BIOLOGY 102Medical-Surgical Nursing Critical Thinking in Client Care, CHAPTER 35 AND 36

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER   35 AND 36

Chapter 35

1. The clinic nurse plans a program for clients newly diagnosed with hypertension entitled “Lifestyle Modifications for Hypertension.” Which of the following points are included in this presentation?

1. 1. Avoid milk, eggs, and cheese.
   2. Engage in daily aerobic exercise.
   3. Maintain a potassium-restricted diet.
   4. Use weight training to lose weight.

1. A client admitted to the medical–surgical unit for uncontrolled hypertension has a history of chronic obstructive pulmonary disease (COPD) as well as asthma. Which of the following medications ordered by the physician does the nurse question because of the client’s pulmonary problems?
   1. Amlodipine (Norvasc)
   2. Captropril (Capoten)
   3. Hydrochlorothiazide (HydroDiuril)
   4. Propranolol (Inderal)

1. The nursing diagnosis Noncompliance related to unknown factors is established for a client with hypertension who admits to taking his antihypertensive medications only occasionally. The most therapeutic nursing attitude when talking with this client about the reasons for his noncompliance is:

1. 1. Confrontational.
   2. Directive.
   3. Indifferent.
   4. Non-judgmental.

1. A client with an abdominal aortic aneurysm is admitted to the medical–surgical unit prior to the scheduled surgery for repair. Which of the following nursing implementations is most important to reduce the risk of the aneurysm rupturing?

1. 1. Allow the client to rest in a chair for 20 minutes at a time.
   2. Encourage the client to cough and deep-breathe hourly.
   3. Elevate the client’s legs on one pillow when in bed.
   4. Instruct the client to avoid holding her breath when moving.

1. The nurse on the medical–surgical unit performs an admission assessment for the client with arterial peripheral vascular disease and asks the client which of the following questions in order to determine whether the client has intermittent claudication?

1. 1. “Do you get pain in your calves or thighs with activity?”
   2. “Do you feel burning sensations in your legs at night?”
   3. “Do you notice any paleness in your legs when you elevate them?”
   4. “Do you have any numbness or tingling sensations in your legs?”

1. The nursing diagnosis of: Tissue Perfusion, Ineffective, Peripheral related to decreased arterial flow to extremities is established. Which of the following measures does the nurse teach the client in order to improve blood flow?

1. 1. Cross the legs at the knees when seated.
   2. Elevate the feet while reclining.
   3. Position with the extremities dependent.
   4. Use a heating pad to increase warmth.

1. Which of the following is most essential for the nurse to recommend to the client who has been newly diagnosed with thromboangitis obliterans (Raynaud’s disease)?

1. 1. Avoid alcohol.
   2. Buy shoes in the morning.
   3. Walk in bare feet when indoors.
   4. Stop smoking.

1. Which of the following clients does the nurse identify as having the greatest risk for deep venous thrombosis?

1. 1. The client admitted with new-onset type II diabetes mellitus.
   2. The client admitted with community-acquired pneumonia.
   3. The postoperative client following knee replacement surgery.
   4. The postoperative client following laparoscopic gallbladder surgery.

1. A client being treated for deep venous thrombosis by intravenous heparin therapy puts the call light on and complains to the nurse about having severe chest pain and shortness of breath. The nurse suspects pulmonary embolism, and therefore does which of the following actions first?

1. 1. Increases the rate of heparin infusion.
   2. Initiates oxygen and elevates the head of the bed.
   3. Reassures the client and calls family members.
   4. Takes pulse, respirations, and blood pressure.

1. The home health nurse teaches the client with chronic lymphedema of the left arm secondary to treatment for breast cancer the importance of removing the intermittent pressure device used for the affected arm at least every eight hours. The best rationale for this teaching measure is because this device does which of the following?

1. 1. Causes pain in the affected extremity, and when removed periodically, client comfort is promoted.
   2. Compresses small vessels, and without periodic removal, tissues nourished by these vessels can break down. ***
   3. Exerts continuous pressure, and can cause a rebound effect and lead to more lymphatic fluid if not interrupted.
   4. Moves edema from the distal to proximal area of the arm, and periodic removal will increase effectiveness of treatment.

Cognitive Level: Analysis

Nursing Process: Application

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

CHAPTER 36

1. When preparing a client for a pulmonary function test, the nurse will inform the client:

a. “You will be sedated for the test.”

b. “ We will give you anti-nausea medication prior to the test.”

c. “You will wear a nose clip during the test.”

d. “You might need oxygen for a while after the test.”

Answer: C

Rationale: A nose clip is placed on a non-sedated client during the pulmonary function testing. Nausea is not a common issue with the tests. Oxygen is typically not needed after the test.

Implementation: Physiological Integrity: Application

2. Older clients can be at risk for problems related to the volume of air remaining in the lungs. One reason for this might be:

a. Elasticity of lungs decreases with age.

b. Older adults have a more rapid respiratory rate.

c. There is a tightening of the diaphragm with age.

d. Intercostal muscles become weaker with age.

Answer: D

Rationale: As a person ages, the intercostal muscles become weak. This reduces the movement of the chest wall. Elasticity of the diaphragm, not necessarily of the lungs, is lost, and the diaphragm flattens, or tightens. The respiratory rate of well older adults slows, not increases, with age.

Assessment: Health Promotion and Maintenance: Application

3. A client has lost a moderate amount of blood following a motor vehicle accident. The nurse applies oxygen upon the client’s arrival to the Emergency Department. The primary reason for this is:

a. To ease the work of breathing.

b. To compensate for the reduction in circulating oxygen.

c. As a comfort measure.

d. To prevent shock.

Answer: B

Rationale: As blood volume is lost, hemoglobin is lost. Oxygen is carried from the respiratory system to the cells by hemoglobin in the blood. Breathing might be easier, the client might be more comfortable, and the risk of shock might be decreased through the oxygen administration, but these are additional benefits, and not the primary reason.

Implementation: Physiological Integrity: Analysis

4. After a fall from a 10-foot platform, a client is diagnosed with multiple fractured ribs. The nurse anticipates that a major potential problem might be:

a. Decreased lung expansion.

b. Increased respiratory rate.

c. Prolonged expiratory phase.

d. Low arterial carbon dioxide level.

Answer: A

Rationale: Due to the rib fractures, it might be difficult for the client to have full rib cage expansion related to the pain. The respiratory rate might tend to be slower and more shallow than usual. As a result, the carbon dioxide would be high instead of low. The expiratory phase might be shortened due to the pain.

Planning: Physiological Integrity: Analysis

5. A client has been admitted with probable emphysema. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client’s acid–base balance?

a. Bronchoscopy

b. Sputum studies

c. Pulse oximetry

d. Arterial blood gases (ABGs)

Answer: D

Rationale: ABGs are done to assess alterations in acid–base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

Evaluation: Physiological Integrity: Application

6. While preparing a client for a bronchoscopy, the nurse checks the suction equipment in the room. The primary reason for this is:

a. There is a high risk of a reaction to medications used for sedation.

b. Laryngospasm and respiratory distress could follow this test.

c. Equipment should always be checked prior to a test.

d. Pulmonary emboli is a complication following this test.

Answer: B

Rationale: Anesthetics given for the procedure might suppress the cough and gag reflexes. Secretions might be difficult for the client to expectorate without assistance. If the secretions are not removed, respiratory distress can occur. The suction equipment would be used to remove the secretions, so it must be ready to go before the procedure even starts. A potential reaction to medications used for anesthesia or sedation would be assessed prior to the test. It is ideal to check all equipment prior to a test, but this is not the most specific answer for this situation. Pulmonary emboli development is not a commonly anticipated complication of a bronchoscopy.

Planning: Physiological Integrity: Analysis

7. Nursing care following a bronchoscopy would include: (Select all that apply.)

a. Instruct the client to avoid eating and drinking for two hours after the test.

b. Report dark blood–tinged respiratory secretions to the physician.

c. Instruct the client that a mild fever 24 hours following the test is expected.

d. Administer pain medications immediately following the procedure.

Answer: A; C

Rationale: A client should not eat or drink for approximately two hours after a bronchoscopy, or until he is fully awake with an intact cough and gag reflex. Eating or drinking sooner can increase the risk of aspiration. A mild fever is common 24 hours following the procedure. Dark-tinged blood, especially if biopsies were collected, is common after the procedure. The presence of grossly bloody sputum could indicate a perforation, and would be reported to the physician. There is commonly minimal discomfort following this procedure, so an immediate administration of pain medication would not be indicated.

Implementation: Physiological Integrity: Analysis

8. The client asks the nurse why she is undergoing a positron emission tomography (PET) scan instead of a computed tomography (CT) scan. The nurse was present in the room when the physician discussed the test. What is the best response by the nurse?

a. “Your doctor prefers to order PET scans.”

b. “Why are you concerned about this test?”

c. “PET scans have less radiation than CT scans.”

d. “You will still need a CT scan also.”

Answer: C

Rationale: There is a great difference between the amount of radiation in a PET scan and in a CT scan. A PET scan is used more specifically to identify lung cancers. Making a personal reference to the physician is not professional. The client did not express concern about the test merely by asking the question. A CT scan would not typically be indicated in addition to or following a PET scan.

Implementation: Safe, Effective Care Environment: Application

9. The nurse is educating a client on sputum collection. When would the greatest chance be for the specimen to be collected?

a. After a meal

b. Upon awakening from a nap

c. Before a meal

d. Upon awakening in the morning

Answer: D

Rationale: There is the greatest opportunity to obtain a sputum specimen in the morning. Respiratory secretions pool more during sleep. Clients with respiratory illness cough more when awakening, so sputum collection would be best before daily activities are initiated. There might not be the same opportunity after a nap due to the shortened time frame. Before a meal would not produce the same results, and can tire a client. Collecting a specimen after a meal would not produce a specimen, and could induce vomiting.

Planning: Physiological Integrity: Application

10. What factors related to aging can predispose an older adult to pneumonia? Select all that apply.

a. Slower respiratory rate

b. Less effective cough

c. Immobility

d. Increased pain response

Answer: B; C

Rationale: Skeletal muscle strength is lost in the thorax and diaphragm with aging. This contributes to a less effective cough and the ability to remove respiratory secretions. The secretions can pool in the lungs if the client is not mobile, providing an environment for pneumonia to develop. Respiratory rate does not contribute to the risk of pneumonia. It is a myth that older adults have an increased pain response, and this would not directly contribute to the development of pneumonia.

Assessment: Health Promotion and Maintenance: Analysis