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FINAL EXAM MED SURGE SUCCESS
Terms in this set (46)
The nurse is assessing the client with COPD which health promotion information is most important for the nurse to obtain?
A)Number of years the client has smoked
B) risk factors for complications
C) ability to administer inhaled medication
D)Willingness to modify lifestyle
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
A) assist the client into a sitting position at 90°
B) administer oxygen X 6 L per minute via nasal cannula
C) Monitor vital signs with the client sitting upright
D) notify the healthcare provider about the clients status
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse?
A) large amounts of thick white sputum
B) oxygen flow meter set on 8 L
C) use of accessory muscles during inspiration
D)Presence of a barrel chest and dyspnea
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
A) The client has no signs of respiratory distress
B) The client shows an improved respiratory pattern
C) The client demonstrates and tolerance to activity
D) The client participates in establishing goals
The nurse is caring for the client diagnosed with in stage COPD. Which data warrant in mediate intervention by the nurse?
A) The clients pulse oximetry rating is 92%
B) The clients ABG level is 74
C) The client has shortness of breath when walking to the bathroom
D) The client sputum is rusty colored
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD. select all that apply.
A) impaired gas exchange
B) inability to tolerate temperature extremes
C) activity intolerance
D) inability to cope with changes in roles
E) alteration in nutrition
All of the above
Which outcome is appropriate for the client problem ineffective gas exchange for the client for The client recently diagnosed with COPD?
A) The client demonstrates the correct way to pursed lip breathing
B) The client list three signs and symptoms to report to the healthcare provider
C) The client will drink at least 2500 mL of water daily
D) The client will be able to ambulate 100 feet with dyspnea
The nurse observes the unlicensed assistive personnel removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which actions should the nurse implement?
A) praise the UAP because this prevents the client from tripping on the oxygen tubing
B) place the oxygen back on the client while sitting in the bathroom and say nothing
C) explain to the UAP in front of the client oxygen must be left in place at all times
D) discuss the UAP's action with the charge nurse so appropriate action can be taken
Which clinical manifestation should the nurse expect to assess and the client recently diagnosed with COPD?
A) clubbing in the clients fingers
B) infrequent respiratory infections
C)Chronic sputum production
D)Non-productive hacking cough
Which statement made by the client indicates the nurses discharge teaching is effective for the client diagnosed with COPD?
A) I need to get a flu vaccine each year even when there is a shortage
B) I need to get a vaccine for pneumonia each year with my flu shot
C) if I reduce my cigarettes to six a day I won't have difficulty breathing
D) I need to restrict my drinking liquids to keep from having so much phlegm
Which referral is most appropriate for a client diagnosed with end-stage COPD?
A)The asthma foundation of America
B) The American Cancer Society
C)The American lung Association
D)The American heart Association
The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms were the nurse expect to find?
A) fever and crepitus
B) rales and hives
C)dyspnea and wheezing
D) normal chest shape and eupnea
The nurse is planning the care of a client diagnosed with asthma and has written a problem of anxiety. Which nursing intervention should be implemented?
A) remain with the client
B) notify the healthcare provider
C) administer an anxiolytic medication
D)Encourage the client to drink fluids
The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult onset asthma. Which healthcare disciplines should participate in the meeting? Select all that apply
C) social work
E) speech therapy
A, B, C
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
A) daily inhaled corticosteroids
B) use of a rescue inhaler
C) use of systemic steroids
D) leukotriene agonists
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications?
A) I should take two puffs when I begin to have an asthma attack
B) I must taper off the medication and not stop taking them abruptly
C) these drugs will be most effective if taken at bedtime
D) these drugs are not good at the time of an attack
The client diagnosed with asthma is admitted to the ED with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client?
A) complete blood count
B) pulmonary function test
C) allergy skin testing
D) drug cortisol level
The nurse and a licensed practical nurse or caring for five clients on a medical unit. Which client shut the nurse assigned to the LPN? Select all that apply
A) The 32-year-old female diagnosed with exercise induced asthma who has a forced vital capacity of 1000 mL
B) The 45-year-old male with adult onset asthma he was complaining of difficulty completing all of the ADLs at one time
C) The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed
D) The six-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medication's
E)the 20 year old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time
A, B, E
The charge nurse is making rounds. Which client should the nurse assess first?
A) the 29 year ole client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude
B) the 76 year old client diagnosed with heat failure who has 2+ edema of the lower extremities
C) the 15 year ole client diagnosed with diabetic ketoacisosis after a bout with the flu who has a blood glucose reading of 189mg/dL
D) the 62 year old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at 2 liters per minute
The client diagnosed with exercise induced asthma is being discharged. Which information should the nurse include in the discharge teaching?
A) take two puffs on the rescue inhaler and wait 5 minutes before exercise
B) warm up exercises will increase the potential for developing the asthma attacks
C) use the bronchodilator inhaler immediately prior to beginning to exercise
D) increase dietary intake of food high in MSG
The client diagnosed with restrictive airway disease has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?
A) do not abruptly stop taking this medication; it must be tapered off
B) immediately rinse the mouth following administration of the drug
C) hold the medication in the mouth for 15 seconds before swallowing
D) take the medication immediately when an attack starts
The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching?
A) referral to a dietitian
B) referral for allergy testing
C) referral to the development psychologist
D)Referral to a home health nurse
The nurse is discharging a client newly diagnosed with asthma. Which statement indicates the client understands the discharge instructions?
A) I will call 911 if my medication's don't control an attack
B) I should wash my bedding in warm water
C) I can still eat at the Chinese restaurant when I want
D) if I get a headache I should take a nonsteroidal anti-inflammatory drug
The client is admitted to the emergency department complaining of shortness of breath and fever. The vital signs are: temperature - 100.4°, pulse - 94, respirations - 26, blood pressure 134/86. Which concepts should the nurse identify and a concern for the client? Select all that apply
B and C
The nurse observed the client sitting on the side of the bed with arms propped on the over bed table. The chest is barrel shaped and the client is breathing three lips spaced close together and is exhaling slowly. Which concept is priority for this client?
C) activity intolerance
The client diagnosed with COPD is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple bruises on the arms. Based on the assessment data, which question should the nurse ask the client?
A) do you take prednisone?
B) can you tell me who hurts you?
C) May I check your coccyx for pressure areas?
D) do you sleep with the head of the bed elevated?
The client is diagnosed with COPD and pneumonia. Which medication should the day nurse question administering?
C) Tessalon perles
Which diagnostic test should the nurse anticipate the healthcare provider ordering to rule out the diagnosis of asthma and clients diagnosed with COPD?
A) A bronchoscopy
B) an immunoglobulin e
C) an ABG
D) A bronchodilator reversibility test
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
A) I will take Singulair every day to prevent allergic asthma attacks
B) I need to use my intal, cromolyn inhaler, 15 minutes before I begin my exercise
C) I need to take oral glucocorticoids every day to prevent my asthma attacks
D) if I have an asthma attack I need to use my albuterol inhaler
Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack?
A) administer glucocorticoids IV
B) administer oxygen 5 L per nasal cannula
C) establish and maintain a 20 gauge saline lock
D)Assess breath sounds every 15 minutes
The client diagnosed with respiratory distress has a ABG of pH 7.45; PaCO2 54; HC03 25; PaO2 52. Which should the nurse implement? Select all that apply
A) apply oxygen via nonrebreather mask
B) call the rapid response team
C) elevate the head of the bed
D) stay with the client
E) notify the healthcare provider
All of the above
The nurse is applying oxygen via nasal cannula 2 o'clock diagnosed with COPD. The client complains of extreme shortness of breath. At which rate should the nurse at the flowmeter?
Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis? Select all that apply
A) perform postural drainage and percussion every four hours
B) modify activities to accommodate daily physiotherapy
C) increase fluid intake to 1 L daily to thin secretions
D) recognize and report signs and symptoms of respiratory infections
E) avoid anyone suspected of having an upper respiratory infection
A, B, D, E
Which clinical manifestations indicates to the nurse the child has cystic fibrosis?
A) wheezing with a productive cough
B) excessive salty sweat secretions
C) multiple vitamin deficiencies
D) clubbing of all fingers
Which intervention should the nurse implement first when caring for a client with a respiratory disorder?
A) administer a respiratory treatment
B) check the clients radial pulses daily
C) Monitor the clients vital signs daily
D)Assess the clients capillary refill time
The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL. Which intervention should the nurse implement?
A) hang the next bag and continue the infusion
B) do not hang the next bag and decrease the rate
C) notify the healthcare provider of the level
D) confirm the current serum theophylline level
The nurse assessing an elderly client diagnosed with COPD notes purple, brown, nontender areas on the clients back. Which question shit the nurse asked the client?
A) have you had cupping performed
B) do you always bruises easily
C) did someone living with you hurt you
D) what have you done to cause these
The nurse is discussing placing the client diagnosed with COPD in hospice care. Which prognosis must be determined to place the client in hospice care?
A) The client is doing well but could benefit from the added care by hospice
B) The client has a life expectancy of six months or less
C) The client will live for about 1 to 2 more years
D) The client has about eight weeks to live and needs pain control
The six-year-old client diagnosed with cystic fibrosis needs a long transplant. Which individual would be the best donor for the client?
A) The 20-year-old brother who does not have cystic fibrosis
B) The 45-year-old father who carries the cystic fibrosis gene
C) The 18-year-old who died in a MVA who matches on four points
D) The five-year-old drowning victim who is a three point match
The client diagnosed with COPD is being discharged and is prescribed a steroid prednisone. Which scientific rationale supports while the nurse instruct the client to taper off the medication?
A) The pituitary gland must adjust to the decreasing dose
B)The beta cells of the pancreas have to start secreting insulin
C) this will allow the adrenal gland time to start functioning
D) The thyroid gland will have to start producing cortisol
The client diagnosed with status asthmaticus is prescribed IV aminophylline, a bronchodilator. Which assessment data would warrant immediate intervention?
A) The theophylline level is 12 mcg/mL
B) The client has expiratory wheezing
C) The client complains of muscle twitching
D) The client is refusing to eat the meal
The client diagnosed with adult onset asthma is being discharged. Which medication would the nurse expect a healthcare provider to prescribe?
A) A nonsteroidal anti-inflammatory medication
B) an anti-histamine medication
C) an angiotensin converting enzyme inhibitor
D) A proton pump inhibitor
The 38-year-old client with chronic asthma as prescribed a leukotriene receptor antagonist. Which is the specific rationale for administering this medication?
A) this medication is use prophylactically to control asthma
B) this medication will cure the clients chronic asthma
C) it will stabilize mast cell activities and reduce asthma attacks
D) it will cause the bronchioles to dilate and increase the airway
The nurse is preparing the client newly diagnosed with asthma for discharge. Which data indicates a teaching about the peak flow meter has been effective?
A) I can continue my usual activities without medication if I am in the yellow zone
B) it takes one to two days to establish my personal best
C) when I can't talk while walking I need to take my quick relief medicine
D) when I am in the red zone I must take my quick relief medication and not exercise
The 85-year-old client diagnosed with severe end-stage COPD has a chest x-ray incidentally revealing an 8 cm abdominal aortic aneurysm. Which intervention should the nurse implement?
A) discuss possible end-of-life care issues
B) prepare the client for abdominal surgery
C) teach the client how to do pursed lip breathing
D) talk with the family about the clients condition
The unlicensed assistive personnel notifies the nurse the client diagnosed with COPD is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement?
A) notify the respiratory therapist
B) ask the UAP to increase the oxygen
C) obtain a stat pulse oximetry reading
D) tell the UAP to leave the oxygen alone
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