, the nurse knows that which statement is true?
Thelargestchestvolumesarefoundinwhites

A 35-year-old recent immigrant is being seen in the clinic for

complaints of a cough that is associated with rust-colored sputum, lowgrade afternoon fevers, and night sweats for the past 2 months. The
nurse's preliminary analysis, based on this history, is that this patient
may be suffering from:
tuberculosis

A 70-year-old patient is being seen in the clinic for sever exacerbation

of his heart failure. Which of these findings is the nurse most likely to
observe in this situation?
Shortnessofbreath,orthopnea,paroxysmalnocturnaldyspnea,andleadema

A patient comes to the clinic complaining of a cough that is worse at

night but not as bad during the day. The nurse recongnizes that this
may indicate:
postnasaldriporsinusitis

During a morning assessment, the nurse notices that the patient's

sputum is frothy and pink. Which condition could this finding indicate?
Pulmonaryedema

During auscultation of breath sounds, the nurse should use the

stethoscope correctly, in which of the following ways?

Listentoatleastonefullrespirationsineachlocation

A patient has been admitted to the emergency department with a

possible medical diagnosis of pulmonary embolism. The nurse expects
to see which assessments findings related to this condition?
Chestpainthatisworseondeepinspiration,dyspnea

During palpation of the anterior chest wall, the nurse notices a coarse,
crackling sensation over the skin surface. On the basis of these
findings, the nurse suspects:
crepitus

The nurse is auscultating the lungs of a patient who had been sleeping
and notices short, popping, crackling sounds that stop after a few
breaths. The nurse recongnizes that these breath sounds are:
atelectaticcrackles,andthattheyarenotpathologic.

A patient has been admitted to the emergency department for a

suspected drug overdose. his respirations are shallow, with an irregular
patter, with a rate of 12 per minute. The nurse interprets this
respiration pattern as which of the following?
Hypoventilation

A patient with pleuritis has been admitted to the hospital and

complaints of pain with breathing. What other key assessment finding
would the nurse expect to find upon auscultation?
Frictionrub

The nurse is assessing voice sounds during a respiratory assessment.

Which of these findings indicates a normal assessment? Select all that
apply
Voicesoundsarefaint,muffled,andalmostinaudiblewhenthepatientwhispers"one,two,three"inavery
softvoice
Whenthepatientspeaksinanormalvoice,theexaminercanhearasoundbutcannotdistinguishexactly
whatisbeingsaid.
Asthepatientsaysalong"eeeeee"sound,theexamineralsohearsalong"eeeeee"sound.

While preparing the client for a colonoscopy, the nurse's

responsibilities include:
Explaining the risks and benefits of the exam
Instructing the client about the bowel preparation prior to the test
Instructing the client about medication that will be used to sedate the
client
Explaining the results of the exam
Instructingtheclientaboutthebowelpreparationpriortothetest

A certified nursing assistant is collecting a 24-hour urine specimen

from a client. Which statement by the assistant indicates that the
specimen collection will need to be restarted?
"I used a container from the lab that has a preservative in it."
"The client voided in it right away, and I wrote the time on the
container."
"I have the container in a plastic bucket with ice in it."
"I told the client that every single urination must be put in the
container. If one is missed, call one of us."
"Theclientvoidedinitrightaway,andIwrotethetimeonthecontainer."

A client is admitted with gastrointestinal bleeding. One of the earliest

and most important blood tests completed will be:
Electrolyte Panel
Arterial Blood Gases
Liver Panel
Complete Blood Count
CompleteBloodCount

A client is to obtain a clean-catch urine specimen. Which statement by

the client demonstrates a lack of understanding regarding the
procedure?
"I should use all of the towelettes in the kit and use each only once."
"Urinate into the cup as soon as I start to go."
"I don't have to fill the cup. Just get an ounce or two."
"Put the cover on right away, without touching the inside of the cover
or the cup."
"UrinateintothecupassoonasIstarttogo."

The nurse is having difficulty obtaining a capillary blood sample from a

client's finger to measure blood glucose using a blood glucose monitor.
Which procedure will increase the blood flow to the area to ensure an
adequate specimen?
Raise the hand on a pillow to increase venous flow.
Pierce the skin with the lancet in the middle of the finger pad.
Wrap the finger in a warm cloth for 30--60 seconds.
Pierce the skin at a 45-degree angle.
Wrapthefingerinawarmclothfor3060seconds.

A client has a streptococcal throat infection. The White Blood Cell count
is elevated. When looking at the differential, the nurse expects which
type of white blood cell to be elevated?

Open Hint for Question 6 in a new window.

Eosinophils
Monocytes
Lymphocytes
Neutrophils
Neutrophils
Neutrophilcountiselevatedwhenaclienthasastreptococcalinfection.
Eosinophilcountiselevatedinallergicreactions
Monocytecountiselevatedinchronicinflammatorydisorders.Lymphocytecountiselevatedinviral
infections.

A client is to have a thoracentesis in order to aspirate pleural fluid for

biopsy. In order to prepare the client for the procedure, the nurse best
positions the client in which manner?
Lying in a lateral position with the affected lung down and back, curved
into a fetal position. The head is supported with a pillow. The arms are
positioned comfortably away from the chest wall.
Lying in a 10-degree reverse Trendelenburg position with the arms over
the head. Small pillows allowed under the head and arms.
Sitting in a Fowler's position with the arms abducted and supported by
pillows placed on each side of the body. The head is lying flat against
the mattress.
Sitting on the side of the bed, leaning over a bedside table with a
pillow on it, arms overhead supported by the pillow
Sittingonthesideofthebed,leaningoverabedsidetablewithapillowonit,armsoverheadsupportedby
thepillow

A nurse cares for a client following a liver biopsy. Which nursing care
plan reflects proper care?
Position in a dorsal recumbent position, with one pillow under the head
Bed rest for 24 hours, with a pressure dressing over the biopsy site
Position to a right side-lying position, with a pillow under the biopsy
site
Neurological checks of lower extremities every hour
Positiontoarightsidelyingposition,withapillowunderthebiopsysite

A client reports an iodine allergy. This information is most significant if

the client is scheduled for which exam?
Lung Scan
Computed Tomography
Magnetic Resonance Imaging
Intravenous Pyelogram

IntravenousPyelogram

Following a gastroscopy, a client asks for something to eat. The nurse

correctly responds:
"I will first check your gag reflex."
"I will first listen for bowel sounds."
"I will first have you cough and deep-breathe."
"I will first listen to your lungs."
"Iwillfirstcheckyourgagreflex."

The nurse would call the primary care provider immediately for which
laboratory result?
Hgb = 16 g/dL for a male client.
Hct = 22% for a female client.
WBC = 9 x 10/mL
Platelets = 300 x 10/mL
Hct=22%forafemaleclient.

A 78-year-old male client needs to complete a 24-hour urine specimen.

In planning his care, the nurse realizes that which measure is most
important?
Instruct the client to empty his bladder and save this voiding to start
the collection.
Instruct the client to use sterile individual containers to collect the
urine.
Post a sign stating "Save All Urine" in the bathroom.
Keep the urine specimen in the refrigerator.
Postasignstating"SaveAllUrine"inthebathroom.
Option3isthemostimportantnursingmeasure.Thiswillinformthestaffthattheclientisona24hour
urinecollection.Option1isnotappropriatesincethefirstvoidedspecimenistobediscarded.Option2is
notanappropriatenursingmeasuresincethespecimencontaineriscleannotsterile,andonecontaineris
needednotindividualcontainers.Option4isinappropriatebecausesome24hoururinecollectionsdonot
requirerefrigeration.

The client has a urinary health problem. Which procedure is performed

using indirect visualization?
Intravenous pyelography (IVP)
Kidneys, ureter, bladder (KUB)
Retrograde pyelography
Cystoscopy
Kidneys,ureter,bladder(KUB)
AKUBisanxrayofthekidneys,ureters,andbladder.Thisdoesnotrequiredirectvisualization.Option1
isanIVP,anintravenouspyelogram,whichrequirestheinjectionofacontrastmedia.Option3isa

retrogradepyelography,whichrequirestheinjectionofacontrastmedia.Option4isacytoscopy,which
usesalightedinstrument(cystoscope)insertedthroughtheurethra,resultingindirectvisualization.

Which noninvasive procedure provides information about the

physiology or function of an organ?
Angiography
Computerized tomography (CT)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Positronemissiontomography(PET)
Rationale:Thistypeofnuclearscandemonstratestheabilityoftissuestoabsorbthechemicaltoindicate
thephysiologyandfunctionofanorgan.Option1isaninvasiveprocedurethatfocusesonbloodflow
throughanorgan.Options2and3provideinformationaboutdensityoftissuetohelpdistinguishbetween
normalandabnormaltissueofanorgan.

When assisting with a bone marrow biopsy, the nurse should take
which action?
Assist the client to a right side-lying position after the procedure.
Observe for signs of dyspnea, pallor, and coughing.
Assess for bleeding and hematoma formation for several days after the
procedure.
Stand in front of the client and support the back of the neck and knees.
Assessforbleedingandhematomaformationforseveraldaysaftertheprocedure.
Rationale:Bonemarrowaspirationincludesdeeppenetrationintosofttissueandlargebonessuchasthe
sternumandiliaccrest.Thispenetrationcanresultinbleeding.Theclientshouldbeobservedforbleeding
inthedaysfollowingtheprocedure.Option1isanursingactionduringaliverbiopsy.Option2isa
nursingactionforathoracentesis,andOption4isanursingactionforalumbarpuncture.

During an assessment, the nurse learns that the client has a history of
liver disease. Which diagnostic tests might be indicated for this client?
Select all that apply.
Alanine aminotransferase (ALT)
Myoglobin
Cholesterol
Ammonia
Brain natriuretic peptide or B-Type natriuretic peptide (BNP)
Alanineaminotransferase(ALT)
Ammonia
ALTisanenzymethatcontributestoproteinandcarbohydratemetabolism.Anincreaseintheenzyme
indicatesdamagetotheliver.
Thelivercontributestothemetabolismofprotein,whichresultsintheproductionofammonia.Iftheliver

isdamaged,theammonialevelisincreased.
Options2,3,and5(myoglobin,cholesterol,andBNP)arerelevantforheartdisease.

The nurse practitioner requests a laboratory blood test to determine

how well a client has controlled her diabetes during the past 3 months.
Which blood test will provide this information?
Fasting blood glucose
Capillary blood specimen
Glycosylated hemoglobin
GGT (gamma-glutamyl transferase)
Glycosylatedhemoglobin
Aglycosylatedhemoglobinwillindicatetheglucoselevelsforaperiodoftime,whichisindicatedbythe
nursepractitioner.
Options1and2willprovideinformationaboutthecurrentbloodglucosenotthepasthistory.Option4is
usedtoassessforliverdisease.

The client is supposed to have a fecal occult blood test done on a stool
sample. The nurse is going to use the Hemoccult test. Which of the
following indicates that the nurse is using the correct procedure?
Select all that apply.
Mixes the reagent with the stool sample before applying to the card.
Collects a sample from two different areas of the stool specimen.
Assesses for a blue color change.
Asks a colleague to verify the pink color results.
Asks the client if he has taken vitamin C in the past few days.
Collectsasamplefromtwodifferentareasofthestoolspecimen.
Assessesforabluecolorchange.
AskstheclientifhehastakenvitaminCinthepastfewdays.
Rationale:Thenurseshouldobtainthestoolspecimenfromtwodifferentareasofthestool.
Thenurseshouldobserveforabluecolorchange,whichisindicativeofapositiveresult.
ThenurseshouldassessfortheingestionofvitaminCbytheclientbecauseitiscontraindicatedfor3days
priortotakingthespecimen.
Option1isincorrectsincethereagentisplacedonthespecimenafteritisappliedtothetestingcard.
Option4isincorrectbecauseapinkcolorwouldbeconsiderednegativeanddoesnotrequireverification.

A primary care provider is going to perform a thoracentesis. The

nurse's role will include which action?
Place the client supine in the Trendelenburg position.
Position the client in a seated position with elbows on the overbed

table.
Instruct the UAP to measure vital signs.
Administer an opioid analgesic.
Positiontheclientinaseatedpositionwithelbowsontheoverbedtable.

The nurse needs to collect a sputum specimen to identify the presence

of tuberculosis (TB). Which nursing action(s) is/are indicated for this
type of specimen? Select all that apply.
Collect the specimen in the evening.
Send the specimen immediately to the laboratory.
Ask the client to spit into the sputum container.
Offer mouth care before and after collection of the sputum specimen.
Collect a specimen for 3 consecutive days.
Sendthespecimenimmediatelytothelaboratory.
Offermouthcarebeforeandaftercollectionofthesputumspecimen.
Collectaspecimenfor3consecutivedays.