Post-test.

SWU BSN 4- Medical- Surgical

Nursing 3
Total points44/50
 
 
1.  A client has an order to have radial ABG drawn. Before drawing the sample, a nurse
occludes the:*
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A. Brachial and radial arteries, and then releases them and observes the circulation of the hand.
B. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the
process with the other artery.
 
C. Radial artery and observes for color changes in the affected hand.
D. Ulnar artery and observes for color changes in the affected hand.

 
2.  A nurse is assessing a client with chronic airflow limitation and notes that the client
has a “barrel chest.” The nurse interprets that this client has which of the following forms
of chronic airflow limitation?*
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a. Chronic obstructive bronchitis

b. Emphysema
 
c. Bronchial asthma
d. Bronchial asthma and bronchitis

 
3. An elderly client has been ill with the flu, experiencing headache, fever, and
chills. After 3 days, she developed a cough productive of yellow sputum. The nurse
auscultates her lungs and hears diffuse crackles. How would the nurse best interpret
these assessment findings?*
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a. It is likely that the client is developing a secondary bacterial pneumonia.

 
b. The assessment findings are consistent with influenza and are to be expected.
c. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions
d. The client has not been taking her decongestants and bronchodilators as prescribed.

 
4. Guaifenesin 300 mg four times daily has been ordered as an expectorant. The
dosage strength of the liquid is 200mg/5ml. How many mL should the nurse administer
each dose?*
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a. 7 ml
b. 6.5 ml
c. 7.5 ml
 
d. 5.7 ml

 
5. A client with COPD reports steady weight loss and being “too tired from just
breathing to eat.” Which of the following nursing diagnoses would be most appropriate
when planning nutritional interventions for this client?*
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a. Altered nutrition: Less than body requirements related to fatigue.

 
b. Activity intolerance related to dyspnea.
c. Weight loss related to COPD.
d. Ineffective breathing pattern related to alveolar hypoventilation

 
6. When developing a discharge plan to manage the care of a client with COPD, the
nurse should anticipate that the client will do which of the following?*
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a. Develop infections easily.

 
b. Maintain current status.
c. Require less supplemental oxygen.
d. Show permanent improvement.

 
7. Which of the following outcomes would be appropriate for a client with COPD
who has been discharged to home? The client:*
1/1

a. Promises to do pursed lip breathing at home.

b. States actions to reduce pain.
c. States that he will use oxygen via a nasal cannula at 5 L/minute.
d. Agrees to call the physician if dyspnea on exertion increases.
 
 
8. Which of the following physical assessment findings would the nurse expect to
find in a client with advanced COPD?*
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a. Increased anteroposterior chest diameter.

b. Underdeveloped neck muscles.
c. Collapsed neck veins.
d. Increased chest excursions with respiration.
 
Correct answer
a. Increased anteroposterior chest diameter.

 
9. Which of the following is the primary reason to teach pursed-lip breathing to
clients with emphysema?*
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a. To promote oxygen intake.

b. To strengthen the diaphragm.
c. To strengthen the intercostal muscles.
d. To promote carbon dioxide elimination.
 
 
10. Which of the following is a priority goal for the client with COPD?*
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a. Maintaining functional ability.

 
b. Minimizing chest pain.
c. Increasing carbon dioxide levels in the blood.
d. Treating infectious agents.
 
11. A client’s arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg,
PaCO2 65 mm Hg; HCO3- 36 mEq/L. Which of the following signs or symptoms would
the nurse expect?*
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a. Cyanosis
b. Flushed skin
 
c. Irritability
d. Anxiety

 
12. When teaching a client with COPD to conserve energy, the nurse should teach
the client to lift objects:*
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a. While inhaling through an open mouth.

b. While exhaling through pursed lips.
 
c. After exhaling but before inhaling.
d. While taking a deep breath and holding it.

 
13. The nurse teaches a client with COPD to assess for s/s of right-sided heart
failure. Which of the following s/s would be included in the teaching plan?*
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a. Clubbing of nail beds

b. Hypertension
c. Peripheral edema
 
d. Increased appetite

 
14. The nurse assesses the respiratory status of a client who is experiencing an
exacerbation of COPD secondary to an upper respiratory tract infection. Which of the
following findings would be expected?*
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a. Normal breath sounds

b. Prolonged inspiration
c. Normal chest movement
d. Coarse crackles and rhonchi
 
 
15. Which of the following ABG abnormalities should the nurse anticipate in a client
with advanced COPD?*
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a. Increased PaCO2
 
b. Increased PaO2
c. Increased pH
d. Increased oxygen saturation

 
16. Which of the following diets would be most appropriate for a client with COPD?*
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a. Low fat, low cholesterol

b. Bland, soft diet
c. Low-Sodium diet
 
d. High calorie, high-protein diet

Correct answer
d. High calorie, high-protein diet

 
17. The nurse is planning to teach a client with COPD how to cough effectively.
Which of the following instructions should be included?*
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a. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation.
 
b. Lie flat on back, splint the thorax, take two deep breaths and cough.
c. Take several rapid, shallow breaths and then cough forcefully.
d. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with
coughing.

 
18. The nurse would anticipate which of the following ABG results in a client
experiencing a prolonged, severe asthma attack?*
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a. Decreased PaCO2, increased PaO2, and decreased pH.

b. Increased PaCO2, decreased PaO2, and decreased pH.
 
c. Increased PaCO2, increased PaO2, and increased pH.
d. Decreased PaCO2, decreased PaO2, and increased pH.

 
19. A female client comes into the emergency room complaining of SOB and pain in
the lung area. She states that she started taking birth control pills 3 weeks ago and that
she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are
as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2
86%. Considering these results, the first intervention is to:*
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a. Begin mechanical ventilation.

b. Place the client on oxygen.
 
c. Give the client sodium bicarbonate.
d. Monitor for pulmonary embolism.

 
20. A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to
oxygen, the first nursing action would be to:*
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a. Wait until the client’s lab work is done.

b. Not administer oxygen unless ordered by the physician.
c. Administer oxygen at 2 L flow per minute.
 
d. Administer oxygen at 10 L flow per minute and check the client’s nail beds.

 
21. A client is admitted to the hospital with acute bronchitis. While taking the client’s
VS, the nurse notices he has an irregular pulse. The nurse understands that cardiac
arrhythmias in chronic respiratory distress are usually the result of:*
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a. Respiratory acidosis
b. A build-up of carbon dioxide
 
c. A build-up of oxygen without adequate expelling of carbon dioxide.
d. An acute respiratory infection.

 
22. A client with COPD has developed secondary polycythemia. Which nursing
diagnosis would be included in the plan of care because of the polycythemia?*
1/1

a. Fluid volume deficit related to blood loss.

b. Impaired tissue perfusion related to thrombosis.
 
c. Activity intolerance related to dyspnea.
d. Risk for infection related to suppressed immune response.

 
23. The physician has scheduled a client for a left pneumonectomy. The position that
will most likely be ordered postoperatively for his is the:*
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a. Nonoperative side or back

b. Operative side or back
 
c. Back only
d. Back or either side.

 
24. A client states that the physician said the tidal volume is slightly diminished and
asks the nurse what this means. The nurse explains that the tidal volume is the amount
of air:*
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a. Exhaled forcibly after a normal expiration.

b. Exhaled after there is a normal inspiration.
 
c. Trapped in the alveoli that cannot be exhaled.
d. Forcibly inspired over and above a normal respiration.

 
25. The best method of oxygen administration for client with COPD uses:*
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a. Cannula
b. Simple Face mask
c. Non-rebreather mask
 
d. Venturi mask

Correct answer
d. Venturi mask

 
26. A male adult patient hospitalized for treatment of a pulmonary embolism
develops respiratory alkalosis. Which clinical findings commonly accompany respiratory
alkalosis?*
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a. Nausea or vomiting
b. Abdominal pain or diarrhea
c. Hallucinations or tinnitus
d. Lightheadedness or paresthesia
 
 
27. Rhea, confused and short breath, is brought to the emergency department by a
family member. The medical history reveals chronic bronchitis and hypertension. To
learn more about the current respiratory problem, the doctor orders a chest x-ray and
arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses see
many abbreviations. What does a lowercase “a” in ABG value present?*
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a. Acid-base balance
b. Arterial Blood
 
c. Arterial oxygen saturation
d. Alveoli

 
28. A male patient is admitted to the healthcare facility for treatment of chronic
obstructive pulmonary disease. Which nursing diagnosis is most important for this
patient?*
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a. Activity intolerance related to fatigue.

b. Anxiety related to actual threat to health status.
c. Risk for infection related to retained secretions.
d. Impaired gas exchange related to airflow obstruction.
 
 
29. Nurse Ruth assessing a patient for tracheal displacement should know that the
trachea will deviate toward the:*
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a. Contralateral side in a simple pneumothorax.

b. Affected side in a hemothorax.
c. Affected side in a tension pneumothorax.
 
d. Contralateral side in hemothorax.

Correct answer
d. Contralateral side in hemothorax.

 
30. For a patient with advanced chronic obstructive pulmonary disease (COPD),
which nursing action best promotes adequate gas exchange?*
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a. Encouraging the patient to drink three glasses of fluid daily.

b. Keeping the patient in semi-Fowler's position.
c. Using a high-flow venturi mask to deliver oxygen as prescribed.
 
d. Administering a sedative, as prescribed.

 
31. George Kent is a 54-year-old widower with a history of chronic obstructive
pulmonary disease and was rushed to the emergency department with increasing
shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has
difficulty communicating because of his inability to complete a sentence. One of his
sons, Jacob, says he has been unwell for three days. Upon examination, crackles and
wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse.
Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L,
and PaO2 60 mm Hg. How would you interpret this?*
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a. Respiratory Acidosis, Uncompensated

b. Respiratory Acidosis, Partially Compensated
 
c. Metabolic Alkalosis, Uncompensated
d. Metabolic Acidosis, Partially Compensated

 
32. What is the leading cause of CAP?*
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a. S. aureus.
b. H. influenza.
c. E. coli.
d. S. pneumonia.
 
 
33. Which of the following is not considered as pneumonia in the
immunocompromised host?*
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a. Nosocomial pneumonia.
b. Fungal pneumonia.
c. Pneumocystis pneumonia.
d. Mycobacterium tuberculosis.
 
Correct answer
a. Nosocomial pneumonia.

 
34. HAP is the onset of pneumonia symptoms more than _____ hours after
admission in patients with no evidence of infection at the time of admission.*
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a. 72
b. 36.
c. 48.
 
d. 24.

 
35. CAP occurs either in the community setting or within the first _____ hours after
hospitalization.*
1/1

a. 24
b. 48.
 
c. 72.
d. 36

 
36. Which of the following pathophysiological mechanisms that occur in the lung
parenchyma allow pneumonia to develop?*
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a. Atelectasis
b. Bronchiectasis
c. Effusion
d. Inflammation
 
 
37. Which of the following organisms most commonly causes community-acquired
pneumonia in adults?*
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a. Haemophilus influenzae
b. Klebsiella pneumoniae
c. Streptococcus pneumoniae
 
d. Staphylococcus aureus

 
38. An elderly client with pneumonia may appear with which of the following
symptoms first?*
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a. Altered mental status and dehydration

 
b. Fever and chills
c. Hemoptysis and dyspnea
d. Pleuritic chest pain and cough

 
39. When auscultating the chest of a client with pneumonia, the nurse would expect
to hear which of the following sounds over areas of consolidation?*
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a. Bronchial
 
b. Bronchovesicular
c. Tubular
d. Vesicular

 
40. A diagnosis of pneumonia is typically achieved by which of the following
diagnostic tests?*
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a. ABG analysis
b. Chest x-ray
c. Blood cultures
d. Sputum culture and sensitivity
 
 
41. A client with pneumonia develops dyspnea with a respiratory rate of 32
breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung
fields and hears bronchial sounds in the left lower lobe. The nurse determines that the
client requires which of the following treatments first?*
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a. Antibiotics
b. Bed rest
c. Oxygen
 
d. Nutritional intake

 
42. A client has been treated with antibiotic therapy for right lower-lobe pneumonia
for 10 days and will be discharged today. Which of the following physical findings would
lead the nurse to believe it is appropriate to discharge this client?*
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a. Continued dyspnea
b. Fever of 102*F
c. Respiratory rate of 32 breaths/minute.
d. Vesicular breath sounds in the right base.
 
 
43. The right forearm of a client who had a purified protein derivative (PPD) test for
tuberculosis is reddened and raised about 3mm where the test was given. This PPD
would be read as having which of the following results?*
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a. Indeterminate
b. Needs to be redone
c. Negative
 
d. Positive

 
44. A client with a positive Mantoux test result will be sent for a chest x-ray. For
which of the following reasons is this done?*
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a. To confirm the diagnosis.

b. To determine if a repeat skin test is needed.
c. To determine the extent of the lesions.
 
d. To determine if this is a primary or secondary infection.

 
45. The nurse is preparing to assess a patient diagnosed with viral pneumonia.Which
complication should the nurse anticipate?*
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a. Dehydration
 
b. Respiratory distress
c. Pulmonary edema
d. Confusion

 
46. The nurse is providing discharge teaching for a patient with pneumonia.Which
information should the nurse include to promote effective gas exchange?*
1/1
a. "Limit activities."
b. "Maintain adequate fluid intake."
 
c. "Limit analgesia use."
d. "Take shallow breaths."

 
47. The nurse is caring for a patient diagnosed with lobar pneumonia. The patient is
experiencing dyspnea and asks the nurse, "Why is it so difficult for me to breathe? "The
nurse should understand that which statement describes the pathophysiology causing
the dyspnea?*
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a. The disease causes vasoconstriction, impeding gas exchange at the alveolar level.
b. The alveoli become atrophied due to an inadequate blood supply from the capillaries
c. An inflammatory response results in fluid leakage into the interstitial spaces.
 
d. The invading pathogen destroys the alveoli and capillaries, resulting in consolidation.

 
48. The nurse is providing dietary teaching to a patient with pneumonia. The patient
asks, "Why do I need extra calories if I am not hungry or doing any activity? "Which
explanation should the nurse provide to the patient?*
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a. "You can lose greater than 10% of body weight during the illness."
b. "You need to keep up your energy during the illness."
c. "You need the extra calories to help fight off the illness."
 
d. "Your body needs the extra calories when you are ill."

Correct answer
d. "Your body needs the extra calories when you are ill."

 
49. The nurse is reviewing a patient's chest x-ray results, which are inconclusive for
a diagnosis of pneumonia.For which additional diagnostic testing should the nurse
prepare the patient to confirm diagnosis?*
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a. Complete blood count laboratory draw

b. Computerized tomography (CT) scan
 
c. Fiber optic bronchoscop
d. Sputum Gram stain

 
50. The nurse is caring for a patient with pneumonia who is experiencing fatigue.
Which finding indicates that the patient has met the goal of obtaining adequate rest?*
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a. The patient only experiences mild orthopnea.

b. The patient is able to obtain uninterrupted sleep in a sitting position leaning forward.
c. The patient's sleep is uninterrupted
 
d. The patient maintains an oxygen saturation greater than 95%.
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