Prepared by: Mark Francis S. De Vera 1.

When planning care for a client who has had a thyroidectomy, the nursing action that should be given highest priority during the first 24 hours postoperatively is: A. Humidifying the room air continuously B. Performing range-of-motion neck exercises q4h C. Assessing for hoarseness and voice weakness every two hours D. Checking vital signs every two hours after they have stabilized Answer: D. this help detect complication such as thyrotoxic crisis, hemorrhage and respiratory obstruction that occur early in the postoperative period A. This is contraindicated; humidifiers can contribute to the spread of bacteria and infection B. This should not begin until two to four days postoperatively because it can disrupt the suture line C. Hoarseness and voice weakness usually are temporary and not life threatening; the priority is to observe for thyroid storm, hemorrhage and respiratory obstruction 2. Nursing intervention for a client who is hyperventilating should focus on providing reassurance and: A. Administering oxygen B. Using an incentive spirometer C. Having the client breath into a paper bag D. Administering an IV containing bicarbonate ions Answer: C. Reassurance decreases anxiety and slows respiration; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to acid-base balance A. This is not necessary because there is no evidence of hypoxia B. This is used to prevent atelectasis D. The client is already alkalotic; bicarbonate ions would increase the porblem 3. When a client develops respiratory alkalosis, the nurse should expect the laboratory values to reflect: A. An elevated pH, elevated PCO2 B. A decreased pH, elevated PCO2 C. An elevated pH, decreased PCO2 D. A decreased pH, decreased PCO2 Answer: C. In respiratory alkalosis the pH level is elevated because of lodd of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation A. This is partially compensated metabolic alkalosis B. Same as answer A C. This is metabolic acidosis with some compensation 4. When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse should expect the client to mention symptoms associated with the classic signs of diabetes, such as: A. Polydipsia, Polyuria, irritability B. Polydipsia, ployhagia, Polyuria C. Polydipsia, nocturia, weight loss D. Polyphagia, diaphoresis, Polyuria Answer: B. Excessive thirst, excessive hunger, and frequent urination are caused by the bodys inability to correct metabolize glucose A. Lethargy, not irritability, result because of a lack metabolized glucose for energy C. Frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it; weight loss occurs with type 1 diabetes, not with type 2 diabetes D. Diaphoresis occurs with severe hypoglycemia 5. When obtaining the history of 24-year-old graduate student recently diagnosed with type 1 diabetes, the nurse would expect to identify the presence of: A. Edema B. Anorexia C. Weight loss D. Hypoglycemic episode Answer: C. Protein and lipid catabolism occurs because carbohydrates cannot be used by the cells; this result weight loss and muscle wasting A. Dehydration, not edema, would be more likely to occur because of the Polyuria associated with hyperglycemia B. Polyphagia, not anorexia, occurs with diabetes as the attempts to meet metabolic needs d. hyperglycemia no hypoglycemia is present in both type 1 and type 2 diabetes 6. A tuberculin skin test with purified protein derivative (PPD) tuberculin is performed as part of a routine physical examination. The nurse should instruct the client to make an appointment so the test can be in A. 3 days B. 5 days C. 7 days D. 10 days Answer: a. It takes this length of time for antibodies to respond to the antigen and form an indurated area b. This is longer than necessary; the site will reveal induration in two three days c. Same as answer B d. Same as answer B 7. A client is admitted with early heart failure. The statement by the client that is uniquely related to heart failure that the nurse would expect is: A. I see spot before my eyes. B. I am tired at the end of the day. C. I feel bloated when I eat a large meal. D. I have trouble breathing when I climb a fight of stairs. Answer: D. Dysnea on exertion occurs with heart failure because of the hearts inability to meet the oxygen need of the body tissue A. This is not specific to heart failure B. Same as answer A C. Same as answer A 8. A 76-year-old client is admitted with the diagnosis of mild chronic heart failure. The sounds indicative of chronic heart failure that the nurse expect to hear when listening to the clients lungs would be: A. Stridor B. Crackles C. Wheezes D. Friction rubs Answer: B. Left-sided heart failure causes fluid accumulation in the capillary network of the lung; fluid eventually enters alveolar spaces and causes crackling sound at the end of inspiration A. This is not heard in chronic heart failure; it is associated with tracheal constriction or obstruction C. This is not heard in chronic heart failure is is associated with asthma D. This is not heard ion chronic heart failure it is associated with pleurisy 9. When assessing a client with a diagnosis of left ventricular failure, the nurse should expect to find: A. Crushing chest pain B. Dyspnea on exertion C. Jugular vein distention D. Extensive peripheral edema Answer: B. Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing A. This is a hallmark of myocardial infarction; it is caused by inadequate oxygen supply to the myocardium C. This result from increased pressure in the right atrium associated with right ventricular failure D. This is sign of right, not left, ventricular failure; a weakened right ventricle causes venous congestion in the systemic circulation 10. To determine when a client who has had a subtotal gastrectomy can begin oral feedings after surgery, the nurse must assess for the: A. Presence of flatulence B. Extent of incisional pain C. Stabilization of hematocrit levels D. Occurrence of dumping syndrome Answer: A. Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the GI tract B. Incisional pain is unrelated to intestinal peristalsis C. Hematocrit levels indicate blood loss; they are unaffected by GI functioning D. Dumping syndrome occurs after, not before, the ingestion of food and would not be an indication of food and would not be an indication that the client was ready to ingest food. 11. An extremely obese client must self-administer insulin with an insulin syringe. The nurse should teach the client to: A. Pinch the tissue and inject at a 45-degree angle B. Pinch the tissue and inject at a 60- degree angle C. Spread the tissue and inject at a 45- degree angle D. Spread the tissue and inject at a 90-degree angle Answer: D. In the obese individual this help to inject the medication into subcutaneous tissue rather than adipose tissue, where its absorption would be poor

a. This will result in the drug being injected into adipose tissue, where it will be poorly absorbed b. Same as answer A c. Same as answer A 12. When preparing to assess the vagus nerve (Cranial nerve X) of a client, the nurse will need: A. A Tuning fork B. A tongue depressor C. An opthalmioscope D. Cotton and a straight pin Answer: B. These are used to depress the tongue to observe the pharynx and larynx, and to assess soft palate symmetry and the presence of the gag reflex; the information obtained provides date about cranial nerve X (vagus). A. This is used to assess cranial nerve VIII (auditory) C. This is used to assess cranial nerve II (optic) D. These are used to assess sensory function; that is light touch and pain. 13. A client with diagnosis of asthma is admitted to the hospital with respiratory distress. What type adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? a. Stridor b. Crackles c. Wheezes d. Diminished Rationale Answer: C Asthma is respiratory disorder characterized by recurring episodes of dyspnea, constriction of bronchi and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is harsh sound noted with an upper airway obstruction and often signal a life0threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sound are hear over lung tissue where poor oxygen exchange is occurring 14. A nursing is caring for a client who is suspected of having lung cancer. The nurse assesses the client for which most frequent early symptom of lung cancer? a. Hemoptysis b. Cough c. Hoarseness d. Pleuritic pain Rationale Answer B Cough is the most frequent symptoms of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has cough a change in the character and frequency of cough usually occurs. Wheezing and blood-streaked sputum( hemoptysis) are later sign. Pain is very late sign and is usually pleuritic pain in nature. Hoarseness indicate that the affected tissue is in the upper airway Cognitive level: applying References: ignativicius : patient centered collaborative care 6th ed p 643 15. A nurse is assessing a client with chronic airflow limitation and notes that the clients a hyperinflation of the alveoli and flattening of the diaphragm. The nurse interprets that this client has which of the following form of chronic airflow limitation? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis Rationale Answer: A The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm or Barrel chest. These lead to increased anteroposterior diameter, reffered to as barrel chest. The client also has dyspnea with prolonged expiration and has hyper resonant lungs to percussion Cognitive level: Analyzing Reference: copstead-kirkhorn L & Banasik j (2010) pathophysiology 4th ed 553 St. Louis mosby 16. A nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sound, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which of the following? a. A leak in the endotracheal tube cuff b. Displacement of the endotracheal tube c. A disconnection of the ventilator tubing d. A kink in the ventilator circuit

Rationale Answer:D A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the present amount. Cause of high-pressure alarm activation include excess secretions; mucous plugs; the clients biting on the endotracheal tube; kinks in the ventilator tubing; and the clients coughing, gagging or attempting to talk. Option A,B, C would trigger the low-pressure alarm Cognitive level understanding Reference: saunders 6th 695 17. A nurse is caring for a client with a chest tube drainage system. During reposition of the client, the chest tube accidentally pulls out of the pleural cavity. The initial nursing action is which of the following ? a. Contact the physician b. Contact the respiratory therapist c. Applying an occlusive dressing d. Reinsert the chest tube quickly Rationale Answer:c If the chest tube is accidentally pulled out, the nurse would Immediately apply an occlusive dressing and when contact the physician. The physician needs to be notified, but this is not the initial nursing action. It is not necessary to contact the respiratory therapist. It is not appropriate and not a nursing role to reinsert a chest tube Cognitive level: applying Reference: saunders 8th ed p 1623 18. A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate crackles and cyanosis and is coughing but is unable to expectorate. Which nursing diagnosis is the priority for this client? a. Risk for decreased cardiac output secondary to cor pulmonale b. Impaired gas exchange related to ventilation-perfusion mismatch c. Ineffective breathing pattern related to increased work of breathing d. Ineffective airway clearance related to inability to expectorate sputum Rationale Answer: D COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the diagnoses listed are potentially appropriate for a client with COPD. For the nurse prioritizing this clients problems, it is important to first maintain airway, breathing, and circulation. At present, the client demonstrates problems with ventilation because of ineffective coughing, so option 4 would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The clients respiratory rate is only slightly elevated, so ineffective breathing pattern is not as important as airway. The client is cyanotic, but this probably is due to the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support decreased cardiac output as being most important at this time. 19. A nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal compartment has stopped. On the basis of this assessment finding the nurse would suspect that: a. The chest tubes are obstructed b. Suction needs to be increased c. The system needs changing d. Suction needs to be decreased Rationale Answer: A Fluid in the water seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 2, 3, and 4 are incorrect interpretations. 20. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding b. Immediately clamp the chest tube and notify the physician c. Check for an air leak because the bubbling should be intermittent d. Increase the suction pressure so that the bubbling becomes vigorous Rationale Answer: A Continuous gentle bubbling should be noted in the suction control chamber. Option 2 is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option 3 is incorrect. Bubbling should be continuous and not intermittent. Option 4 is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

21. A client who is human immunodeficiency virus-positive has had mantoux skin test. The nurse note a 8mm area of induration at the site of the skin test. The nurse interprets the result as: a. Positive b. Negative c. Inconclusive d. Indicating the need for repeat testing Rationale Answer:A The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations. 22. A client with emphysema is short of breath and using accessory muscle of respiration. The nurse recognizes that the clients dyspnea is caused by: A. Spasm of the bronchi that traps the air B. An increase in the vital capacity of the lungs C. A too rapid expulsion of the air from the alveoli D. Difficulty in expelling the air trapped in the alveoli Answer: D. Emphysema involves destructive changes in the alveolar walls leading to dilation of the air-sacs ; there is subsequent air trapping and difficulty with expiration a. Brochospasm is characteristic of asthma and it cause narrowing of the airways b. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement c. Expiration should be slowed by purser-lip breathing to keep the airways open so ther is less air trapping 23. A nurse instruct a client to use the purse-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of purse-lip breathing is to: a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination Rationale: Answer: D Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. 24. A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam(Versed) c. Encouraging additional fluid for the next 24hours d. Ensuring the return of the gag reflex before offering food or fluid Rationale: Answer:D After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. 25.To make a definitive diagnosis of tuberculosis, the nurse understands that the physician must order a:

A. Chest x-ray film B. Tuberculin skin test C. Pulmonary function test D. Sputum for acid-fast testing 26Mario, a recently diagnosed to have Chronic Airway Limitation. The patient undergone an ABG and the following results are the following: pH 7.23; PCO2 61; HCO3 29. As a nurse, you must interpret this as: A. Metabolic Acidosis Compensated C. Metabolic Acidosis Uncompensated B. Respiratory Acidosis Uncompensated D. Respiratory Acidosis Compensated 27. When a client develops respiratory alkalosis, the nurse should expect the laboratory values to reflect: A. An elevated pH, elevated PCO2 B. A decreased pH, elevated PCO2 C. An elevated pH, decreased PCO2 D. A decreased pH, decreased PCO2 Answer: C. In respiratory alkalosis the pH level is elevated because of lodd of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation a. This is partially compensated metabolic alkalosis b. Same as answer A c. This is metabolic acidosis with some compensation 28. A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60. These blood gases require nursing attention because they indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Answer: C. The pH of the blood indicates acidosis; CO2 is the parameter for respiratory function; normal PCO2 is 40 a. HCO3 is the parameter for metabolic functions b. Same as answer a c. A pH of 7.25 is acidic, indicating acidosis not alkalosis 29. What is the rationale that supports multidrug treatment for a client with tuberculosis? a. Multiple drugs potentiate the drugs actions b. Multiple drugs reduce undesirable drug side effect c. Multiple drugs allow to reduced drug dosages to be given d. Multiple drugs reduce development of resistant strain of the bacteria 30. A client with pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should: A. Apply suction while inserting the catheter B. Hyperoxygenate with 100% oxygen before and after suctioning C. Use short, jabbing movement of the catheter to loosen secretion D. Suction two to three times quick succession to remove all secretion Answer: B. Suctioning also removes oxygen, which can cause cardiac dysrhymias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning a. To prevent trauma to the trachea, suction should be applied only while removing the catheter C. This kind of movement could cause tracheal damage D. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production