Study sets, textbooks, questions
Upgrade to remove ads
Chp. 19, 20, 21 for NSG 231 TEST 3
Terms in this set (152)
Arrange the following steps to show the order in which lung development takes place from the embryonic stage to the birth of the infant.
Primitive lung bud emerges during the first 5 weeks of fetal life.
Conducting airways reach the same number as in an adult
Surfactant is a complex lipid substance needed for sustained inflation of the air sacs
Lungs have 70 million primitive alveoli
Blood supply is detached from the placenta.
Blood gushes into the pulmonary circulation.
Palpable rhonchal fremitus indicates which condition?
Thick bronchial secretions
Decreased tactile fremitus is consistent with which diagnosis?
The nurse learns in shift report that the patient has Biot's respirations. The nurse anticipates which assessment?
Normal breathing interrupted by apnea
During the chest assessment of a patient, which reference line would the nurse note on the posterior chest wall?
Which part of the lungs is assessed on the posterior chest?
All parts of the lower lobes
Which term is used to document excessive sweating associated with shortness of breath?
n which location would the nurse auscultate the highest point of the lung on the anterior side of the chest?
3 to 4 cm above the clavicle
Which abnormality would the nurse expect in a patient with kyphosis?
An exaggerated posterior curvature of the thoracic spine
Which changes take place during the process of inspiration? Select all that apply.
Intercostal muscles contract
Intrathoracic pressure decreases
Which statement describes the structure of the lungs?
The right lung is shorter and wider than the left lung
Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? Select all that apply.
Which statement precisely describes the "angle of Louis"?
It is the articulation of the manubrium and the body of the sternum.
Which finding of an umbilical cord during a newborn's assessment is cause for concern?
It has one artery and one vein.
Which is the nurse performing when placing the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the midclavicular line from the right lower quadrant (RLQ)?
Which finding is consistent with sudden onset of severe colicky pain in the lower abdomen?
Which quadrant would the nurse assess in a pregnant patient for pain related to appendicitis?
Right lower quadrant (RLQ)
Which abdominal assessment would the nurse use to confirm rebound tenderness?
Which is indicative of rebound tenderness in the abdomen?
Which are changes in the gastrointestinal system because of aging? Select all that apply.
Impaired drug metabolism
Decreased sense of taste
Decreased liver size
Which condition causes the stool to be gray in color?
Presence of jaundice or hepatitis
Which soft, lobulated gland is located behind the stomach?
Which is a normal finding in the assessment of a 3-year-old child?
Which stool color is expected for a patient who is taking an iron supplement?
Nontarry black stool
Which test would the nurse use to assess a patient with suspected appendicitis pain?
Iliopsoas muscle test
Which are the normal features of the spleen? Select all that apply.
It lies under the diaphragm.
It lies parallel to the tenth rib.
it is a soft mass of lymphatic tissue.
Which feature is specific to the right kidney?
May be palpable
Which site is appropriate for palpation of the popliteal pulse?
Below the knee
Which is a characteristic of the great saphenous vein?
Located inside the leg
Which increased serum level leads the nurse to conclude the patient is at risk of atherosclerosis? Select all that apply.
Glucose, Cholesterol, Triglycerides
Which statement by the student nurse needs correction by the instructor concerning the physiologic effects of smoking cigarettes?
"Smoking decreases coagulability."
Which would the nurse infer from the finding of enlarged, warm, and tender cervical lymph nodes on an infant?
Which finding supports the nurse's assessment of a patient with acute asthma who the nurse suspects may have pulsus paradoxus?
Blood pressure falls > 10 mm Hg during inspiration.
Which arteries are described as having superficial and deep palmar arches? Select all that apply.
The accumulation of lymph in the breasts and upper arms is a result of an obstruction of which lymph nodes?
For which complications would the nurse monitor in a patient with deep vein thrombosis?
Which statements would the nursing instructor include in a lecture about inguinal lymph nodes? Select all that apply.
They drain the lymph of the lower extremities.
They drain the lymph of the external genitalia
They drain the lymph of the anterior abdominal wall.
Arrange the order of the steps that the nurse would follow to determine the weak peripheral pulse of a patient by using a Doppler ultrasonic probe.
Place the patient in a supine position with the legs rotated externally.
Place a drop of coupling gel at the end of the handheld transducer.
Place the transducer over the pulse site at a 90° angle.
Apply very light pressure and locate the pulse site.
While assessing a patient with an infection of the forearm, the nurse uses one hand to shake the patient's hand and keeps the other hand near the patient's elbow. Which is the reason for the nurse's action?
To check for enlarged epitrochlear nodes
Which description of semilunar valves is correct?
Lie between the ventricles and the great vessels
Which statement describes a lift with respect to the cardiovascular system?
Sustained thrust of the ventricle of the heart
Which heart rate would be found in a 4-month-old infant with bradycardia?
Which statement describes the pericardium?
Tough, fibrous sac surrounding the heart
Which jugular pulse component reflects ventricular contraction?
Which method would the nurse use to detect a pericardial friction rub?
Auscultate with the diaphragm of a stethoscope.
Which term is used to describe the pacemaker of the heart?
Which murmur is caused by an obstruction of the flow of blood into the ventricles?
Which blood vessel drains the blood from the head and upper extremities?
Superior vena cava
Which patient positions are necessary during a cardiac assessment? Select all that apply.
Left lateral recumbent
Which condition can cause a wide split in the second heart sound?
Right bundle branch block
Which section of the electrocardiogram (ECG) indicates atrial depolarization?
A client who recently immigrated from Korea to the US or Canada is hospitalized with
second- and third-degree burns. He speaks little English and has been lying quietly in
bed. Ten hours after the client's admission, the nurse conducts a serial assessment and
asks him whether he's in pain. He smiles and shakes his head vigorously back and
forth. Which nursing action is most appropriate at this time?
checking vital signs and assessing for nonverbal indications of pain
Which client would benefit from the application of warm moist heat?
a client with low back pain
When planning pain control for a client with terminal gastric cancer, a nurse should
clients with terminal cancer may develop tolerance to opioids.
A client with cancer-related pain has been prescribed a narcotic analgesic to be given
around the clock. The client is competent and has been actively involved in decisions
regarding care. What should the nurse do if the client refuses the next dose of
Document the client's choice and re-assess pain in 1 hour.
A child with rheumatic fever complains of painful joints. Which nonpharmacologic
measures should the nurse use to reduce the child's pain?
Use a bed cradle to keep linens from pressing on the child's joints.
A client is receiving massage therapy to relieve pain. Which statement explains why
massage is an effective way to relive pain?
blocks pain impulses from the spinal cord to the brain.
A client is using healing touch therapy to manage pain. What should the nurse tell the
client about how healing touch can be effective in pain management?
directing the flow of energy fields.
A client with osteoarthritis purchased a copper bracelet to wear and tells the nurse that
there is less pain now. Which response by the nurse is most appropriate?
Acknowledge that the client feels better, but encourage the client to continue
with the prescribed therapy.
A client twists his right ankle while playing basketball and seeks care for ankle pain and
swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement
suggests that ice application has been effective?
"My ankle looks less swollen now."
The second morning after surgery for a below-the-knee amputation of the left leg, the
client says, "This sounds crazy, but I feel my left toes tingling." This statement would
indicate to the nurse that he is experiencing a:
A client receiving morphine for long-term pain management develops tolerance.
Tolerance is defined as:
a diminished response to a drug so that more medication is required to achieve
the same effect.
The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On
checking the health care provider's (HCP's) prescription, the nurse notes that the
prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The
usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the
nurse to take?
Contact the HCP to verify the prescription.
A client has requested to have patient-controlled analgesia (PCA) after surgery? When
is it appropriate for a client to receive PCA?
The client has the ability to self-administer.
A client with burns is to have a whirlpool bath and dressing change. What should the
nurse do 30 minutes before the bath?
Administer an analgesic.
A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system
after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in
the left thorax that worsens when coughing. What should the nurse do first?
Assess the pain using a pain scale and compare to the previous assessment.
The client is admitted with left lower leg pain, a positive Homans' sign, and a
temperature of 100.4°F (38°C). What additional signs should the nurse assess?
deep vein thrombosis (DVT) in the left leg.
After teaching the client how to use the patient-controlled analgesia (PCA) pump, the
nurse determines that the client understands the use of the PCA when the client makes
The machine will give me only the prescribed amount of pain medication even if
I push the button too soon.
Three days after surgery, a client continues to take hydrocodone 7.5 mg and
acetaminophen 500 mg for postoperative pain. What should the nurse ask the client
before administering the pain medication?
When did you last have a bowel movement?
A client has a patient a controlled analgesia (PCA) infusion to manage postoperative
pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0
to 10 pain scale. What should the nurse do first?
Inspect the infusion site.
A child is admitted with constipation and a diagnosis of possible appendicitis. The child
is in acute pain. Which nursing interventions would be appropriate prior to surgery to
decrease pain? Select all that apply.
Offer an ice pack.
Assume a position of comfort.
Limit the child's activity.
The physician orders docusate sodium 100 mg at bedtime for a primiparous client after
vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the
client to expect which of the following results from taking the medication?
Softening of the stool.
Which teaching instructions by the nurse is appropriate for a client with constipation?
The client will consume foods high in fiber.
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home
because of a change in behavior. The client has a diagnosis of Alzheimer's disease and
has started to experience episodes of incontinence. The hospital staff is having difficulty
with toileting because the client wanders around the unit all day. To assist with
elimination, a nurse should:
incorporate the clients toileting schedule into the pattern of his wandering
A confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. What should the nurse do?
Check on the client at regular intervals to ascertain the need to use the bathroom.
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after
surgery, the nurse notes that the clients stoma appears dusky. How should the nurse
interpret this finding?
Blood supply to the stoma has been interrupted.
The client who is in Buck's traction is constipated. A plan of care that incorporates which
breakfast would be most helpful in reestablishing a normal bowel routine?
an orange, raisin bran and milk, and wheat toast with butter
A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L).
Which prescribed order will the nurse implement first?
I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution
with 20 mEq (20 mmol/L) of potassium chloride at 100 ml/hr
Which nursing intervention is most important in preventing postoperative
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia
repair. Which nursing observation indicates this client is ready to be discharged?
The client voids 500 mL of urine
After teaching the parents about the urethral catheter placed after surgical repair of their
son's hypospadias, the nurse determines that the teaching was successful when the
mother states that the catheter in her child's penis accomplishes which goal?
keeps the new urethra from closing
The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The
nurse should assess the client for which condition most commonly associated with the
ongoing use of magnesium-based antacids?
A nurse is teaching a client what to expect following a barium enema. Which client
statement indicates a need for further teaching?
"I should limit my fiber intake for 1 to 2 weeks following the procedure."
Which intervention would be least appropriate for a client who is in a double hip spica
advising the client to eat large amounts of cheese
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a
bowel retraining program. Which strategy is not appropriate?
limiting fluid intake to 1,000 mL/day
A client with colon cancer is having a barium enema. The nurse should instruct the
client to take which type of medication after the procedure is completed?
Which statement indicates that the client understands the home care of a colostomy?
"I should be able to establish a regular pattern of elimination with my colostomy."
Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority
to which client need?
inserting a Foley catheter
A client's serum ammonia level is elevated, and the health care provider (HCP)
prescribes 30 mL of lactulose. Which effect is common for this drug?
increased bowel movements
While assessing the episiotomy site of a primiparous client on the first postpartum day,
the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the
client about measures to relieve hemorrhoid discomfort, which statement indicates the
need for additional teaching?
"I should lie on my back as much as possible to relieve the pain."
Which question should the nurse ask first when obtaining a history from the parent of a
school-age child with a fever, malaise, and swelling around the eyes?
"Does the child urinate as much as usual?"
A pregnant client in her third trimester asks why she needs to urinate frequently again,
as she did during the first trimester. What should the nurse tell her?
This symptom is normal and results from the fetus exerting pressure on the bladder.
A nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The
child's parents appear protective, never leaving their daughter's side. While the nurse
helps the child's mother provide morning care, the child states, "My uncle doesn't " clean
me that way. Her mother becomes visibly upset and gives the girl a stern warning not
to discuss the matter. She states, "Don't tell anyone about that again." The nurse has a
legal responsibility to:
notify the nursing supervisor and the authorities of the possibility of abuse.
A registered nurse and a nursing assistant are caring for a group of clients. Which
client's care may safely be delegated to the nursing assistant?
A client diagnosed with renal calculi who must ambulate four times daily and drink
plenty of fluids.
The primary reason for lubricating the urinary catheter generously before inserting the
catheter into a male client is to prevent which problem?
friction along the urethra when the catheter is being inserted..
The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse
explain is the expected outcome of these exercises?
strengthening the perineal muscles
A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client
Empty the bladder every 2 to 3 hours.
When a client with an indwelling urinary catheter wants to walk to the hospital lobby to
visit with family members, the nurse teaches the client how to do this without
compromising the catheter. Which client action indicates an accurate understanding of
The client keeps the drainage bag below the bladder at all times.
A nurse is inserting a urinary catheter into a client who is extremely anxious about the
procedure. The nurse can facilitate the insertion by asking the client to:
Which client is at highest risk for developing a urinary tract infection?
a man with an indwelling urinary catheter
A client who had transurethral resection of the prostate has dribbling urine after his
Foley catheter is removed on the second postoperative day. The nurse notes that the
client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What
should the nurse do first?
Assess for bladder distention.
Which aspects of client care would be most appropriate for the nurse to delegate to an
unlicensed assistive personnel (UAP)?
obtaining a urine specimen for a culture and sensitivity analysis from a client who has
an indwelling urinary catheter inserted
The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse
should determine if the client has which symptom?
difficulty starting the urinary stream
Nitrofurantoin, 75 mg four times per day, has been prescribed for a client with a lower
urinary tract infection. The medication comes in an oral suspension of 25 mg/5 mL. How
many milliliters should the nurse administer for each dose? Record your answer using a
A client developed cardiogenic shock after a severe myocardial infarction and has now
developed acute renal failure. The client's family asks the nurse why the client has
developed acute renal failure. What should the nurse tell the family?
"Because of the cardiogenic shock, there is:
a decrease in the blood flow through the kidneys."
Which intervention should the nurse suggest to help a client with multiple sclerosis
avoid episodes of urinary incontinence?
Establish a regular voiding schedule.
A client with fever and urinary urgency must provide a urine specimen for culture and
sensitivity. The nurse should instruct the client to collect the specimen from the
middle stream of urine from the bladder.
A nurse is caring for a client who is an employee in the hospital. The client has recently
received a diagnosis of genital herpes and is being treated for a urinary tract infection
(UTI). A co-worker asked the nurse how the employee is doing. What is the nurse's best
i'll be sure to tell the client you said hello"
After teaching the mother of a young girl about measures to help prevent urinary tract
infections, which statement by the mother indicates successful teaching?
"We'll make sure she takes a water bottle with her to afterschool events."
A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects
to prepare the client for which diagnostic study?
colonoscopy with biopsy
The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine
specimen from an indwelling catheter. Which statement indicates that the UAP
understands the instructions?
"I'll get a sterile syringe and remove urine from the catheter through the collection
port to place in the specimen container."
A physician orders hourly urine output measurement for a postoperative client with an
indwelling catheter. The nurse records these amounts of output for 2 consecutive hours:
8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action
should the nurse take?
Continue to monitor and record hourly urine output.
When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24
hours ago, the nurse determines that the fundus is firm but to the right of midline. Based
on this finding, the nurse should further assess for which complication?
A client is admitted to the health care facility with bowel obstruction secondary to colon
cancer. The nurse obtains a health history, measures vital signs, and auscultates for
bowel sounds. Which step of the nursing process is she performing?
The wife of a terminally ill client asks the nurse, "Why is my husband having frequent
bowel movements if he is not eating?" What should the nurse tell the wife?
"The intestines still produce some waste products even when a person is not eating."
A nurse asks a client who had abdominal surgery 3 days ago if they have moved their
bowels since surgery. The client states, "I haven't moved my bowels, but I am passing
gas." How should the nurse intervene?
Encourage the client to ambulate at least three times per day.
pain from a normal process that results in noxious stimuli being perceived as painful
transduction of pain
Conversion of stimulus into electrical energy
Somatosensory cortex (parietal lobe)
physical sensations/ touch
§emotional reactions to stimuli
thought and reason
recognizing and defining of pain in frontal cortex
Sending of impulse across a sensory pain nerve fiber (nociceptor)
Inhibition of pain/ release of inhibitory neurotransmitters
Gate-control theory of pain (Melzack and Wall)
Pain has emotional and cognitive components, in addition to a physical sensation.
Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses.
Pain impulses pass through when a gate is open and are blocked when a gate is closed.
Closing the gate is the basis for nonpharmacological pain relief interventions.
•Pain Modulation- Changing pain perception....
Nurse can help pt. using 2 mechanisms
-Endogenous analgesia system:
•Release of endogenous opioids and other substances to block pain impulses & provide pain relief
•Endogenous opioids bind to opiate receptor sites in the CNS and peripheral nervous system
•Somatic signals from non-painful sources can inhibit pain signals
•Pain impulses on C fibers meet gate in spinal cord.
•If you can block gate with competing impulses, transmission is inhibited
Protective, identifiable, short duration; limited emotional response
Is not protective, has no purpose, may or may not have an identifiable cause
chronic episodic pain
Occurs sporadically over an extended duration
inferred pathological pain
Musculoskeletal, visceral, or neuropathic
Chronic pain without identifiable physical or psychological cause
Age -face pain scale-
¡Meaning of pain
Classification of Pain
Descriptive terms - sharp or dull, aching, throbbing, stabbing, etc.
intensity - mild, distracting, severe, intolerable
0-10 pain scale
Classification of Pain
•Acute/Transient - short duration, rapid onset, varied intensity, last less than 6 months.
•Chronic/Persistent - lasts 6 months or longer, often interferes with daily activities
Nursing Process and Pain
Pain management needs to be systematic.
Pain management needs to consider the patient's quality of life.
use pain scale
Fifth Vital Sign Assessment
Pain Assessment and Management
¡A: Ask about pain regularly. Assess pain systematically.
¡B: Believe the patient and family in their report of pain and what relieves it.
¡C: Choose pain control options appropriate for the patient, family, and setting.
¡D: Deliver interventions in a timely, logical, and coordinated fashion.
¡E: Empower patients and their families. Enable them to control their course to the greatest extent possible.
caused by stimulation of deep internal pain receptors Ex: menstrual cramps, bowel disorders
arises from ligaments, tendons, nerve, blood vessels, and bones. Ex: fractures, arthritis, bone CA
pain that is perceived but has no identifiable physical cause.
Assess verbalization, vocal response, facial and body movements, and social interaction.
For patients unable to communicate pain, it is vital for you to be alert for indicative behaviors
Influence on activities of daily living
Ability to work (outside of and in the home)
What Provokes the pain?
What is the Quality of the pain?
Does the pain Radiate?
What is the Severity of the pain?
What is the Timing of the pain?
¡Before and after every potentially painful treatment or procedure
¡At rest and at activity
¡Before implementing a pain management activity and within 60 minutes after each intervention
¡With each vital sign check
¡With each complaint of pain
¡IV pain med—reassess within 30 min of administration
¡PO pain med—reassess within 60 min of administration
Things to remember
-Children will not report pain - fear
-Some elderly will not complain - stoic
¡Vital signs will not remain elevated for long
¡Patients may be in pain even if they are asleep
¡Patients may not "act" like they are in pain
¡Use interpreter if needed
¡Assess for depression
Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect
- Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur
Increases blood flow, reduces muscle tension, relieves pain, NEVER use right after surgery for at least 48-72 hr
Patient-controlled analgesia (PCA)
Patient-controlled analgesia (PCA)
client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses- takes 2 RN to set up
Invasive Intervention for Pain Relief
Intrathecal implantable pumps
Spinal cord stimulators
Chronic Non-cancer and Cancer Pain Management
Chronic or Acute
Treatment changes as client's condition changes
Tylenol or ASA + Adjuvants
Opioids + Tylenol or NSAIDS + Adjuvant
Spinal/Epidural + Opioids + nerve block
Client Barriers to pain
Fear of addition
Worry about side effects
Take too many pills
Fear of disease progression
Pain is part of aging
Health care barriers for diverse populations
Concern with addition
No visible cause of pain
Poor pain policies
Lack of money
Inadequate access to pain clinics
Sets with similar terms
Iggy Chapter 3: Pain
NURS (FUNDAMENTAL): NCLEX Comfort and Pain Managem…
NURS (FUNDAMENTAL): Ch 34 NCLEX Comfort and Pain M…
NURS (FUNDAMENTAL): NCLEX Comfort and Pain Mamagme…
Other sets by this creator
420 exam #2 nursing
NR 442 - Exam 1
Med surg 2 test two
medsurg 2 test one
Other Quizlet sets
Orgo 2 Lab Exam 1
Machine Vision Exam 1
Quiz 13 two