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100 Cards in this Set

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1. Which disorder places a person at an increased risk for developing cancer?
Answer- Down Syndrome. Rationale: Patients with Down syndrome are known to be at increased risk of leukemia.
2. Which nursing measure should the nurse plan for a patient with thrombocytopenia resulting from cancer chemotherapy?
Answer: Apply pressure to the venipuncture sites for 5 minutes. Rational: Thrombocytopenia—depletion of platelets—places the patient at increased risk for bleeding. Applying pressure is an appropriate measure against this risk.
3. A patient with lung cancer asks the nurse if there are any complementary or alternative treatments that can be used. Which is the nurse’s response? The nurse tells the patient,
Answer: “Describe the therapies you want to explore.” Rational: This response is culturally sensitive and honors the patient’s need for self-determination.
4. A woman has had a modified radical mastectomy. What is the nurse's rational for placing a sign above her bed directing that blood samples are to be drawn and blood pressure is to be taken in the unaffected arm? These interventions may cause
Answer: Increased risk for infection. Rational: Blood draws and blood pressure readings both require constriction of the arm, which places the patient at increased risk for infection.
5. Which patient statement should alert the nurse to assess the need for additional instruction regarding breast self-examination following surgery for breast cancer?
Answer: "The only good thing about my situation now is that I just need to examine one breast." Rational: Breast self-examination for the patient who has had breast cancer surgery should include examination of the chest wall where the breast was removed.
6. In assessing a patient one day following a mastectomy, the nurse should be aware that this patient is at greatest risk for developing which of the following?
Answer: Pulmonary complications. Rational: Pulmonary complications are a concern with any post-surgical patient. The concern is heightened after mastectomy because of the surgical location. Issues including pain, hematoma, and fluid accumulation can affect the patient's ability to clear the airway.
7. Which intervention is important for a patient following an abdominal perineal resection for rectal cancer? Encourage the patient to
Answer: lie in sidelying position when in bed. Rational: A sidelying position in bed is the resting position least likely to be uncomfortable or irritating while the surgical wound is healing.
8. To prevent lymphedema, what should the nurse teach the patient?
Answer: Wear gloves when using strong detergents. Rational: Wearing gloves to protect the hand and arm from irritation and infection will help to prevent lymphedema.
9. Which intervention should be included in a care plan for a patient with multiple myeloma?
Answer: Promote good hydration. Rational: Hypercalcemia is a common complication of multiple myeloma because the breakdown of bone releases calcium into the bloodstream. Maintaining hydration is most important.
10. Which dietary intervention should the nurse recommend for the family to implement in the care of a client with colorectal cancer who develops stomatitis related to chemotherapy?
Answer: Increased fluid intake to maintain fluid and electrolyte balance and excretion of wastes. Rational: Dehydration is a substancial risk with both colorectal cancer and chemotherapy, and contributes to the fragility of the oral mucosa. Increased fluid intake is the highest priority in dietary planning.
11. Early cancer of the prostate can be detected in a routine physical examination by which method?
Answer: rectal examination. Rational: Digital rectal examination is recommended for all males age 40 and older, because it is simple and very effective way of screening for prostate cancer.
12. Which findings in a 4 year old with abdominal neuroblastoma indicate the development of distant metastasis?
Answer: Periorbital edema and exophthalmus. Rational: Among the findings listed, only this pair lists clinical manifestations of distant metastasis of a neuroblastoma.
13. A patient with a colostomy is being discharged. Which instruction should the nurse give the patient to help prevent skin breakdown?
Answer: Wash the area with mild soap and pat dry. Rational: Soap is mildly abrasive, and works well to clean residue around the stoma. The patient should dry the area by patting rather than rubbing, to avoid irritation and injury to the site.
14. The nurse counsels a family about available community resources to assist in the recovery of their father who has had a total laryngectomy for treatment of cancer. the nurse should consider the counseling effective if the family contacts which support group?
Answer: Lost Chord Club. Rational: The lost chord club is a support group for people who have had laryngectomies ( removal of the larynx including the vocal cords)
15. Which sign should immediately alert the nurse to a potential problem in a patient following colostomy surgery for cancer of the colon?
Answer: The color of the stoma is dark red to black. Rational: Dark red or black coloring of the stoma may indicate an infection.
16. The nurse formulates a nursing Dx of dysfunctional grieving related to a family member's recent pelvic exenteration for vaginal cancer. The nursing care plan for this family should be directed primarily toward which measure?
answer: dealing with anger, guilt, and other expressions of emotional pain. Rationale: The dx indicates that the family's problem is the way they are dealing with the grief process. Anger and guilt are common feelings that it is often difficult for family members to express. The nurse can assist them in working through these feelings in a supportive setting.
17. a patient with cancer is receiving radiation therapy and is in a state of cachexia. Which instruction should the nurse include in the plan of care?
Answer: Eat 6 small meals per day and report any further weight loss. Rationale: A patient in cachexia needs the best nutritional content possible. small frequent meals often work best to maintain weight for these patients.
18. Why should the nurse plan to place a patient with neutropenia in a private room?
Answer: to minimize exposure to infection. Rationale: The greates risk posed by neutropenia (low absolute neutrophil count) is infection. Placement in a private room along with strict asepsis, administration of antibiotics, and careful nutritional planning are key to reducing this risk.
19. Which is the most appropriate instruction to give to the visitors of a patient receiving internal radiation therapy?
Answer: Maintain a distance of 6 feet from isotope source. Rationale: Visitors should be advised to remain 6 feet from the source of the radiation.
20. A pt. with breast CA asks the nurse why she is being treated with 2 different chemotherapy drugs instead of 1. Which information should the nurse include in a response? 2 drugs
Answer: increase the number of tumor cells destroyed. Rationale: Combination ( two-drug) chemotherapy uses drugs that target different phases of the cell-cycle or have different chemical action, to increase the # of tumor cells attacked in each treatment cycle.
21. In planning teaching for parents of a child with osteogenic sarcoma who is receiving chemotherapy, the nurse will focus of the importance of early recogniton of complications of myelosuppression. which signs and symptoms should the nurse tell the parent to look for?
Answer: temperature elevation and gingival bleeding. Rationale: Myelosuppression (depressed bone marrow function) is common in chemotherapy, leading to a risk for infection ( siggnaled by the elevation in temperature) and bleeding.
22. In assessing a pt. who has oral lesions to chemotherapy, the nurse should also assess for lesions in which part of the body?
Answer: perianal area. Rationale: The risk for infection is especially associated with pathogen entry sites such as the oral cavity, IV sites, and the perineum.
23. When preparing a plan to meet the learning needs of a patient with cancer who is undergoing chemotherapy, the nurse should include which instruction?
Answer: Use the recommended antiemetic drug therapy. Rationale: Antiemetic drugs are important to limit or reduce the nausea and vomiting common before, during, and after chemotherapy.
24. The home health nurse should instruct the family of a patient who has just had a bone marrow transplant to report all EXCEPT which finding?
Answer: alopecia. Rationale: Alopecia is an expected result of the high-dose chemotherapy that must precede bone marrow transplant.
25. Which behavior by a pt. with an ileal conduit should alert the nurse to the need for additional teaching related to self-care> The pt.
Answer: secures the face-plate of the appliance with tape. Rationale: Tape is used around the skin barrier, but it should never be used directly on the pouch.
26. During the admission physical of a 3 yr. old child with Wilms' tumor, the nurse should NOT perform which assessment technique?
Answer: palpation of the abdomin. Rationale: Palpation of the abdomen may cause cancer cells to migrate into nearby or even distant sites, if a Wilms' tumor is, in fact, present.
27. A pt. with CA is experiencing pain as a result of metastasis. In developing a plan for pain control, the nurse should include which initial intervention?
Answer: Have the patient rate the severity of the pain using a pain scale. Rationale: Understanding the patient's perception of pain is the first step to planning pain control while providing the patient some autonomy in selecting methods & level of control.
28. which Laboratory finding, if abnormal, for a patient with Ca indicates that chemotherapy should be withheld?
answer: bone marrow suppression. Rationale: some degree of bone marrow suppression is expected with chemotherapy, but abnormal findings may indicate the need to limit or withhold the dose & increase measures to protect the pt. from infection & injury.
29. The nurse is developing a long-term plan for a pt. with an advance malignancy. Which finding would disqualify the pt. for hospice services?
Answer: the pt. has a life expectancy of 1 to 2 years. Rationale: hospice services are generally offered to pts. with a life expectancy of 6 months or less.
30. What should the community health nurse recommend in response to a pts. inquiry about how to cope with anticipated alopecia related to scheduled chemotherapy?
Answer: acquire a wig or hairpiece prior to hair loss to match original hair color. Rationale: selecting a wig or hairpiece before the hair has begun to fall out makes it easier to match color & texture.
31. The nurse is demonstrating breast self-examination (BSE) to a group of older adults. Which is the best indication that learning has taken place?
Answer: return demonstration by participants. Rationale: a return demonstration is almost always the best way to evaluate the success of the nurse's teaching.
32. a pt. with stage 4 adenocarcinoma of the rt. lung has a respiratory rate of 20, heart rate of 92, cyanosis, and a small amount of pale yellow mucus during coughing. Which nursing Dx is indicated for the pt.?
Answer: Impaired gas exchange. Rationale: stage 4 adenocarcinoma indicates that the tumor has metastasized. Gas exchange become impaired as the amount of cancerous tissues increases. the findings listed are consistent with the Dx of impaired gas exchange.
33. When planning nursing interventions to prevent complications in a patient in the advanced stages of Ca who is receiving morphine for pain, what should the nurse recommend?
Answer: high fluid intake with a high-fiber diet. Rationale: opioids such as morphine often causes constipation. A regimen of increased fluids & lots of fiber is necessary to counteract this effect.
34. Which statement by a home care pt. Dx with leukemia indicates the need for further teaching?
Answer: "I keep fresh cut flowers in my room." Rationale: fresh cut flowers & live plants pose a risk for bringing infectious material into the pts home.
35. Which nursing measure should be included in the immediate postoperative care plan of a pt. following a rt. modified radical mastectomy?
Anser; maintain continuous elevation of the rt. arm & hand on a pillow. Rationale: elevation of the arm on the affected side relieves pain after mastectomy.
36. The nurse teaches a parent of a toddler with leukemia about the health management of stomatitis after chemotherapy. Which statement by the parent indicates that the nurse's teaching has been effective/
Answer: "I can prepare my child's favorite foods like mashed potatoes & chocolate milk. Rationale: mashed potatoes & chocolate milk will be nutritious, bland, and easy to chew, making this an appropriate selection for a child with stomatitis.
37. a pt. is receiving chemotherapy of tx of leukemia. Which interventions should the nurse implement if the pt. develops tumor lysis syndrome?
Answer: increase the pts fluids & assess for signs & symptoms of electrolyte imbalances. Rationale: tumor lysis syndrome arises when the contents of cells destroyed by chemotherapy or radiation are released into the body, causing electrolyte imbalances. increasing fluids assists the kidneys in flushing the material.
38. The nurse is teaching cancer prevention to a group of parents. Which food should the nurse teach the parents to limit in their children's diet?
Answer: smoked meats. Rationale: smoked meats contain nitrates & nitrites, which are associated with increased cancer risk.
39. The nurse should encourage a pt receiving radiation therapy for Hodgkin's disease fo follow which diet?
Answer: High-protein, high-carbohydrate, low residue. Rationale: radiation therapy affects the tissues of the GI tract beginning at the oral cavity. changes in taste sensation plus nausea, vomiting, anorexia, and diarrhea may occur, depending on the site. The diet should be highly nutritious (high in protein & carbohydrates) but not irritating to the affected tissues (low residue).
40. A pt. with prostate Ca is scheduled to have a radical prostatectomy. Which response by the nurse would be best when the pt. asks how the surgery will affect his sexual activity?
Answer: "the surgery may cause impotence & a penile prosthesis may be considered. Rationale: impotence is to be expected with radical prostatectomy. A penile prosthesis can enable the pt. to achieve an erection.
41. Which instruction should the nurse give to the parents of a newborn with galatosemia?
Answer: avoiding giving the infant mild & dairy products. Rationale: Tx consists of eliminating all milk & lactose-containing foods, including breast milk.
42. Which clinical manifestations would lead the nurse to suspect down syndrome in a newborn?
Answer: protruding tongue & presence of a palmar crease. Rationale: these are clinical manifestations seen in a newborn with down syndrome.
43. The nurse is discussing the needs of a child with cystic fibrosis with the child's parents. Which statement made by one of the parents indicates a need for further instruction?
Answer: "We will give our child the pancreatic enzymes after each meal." Rationale: pancreatic enzymes are mixed with meals to ensure the digestive enzymes are mixed with food in the duodenum.
44. the nurse is planning care for a 5 yr. old child with mental retardation who is hospitalized for a surgical procedure. Which nursing action should meet the child's needs/
Answer: ask the parents what words the child uses for elimination. Rationale: this focuses on the child's routine or any behavior that requires intervention.
45. Which toy best help the toddler with cystic fibrosis attain the goals of therapy?
Answer: push-pull toys. Rationale: this is a fun, simple activity that helps to stimulate mucus secretion & provides a sense of well-being or increased self-esteem.
46. What is the goal for an infant with neurogenic bladder caused by meningomyelocele?
Answer: preserving renal function. Rationale: ultrasonography & routine urine culture are used to detect urinary system distress before renal function is compromised.
47. which factor commonly affects the nutritional status of children with cerebral palsy?
Answer: feeding difficulties. Rationale: abnormal postures & motor performance & alteration in muscle tone effect chewing, swallowing, and talking.
48. The nurse notes that a 26-month-old toddler can sit with support, but not stand, and that the parents indicate the child says "mama" and "bye-bye." Which is the most appropriate initial nursing intervention?
Answer: refer the child for developmental testing. Rationale: it is the nurse who frequently identifies a need. It is important to emphasize the child's abilities rather than disabilities.
49. The nurse should give priority to which nursing Dx for an infant with hydrocephalus?
Answer: altered cerebral tissue perfusion related to increased intracranial pressure. Rationale: the infant can be irritable & lethargic, feed poorly, & display changes in level of consciousness.
50. a 3 week-old infant if brought to the ER department with repeated vomiting. 1 of the parents reports having had pyloric stenosis as a baby. Which additional assessment data should lead the nurse to suspect pyloric stenosis?
Answer: palpable, olive-shaped epigastric mass. Rationale: Hypertrophy & hyperplasia causes constriction of the pyloric muscle & obstruction of the gastric outlet.
51. the nurse is giving instructions to a pt. who is scheduled for a pacemaker implant. Which pt. statement indicates an understanding of the procedure?
Answer: "A pacemaker delivers a stimulus to the heart to control heart rate."
52. which action by the pt. with sickle cell anemia indicates the need for more teaching? the pt.
Answer: restricts fluids. Rationale: a pt. with sickle cell anemia should be encouraged to maintain fluid intake. Dehydration is a common complication.
53. which assessment data is indicative of iron deficiency anemia?
Answer: smooth, sore tongue. Rationale: a smooth, sore tongue is characteristic of a pt. with long-term iron deficiency anemia.
54. Which lab result in a pt. with cancer is indicative of disseminated intravascular coagulation (DIC)?
Answer: increased fibrin split products.
Rationale: in DIC, normal hemostatic mechanisms are altered & many tiny clots form in the microcirculation. This condition will cause a finding of increased fibrin split products in the lab results.
55. Which findings should the nurse expect in a pt. admitted with deep vein thrombophlebitis?
Answer: pain in the affected area & unilateral edema. Rational: primary signs of deep vein thrombophlebitis include pain in the affected area & unilateral edema.
56. When should the nurse begin Phase 1 rehabilitation of a pt. who is recovering from a myocardial infarction?
Answer: as soon as the pt. is hemodynamically stable. Rationale: Phase 1 rehabilitation after myocardial infarction begins when medical tx. has stabilized cardiac supply & demand.
57. which is a basic stress reduction technique for pts. with coronary artry disease?
Answer: caring for a pet. Rationale: research has shown that caring for a pet has a favorable effect on blood pressure & promotes relaxation>
58. An older adult pt. who is hospitalized with cardiac failure expresses feelings of powerlessness because of the complexity of the TX. Which nursing action should be included in the plan of care?
Answer: provide a choice of foods for the breakfast meal. Rationale: being allowed to choose what to have for breakfast from a list that contains appropriate choices can provide the pt. with some sense of independence in a situation where there are many imposed restrictions.
59. The nurse is assessing a pt. with an abdominal aortic aneurysm. which clinical manifestation indicates a need for emergency measures?
Answer: severe back pain. Rationale: severe back pain in a pt. with an abdominal aortic aneurysm indicates impending rupture & the need to take emergency measures.
60. A school-aged child who recently recovered from a viral illness presents with bruises on the extremities & trunk. Which condition would the nurse expect?
Answer: idiopathic thrombocytopenic purpura (ITP). Rationale: acute idiopathic thrombocytopenic purpura (ITP) occurs after certain childhood illnesses. clinical manifestations of ITP include bruises, especially over bony prominence.
61. Bradydyshythmias, sinoatrial arrest, & AV block may be treated with which drug?
Answer: atropine. Rationale: the findings listed are characteristic of third-degree atrioventricular block, for which atropine is the initial drug of choice.
62. which physiological change associated with smoking increases the incidence of peripheral arterial disease?
Answer: increase in platelet aggregation. Rationale: nicotine increases the risk of clots by increasing platelet aggregation. clots are a key factor in peripheral arterial disease.
63. The community-based nurse is counseling a pt. who si taking 0.25 mg po of digoxin (lanoxin) daily. What statement by the pt. indicates teaching was effective?
Answer: "I take my pulse." Rationale: Digoxin (Lanoxin), a cardiac glycoside, slows the heart rate. Monitoring pulse is an effective way to ensure that the medication is working as expected & is not beginning to produce toxicity.
64. Which patient-centered outcome indicates successful resolution of congestive heart failure (CHF)?
Answer: pulmonary artery wedge pressure (PAWP) is 8mm Hg. Rationale: The normal value for pulmonary artery wedge pressure is 4-12mm Hg.
65. Which pt. statement indicates that the nurse's teaching about precipitating factors of angina has been successful?
Answer: "I won't walk outside when it is very hot or very cold." Rationale: A pt with angina should avoid exercising in an environment with temperature extremes.
66. What is a common side effect of digitalis?
Answer: nausea. Rationale: nausea is a fairly common side effect of digitalis. If combined with several other clinical symptoms, it can be an early indicator of developing digitalis toxicity.
67. The nurse should expect to administer a combination of nitroglycerin IV (TIDAL) and dopamine (INTROPIN) to a pt. with which condition?
Answer: cardogenic shock. Rationale: Nitroglycerin IV and dopamine (Intropin) is a combination given to pts. with cardiogenic shock.
68. which assessment data would validate a nursing Dx of excess fluid volume relative to excess fluid/sodium retention 2nd to rt.-sided heart failure?
Answer: pedal edema. Rationale: Pedal edema is a characteristic finding in pts. with fluid volume excess.
69. Which is a goal of using morphine sulfate to treat acute myocardial infarction?
Answer: to decrease cardiac workload. Rationale: Morphine sulfate is the drug of choice for treating acute myocardial infarction because it reduces preload & thus decreases cardiac workload overall.
70. The nurse is providing instruction to a pt. with a medical history of long term use of sublingual nitroglycerin. which comment made by the pt. indicates that the nurse should provide the pt. with additional instructions?
Answer: "I repeat the dosage every 30 minutes until the angina goes away." Rationale: Dosage instructions for use of nitroglycerin indicate that the pt. may take 3 tablets at 5-minute intervals. If pain is not relieved after the 3rd tablet, the pt. should call for emergency medical services.
71. A pt. with artrial fibrillation has had a change in the dosage of digoxin (Lanoxin) from 0.125 mg to 0.25 mg po daily. Which clinical manifestation or primary concern to the nurse?
Answer: abdominal pain. Rationale: Abdominal pain in a pt. whose digoxin dose has been decreased may indicate early digoxin toxicity.
72. The nurse provides information regarding prevention of recurrence of rheumatic fever. Which statement made by the pt. indicates that the nurse's instruction is effective?
Answer: "I understand that I will need to take precautions for the rest of my life." Rationale: Rheumatic fever has lifelong consequences. The pt. is at high risk for new infection and fro worsening of problems related to the heart & joint damage.
73. Which physiological change in the cardiac system is expected in the older adult?
Answer: increased atrial irritability. Rationale: the aging heart may have an enlarged lt. atrium & increased atrial irritability.
74. Which information should be included in the discharge plan for a pt. receiving an angiotensin converting enzyme (Ace) inhibitor for blood pressure control? You may experience
Answer: cough. Rationale: A cough is the most common site effect of an ACE inhibitor. It usually resolves within 1 to 4 days after therapy is begun, and the pt. should urge to continue taking the medication with this knowledge.
75. Which direction is provided for a pt. undergoing a Schilling test?
Answer: collect all urine for a 24 hour period. Rationale: The Schilling test requires that all urine produced over a 24-hour period is collected. Otherwise, the results are not useful.
76. The goal for a pt. with COPD is that the pt. will have clear breath sounds> which assessment indicates that the pt. is working on this goal? the pt.
Answer: drinks 2 to 3 L of fluid/day. Rationale: Adequate hydration is one of the simple, effective ways for a pt. with COPD to achieve clear breath sounds.
77. Which complication might occur in a pt. who is experiencing brochospasm?
Answer: respiratory arrest. Rationale: Bronchospasm that becomes uncontrolled leads to status asthmaticus, an emergency that can develop into respiratory arrest.
78. What causes the alteration in arterial blood gas values that occurs in a pt. with lobar pneumonia?
Answer: Exudate infiltrates & fills the alveoli. Rationale: Infiltration of the alveoli with fluids is characteristic of lobar pneumonia, & leads to a ventilation-perfusion mismatch & altered blood gas values.
79. Which is an indication that a chest tube drainage system connected to suction is not functioning properly?
Answer: occasional bubbles in the suction chamber. Rationale: occasional bubbles in the suction chamber indicate that something may be wrong with the system.
80. Which statement best describes the administration of high concentrations of oxygen to a person with carbon dioxide retention due to chronic obstructive pulmonary disease (COPD)?
Answer: the respiratory drive will be reduced. Rationale: reduction of the respiratory drive occurs in this situation because blood oxygen levels have been raised, and as a result, the pt. does not expel carbon dioxide.
81. The nurse hears air escaping from a laceration site of a pt. with a perforated chest wound. What is the nurse's priority action? the nurse will
Answer: stop the flow of air coming through the wound. Rationale: the nurse's 1st. priority is to stop the air flow immediately.
82. What is the nurse's best response to a parent who expresses the intention of giving a stuffed animal to a child who has asthma? The nurse tells the parent that stuffed animals
Answer: collect dust that will precipitate symptoms of asthma. Rationale: this is the primary reason that stuffed animals are not recommended for children with asthma.
83. The pt. with a history of emphysema is talking to the nurse about plans for a future vacation. Which vacation destination would be ill-advised for this pt?
Answer: ski resort. Rationale: a ski resort is not a good choice for a pt. with emphysema because of the cold temperatures & possibly high altitude (increasing the chance of hypoxia).
84. a pts. arterial blood gas values are ph 7.32, pao2 5o, & hco3 27. These blood gas values are indicative of which condition?
Answer: respiratory acidosis. Rationale: the combination of PH < 7.4, ow PaCO2, & a slightly elevated HCO3 indicates respiratory acidosis.
85. Which pt. risk factors may indicate that the nurse should assign feeding responsibilities to a LPN?
Answer: vomiting with a decreased level of consciousness. Rationale: this pt. requires the attention of a nurse trained at the level of LVN/LPN or above.
86. Which child in the emergency department should the triage nurse see 1st?
Answer: toddler with a croupy cough, drooling, and agitation. Rationale: the combination of a croupy cough, drooling, & agitation suggests that this child has epiglottitis, which is rapidly progressive & serious.
87. the nurse instructs a pt. with pulmonary disease to drink 6 to 8 glasses of water a day, to use pursed-lip breathing prior to coughing, & to avoid cigarette smoke. The nurse's instructions are interventions based on which nursing dx?
Answer: ineffective airway. Rationale: all of the nurse's instructions in this case are related to improving airway clearance.
88. Which nursing measure is most important to optimize gas exchange for the pt. who is on a ventilator?
Answer: frequently reposition the pt. Rationale: Immobility has negative effects on the pulmonary system, so repositioning is a key intervention to optimize gas exchange for a pt. who is on a ventilator.
89. What is the cause of the wheezing lung sound heard in children with asthma?
Answer: restricted air movement through narrowed airways. Rationale: Narrowed airways that restrict air movement are a defining aspect of asthma, & the cause of the wheezing lung sound.
90. a pt. with asthma is using a metered dose inhaler (MDI) for the 1st time. Which action by the pt. indicates the need for further pt. education? The pt.
Answer: places the inhaler in the mouth. Rationale: most inhalers without a spacer chamber are positioned 1 to 2 inches away from the mouth. The spacer is usually placed in the mouth. This pt. may require further education.
91. which statement by the pt. with moderate persistent asthma indicates the need for further pt. teaching about medication?
Answer: "I only need to take the long-acting medication when I have respiratory problems." Rationale: Long-acting medication for asthma is designed to alleviate symptoms & improve airway function. It needs to be taken regularly, not just on an as needed basis.
92. A pt. with asthma asks the nurse to explain the reason for using a Cromolyn-containing inhalant before exercising. Which is the nurse's best response?
Answer: "Cromolyn helps you tolerate activity." Rationale: Cromolyn inhalers deliver an anti-inflammatory drug that keeps the airway from narrowing in reponse to exercise or cold.
93. Which nursing intervention is most effective in helping a pt. with COPD to improve activity tolerance?
Answer: establish a regular exercise routine. Rationale: activity intolerance is addressed by establishing a regular exercise program.
94. What is the priority nursing action for a pediatric pt. who suddenly becomes cyanotic in the recovery room?
Answer: Suction the nasopharynx. Rationale: Cyanosis indicates obstruction of the airway. when it occurs in a child who is in the recovery room, the nurse's immediate response should be to suction the child.
95. How should the nurse be positioned when delivering the abdominal thrusts of the Heimlich maneuver to a conscious adult who is choking?
Answer: standing behind the person. Rationale: the proper position for delivering the Heimlich maneuver to a conscious adult is standing behind the person who is choking.
96. Which is the most important assessment for a pt. following thoracotomy?
Answer: bilateral sounds. Rationale: Assessing bilateral lung sounds is the most important action for the nurse who is caring for a pt. after a thoracotomy. airway clearance is one of the critical concerns, because retained secretions can cause a variety of complications.
97. Which action should the nurse take to prevent obstruction of a tracheostomy tube by secretions?
Answer: Humidify the air being inspired. Rationale: it is important to humidify the air when a tracheostomy tube is being used.
98. A postoperative pt. with advanced emphysema becomes very short of breath while ambulating. Which action should the nurse implement to improve the patient's breathing pattern?
Answer: instruct the patient to use pursed-lip breathing. Rationale: pursed-lip breathing improves control over the breathing pattern & is likely to ease shortness of breath for this pt.
99. Why may incentive spirometry be more effective than intermittent positive-pressure breathing (IPPB) in preventing or TX atelectasis? Incentive spirometer
Answer: maximizes the amount of air inhaled while maintaining relatively low airway pressure. Rationale: A pt. with atelectasis should be treated in a way that does not increase air pressure in the lung. Incentive spirometer enhances lung expansion, thus allowing maximum intake per inhalation. IPPB may be tried 1st-line choices are not effective.
100. Which symptom should the nurse expect in a 20-month-old pt. DX with larngotracheobronchitis?
Answer: predominant stridor on inspiration. Rationale: Stridor on inspiration is one of the defining features of laryngobronchitis.