Nursing Chapter 50 Rationale The Seal Between The Clients Face

Kozier & Erb’s Fundamentals of Nursing, 10/E

Chapter 50

Question 1

Type: MCSA

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the

client?

1. The ability to cough

2. Filtration and humidification of inspired air

3. The sneeze reflex initiated by irritants in the nasal passages

4. Decrease in oxygen-carrying capacity of the trachea

Question 2

Type: MCSA

When planning care, for which client should the nurse include close observation for a decreased or absent cough

reflex?

1. The client with a nasal fracture

2. The client with impairment of vagus nerve conduction

3. The client with a sinus infection

4. The client with reduction in respiratory membrane conduction

Question 3

Type: MCSA

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that

complaint?

1. Use of accessory muscles

2. Increased respiratory depth

3. Increased respiratory rate

4. Decreased respiratory depth

5. Decreased respiratory rate

Question 4

Type: MCSA

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the

nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this

diagnosis?

1. Increased hematocrit

2. Decreased BUN

3. Increased blood sugar

4. Increased sedimentation rate

Question 5

Type: MCSA

A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal

cannula is complaining of shortness of breath. What action should the nurse take?

1. Increase the oxygen to 3 liters per minute via nasal cannula.

2. Lower the head of the client’s bed to the semi-Fowler’s position.

3. Have the client breathe through pursed lips.

4. Encourage the client to breathe more rapidly.

Question 6

Type: MCSA

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being

light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse?

1. Prepare to resuscitate the client.

2. Have the client concentrate on slowing down respirations.

3. Place the client in Trendelenburg’s position and ask him to cough forcefully.

4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

Question 7

Type: MCSA

The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse

review in an attempt to understand this phenomenon?

1. Blood sugar

2. Hemoglobin and hematocrit

3. Cardiac enzymes

4. Serum electrolytes

Question 8

Type: MCSA

A client has a medical condition that often results in the development of metabolic acidosis. The nurse should

observe this client for the development of which breathing pattern as a result of this condition?

1. Cheyne-Stokes

2. Biot’s

3. Cluster

4. Kussmaul’s

Question 9

Type: MCSA

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon

exertion. Which nursing diagnosis is best supported by these assessment details?

1. Ineffective Breathing Pattern

2. Anxiety

3. Ineffective Airway Clearance

4. Impaired Gas Exchange

Question 10

Type: MCSA

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this

direction?

1. Sputum contains bacteria that should be expectorated.

2. Swallowing sputum is dangerous to the system.

3. The nurse should view the sputum for quality and quantity.

4. The client is likely to aspirate the sputum while attempting to swallow it.

Question 11

Type: MCSA

The nurse is planning a time schedule for a client’s twice-daily postural drainage. Which time schedule would be

best?

1. 0800 and 1100

2. 1200 and 1800

3. 0700 and 2000

4. 0900 and 2100

Question 12

Type: MCSA

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be

taken by the nurse?

1. Turn the client to the left side.

2. Increase the percentage of oxygen being delivered.

3. Check for an airtight seal between the client’s face and the mask.

4. Increase the liter flow of oxygen being delivered.

Question 13

Type: MCSA

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

1. Tape the airway in place.

2. Suction the client.

3. Turn the client’s head to the side.

4. Insert a nasal trumpet.

Question 14

Type: MCSA

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action

should the nurse plan for this client?

1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.

2. Remove the tracheostomy ties and replace them with an elastic bandage.

3. Remove the tracheostomy inner cannula.

4. Tape the tracheostomy obturator to the head of the bed.

Question 15

Type: MCSA

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?

1. Turn the suction level up to 60 cm prior to inserting the catheter.

2. Increase the oxygen flow to the client by 20% prior to suctioning.

3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.

4. Instruct the client to cough forcefully from the abdomen prior to suction.

Question 16

Type: MCSA

The nurse who is assessing a client’s chest tube insertion site notices a fine crackling sound and feeling upon

palpating the area. What action should the nurse take?

1. Discontinue the chest tube suction.

2. Collaborate with the client’s physician.

3. Mark the area involved and remove the tube.

4. Reinforce the chest tube dressing.

Question 17

Type: MCSA

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string

suture. What materials should the nurse gather for this procedure?

1. An occlusive dressing

2. A 4 × 4 gauze

3. An adhesive gauze pad dressing

4. A non-adherent gauze dressing

Question 18

Type: MCSA

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What

statement made by the client would indicate that this client needs further instruction?

1. “I will replace my cotton blankets with polyester ones.”

2. “My son will not be able to smoke when I am around.”

3. “I will have my electrical appliance checked for grounding.”

4. “I will buy a fire extinguisher for my bedroom.”

Question 19

Type: MCSA

A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if

the tube is still in place?

1. Count the client’s respirations.

2. Assess the depth of the client’s respirations.

3. Auscultate for bilateral breath sounds.

4. Deflate the cuff and listen for minimal leak.

Question 20

Type: MCSA

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive

pulmonary disease. What is the nurse’s next action?

1. Fill the humidifier with normal saline.

2. Pad the tubing where it contacts the client’s ears.

3. Set the oxygen delivery to 5 liters.

4. Secure the cannula with ties around the client’s head.

Question 21

Type: MCSA

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best

method for changing these ties?

1. Remove the old ties, clean the area well, and then put on new ties.

2. Attach the new tape and tie with a square knot behind the client’s neck.

3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.

4. Remove the outer cannula, replace the soiled ties, and reinsert.

Question 22

Type: MCSA

The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to

the UAP?

1. Both oral and tracheal suctioning

2. Only oral suctioning

3. Only tracheal suctioning

4. Neither oral nor tracheal suctioning

Question 23

Type: MCSA

During tracheal suctioning, the nurse notes that the client’ heart rate has increased from 80 to 100 bpm. Based

upon this assessment, what action should the nurse take?

1. Immediately discontinue suctioning.

2. Prepare to resuscitate the client.

3. Continue to suction until the airway is clear.

4. Complete the suction episode as quickly as possible.