Nursing Exam IV Study Guide: Elimination, Oxygenation, Fluids, Exams of Advanced Education

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FUNDAMENTALS OF NURSING EXAM IV STUDY

QUESTIONS (URINARY ELIMINATION FECAL

ELIMINATION OXYGENATION FLUID AND

ELECTROLYTES) WITH CORRECT ANSWERS 100%

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

1. The bladder distends and its capacity increases
2. Older adults ignore the need to void
3. Urine becomes more concentrated
4. The amount of urine retained after voiding increases - CORRECT ANSWERS-Answer : 4 Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don't ignore the urge to void and may have difficulty getting to the toilet in time (Option 2)The kidney becomes less able to concentrate urine with age (Option3) During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
5. Perineal skin irritation
6. Fluid intake of less than 1,500 mL/d
7. History of antihistamine intake
8. Hx of UTI
9. A fecal impaction - CORRECT ANSWERS-Answers: 1,2,4, Rationale: The perineum may become irritated by the frequent contact with urine (Opt.1). Normal fluid intake is at least 1,500 mL/d and clients often decrease their intake to try to minimize urine leakage (Opt.2) UTIs can contribute to incontinence. (Opt4) A fecal impaction can compress the urethra, which results in sm. amts of urine leakage (Opt5) Antihistamines can cause urinary retention rather than urinary incontinence. (Opt3) Which action represents the appropriate nsg management of a client wearing a condom catheter?
10. Ensure that the tip of the penis fits snugly against the end of the condom
11. Check the penis for adequate circulation 30 min after applying
12. Chg the condom every 8 hours
13. Tape the collecting tube to the lower abd. - CORRECT ANSWERS-Answer: 2

Rationale: The penis & condom should be checked 1/2 hour after application to ensure that it's not too tight. A 1 in. space should be left btw the penis and the end of the condom (Opt1) The condom is chgd every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag (opt4) An indwelling catheter is taped to the lower abd. or upper thigh The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?

1. Leaves the catheter in place and gets a new sterile catheter 2.Leaves the catheter in place and asks another nurse to attempt the procedure 3.Removes the catheter and redirects it to the urinary meatus 4.Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus - CORRECT ANSWERS-Answer: 1 Rationale: The catheter in the vagina is contaminated and can't be reused.If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn't indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (op2) Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter? 1."I will keep the collecting bag below the level of the bladder at all times" 2."Intake of cranberry juice may help decrease the risk of infection" 3."Soaking in a warm tub bath may ease the irritation associated with the catheter" 4."I should use clean tech. when emptying the collecting bag" - CORRECT ANSWERS-Answer: 3 Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage.(Opt1)Intake of cranberry juice creates an environment nonconducive to infection(opt2)Clean tech. is appropriate for touching the exterior portions of the system(opt4) During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1.stress urinary incontinence
2. reflex urinary incontinence
3. functional urinary incontinence 4 urge urinary incontinence - CORRECT ANSWERS-Answer: 4 rationale: The key phrase is "the urge to void" option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when

5. Performs pelvic muscle exercises - CORRECT ANSWERS-Answer:2 , Rationale: it is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4) A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? 1.Coughing 2.mobility deficits 3.prostate enlargement 4.urinary tract infection - CORRECT ANSWERS-1. Coughing, which raises the intro abdominal pressure, is related to stress incontinence, not overflow incontinence.
6. Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence. 3.* an enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure with in the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape(overflow incontinence)
7. Urinary tract infections are related to urge incontinence, not overflow incontinence. A nurse must measure the intake and output (I & O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? 1.Urinal 2.graduate, 3.large syringe, 4.urine collection bag - CORRECT ANSWERS-1. Although urinals have volume markings on the side, usually they occur in 100 mL increments that do not promote accurate measurements 2.* A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume
8. This is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter)
9. A urine collection bag is flexible and balloons outward as urine collects .In addition, the volume markings are at 100 mL increments that do not promote accurate measurements. A patient's urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? 1.Urinary retention, 2.urinary tract infection, 3.Keytone bodies in the urine,

4.high urinary calcium level, - CORRECT ANSWERS-1. These clinical manifestations do not reflect urinary retention. Urinary retention is evidenced by supra pubic distention and lack of voiding or small, frequent voiding ( overflow incontinence) 2* The urine appears concentrated (amber)and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria)

3. These clinical manifestations do not reflect Keytone bodies in the urine. A reagent strip dipped in urine will measure the presence of Keytone bodies
4. These clinical manifestations do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24 hour urine specimen. A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? 1.Encouraging the use of bladder training exercises
5. Providing assistance with toileting every four hours
6. Positioning a bedside commode near the bed
7. Teaching the avoidance of fluid after 5 PM - CORRECT ANSWERS-1. Although this should be done, it is not the priority.
8. This may be too often or not often enough for the patient. Care should be individualized for the patient 3.* The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis
9. Fluids may be decreased during the last two hours before bedtime, but they should not be avoided completely after 5 PM. Some fluid intake is necessary for adequate renal perfusion. A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen? 1.Use a sterile specimen container, 2.collect urine from the catheter port, 3.inflate the balloon with 10 mL of sterile water, 4.have the patient void before collecting the specimen - CORRECT ANSWERS- 1.* A culture attempts to identify the micro organisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated micro organisms. A sterile specimen container is used to prevent contamination of the specimen by micro organisms outside the body(exogenous)
10. The urine from straight catheter flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the patient has a urinary retention catheter.
11. A straight catheter has a single lumen for draining urine from the bladder. A straight catheter does not remain in the bladder and therefore does not have a 2nd lumen for water to be inserted into a balloon

should discard the first voiding of the 24 hour urine specimen, and note the time B. The nurse should collect all voidings after that and keep them in a refrigerated container. C. For a urinalysis, the nurse should ask the client to urinate and pour the urine into a specimen container D. For a culture, the nurse should ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply A. Establish a schedule of voiding prior to meal times B. Have the client record voiding times C. Gradually increase the voiding intervals D. Reminded client to hold urine until next scheduled voiding time E. Provide a sterile container for voiding - CORRECT ANSWERS-A. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours. Mealtimes are not regular, and the intervals maybe longer than every four hours B. * ask the client to keep track of voiding times is an appropriate nursing action C. * gradually increasing the voiding interval is an appropriate nursing action D. * The client should be reminded to hold urine until the next scheduled voiding time E. A sterile container is not used in a bladder training program A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply. A. Having sexual intercourse on a frequent basis B. Lowering of testosterone levels C. Wiping from front to back D. The location of the vagina in relation to the anus E. Undergoing frequent catheterization - CORRECT ANSWERS-A. * having sexual intercourse on a frequent basis is a factor that increases the risk of UTI in both males and females B. The decrease in estrogen levels during menopause increases a woman's susceptibility to UTIs C. Wiping from front to back decreases a woman's risk of UTIs D. * The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs E. * undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?

1. Constipation 2.diarrhea 3.incontinence 4.hemorrhoids - CORRECT ANSWERS-Answer: Rationale: habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result-if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (opt2) ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option three). Hemorrhoids would only occur only if severe drying out of the stool occurs, and thus repeated need to strain to pass stool (option four) Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1."I need to drink one and a half to 2 quarts of liquid each day" 2."I need to take a laxative such as milk of magnesium or if I don't have a BM every day" 3."if my bowel pattern changes on its own, I should call you" 4."eating my meals at regular times is likely to result in regular bowel movements" - CORRECT ANSWERS-Answer: Rationale: The standard of practice in assisting the older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well- balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (opt2). In addition, a normal stool pattern for an older adult may not be daily elimination A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? 1.Oil retention 2. return flow 3high large volume 4low, small volume - CORRECT ANSWERS-Answer: Rationale: small volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option one) return flow enemas help expel flatus (option two) because of the risk of loss of fluid and electrolytes high,large volume enemas are seldom used (option three) The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1.The stoma extends 1/2 inch above the abdomen. 2.The skin under the appliance looks red briefly after removing the appliance. 3.The stoma color is a deep red purple.

4.Oil retention. - CORRECT ANSWERS-Answer: Rationale: this provides relief of post operative flatus, stimulating bowel motility. Options one, two, and four manage constipation and do not provide flatus relief Which of the following is most likely to validate that a client is experiencing intestinal bleeding?

1. Large quantities of fat mixed with pale yellow liquid stool. 2.Brown, formed stool. 3.Semi soft tar colored stools. 4.Narrow, Pencil shaped stool - CORRECT ANSWERS-Answer: Rationale: blood in the upper G.I. tract is black and tarry. Option one can be a sign of malabsorbtion in an infant, option two is normal stool, and option four is characteristic of an obstructive condition of the rectum Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply
2. Bowel incontinence. 2.Risk for deficient fluid volume. 3.Disturbed body image. 4Social isolation. 5Risk for impaired skin integrity - CORRECT ANSWERS- Answer:1,3,4, Rationale: option one is the most appropriate. The client is unable to decide when stool evacuation will occur. In option three, client thoughts about self may be altered if unable to control stool evacuation. In option five, increased tissue contact with fecal material may result in impairment. Option two is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site? Referred to page 376 in fundamentals of nursing - CORRECT ANSWERS- Answer: 5 Rationale: option five is a sigmoid ostomy site. Option one is an ileostomy site, option two is an ascending colostomy, option three is transverse colostomy, and option four is descending colostomy A nurse determines that a fracture bedpan should be used for the patient who: 1.has a spinal cord injury. 2.Is on bedrest. 3.Has dementia. 4.Is obese - CORRECT ANSWERS-1* A fracture bedpan has a low back that promotes function of the patient's lower back while on the bedpan.
3. A regular bed pan is appropriate for this patient 3.A regular bed pan is appropriate for this patient 4.A regular bed pan is appropriate for this patient

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material? 1.Whole wheat bread. 2.White rice. 3.Pasta. 4.Kale. - CORRECT ANSWERS-1. One slice of whole wheat bread contains only 1.5 g of dietary fiber. 2.A serving of a 1/2 cup of white rice contains only 0.8 g of dietary fiber. 3.A serving of 3 1/2 ounces of cooked pasta contains only 1.6 g of dietary fiber 4.* Kayle is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contain 6.6 g of dietary fiber Which statement by a patient with an ileostomy alert the nurse to the need for further education? 1."I don't expect to have much of a problem with fecal odor"

2. "I will have to take special precaution to protect my skin around the stoma" 3."I'm going to have to irragate my stoma so I have a bowel movement every morning" 4."I should avoid gas forming foods like beans to limit funny noises from the stoma" - CORRECT ANSWERS-1.The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the large intestine. And ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum)
3. cleansing the skin, skin barriers, and a well fitted appliance are precautions to protect the skin around the ileostomy stoma. The drainage from ileostomy contains enzymes that can damage the skin. 3.* this statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. And ileostomy produces liquid fecal drainage that is constant and cannot be regulated
4. An iliostomy stoma does not have a sphincter that can control the flow of flatus or drainage, resulting in noise A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema The nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?
5. Lubricate the last 2 inches of the rectal tube. 2Insert the rectal tube about 4 inches into the anus.
6. Raise the solution container about 12 inches above the anus. 4.Lower the solution container after instilling about 150 mL of solution - CORRECT ANSWERS-1. All rectal tube should be lubricated to facilitate entry of the tube into the anus and rectum and prevent mucosal trauma. 2.The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to 4 inches ensures that the tip of the tube is beyond the anal Sphincter. This action is appropriate for all types of enemas.

C. Rice pudding and ripe bananas are low residue options that could actually worsen constipation. D. Roast chicken and white rice or low residue options that could actually worsen constipation A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply. A.Bradycardia. B.Hypotension. C.Fever. D.Poor skin turgor. E. Peripheral edema - CORRECT ANSWERS-A. Prolonged diarrhea is more likely to cause take a tachycardia than bradycardia. B.Prolonged diarrhea lead to dehydration, which causes a decrease in blood pressure. C.Prolonged diarrhea leads to dehydration, which causes fever. D. *Prolonged diarrhea leads to dehydration, which causes poor skin turgor. E. Peripheral edema results from a fluid overload. Prolonged diarrhea is more likely to cause a fluid deficit A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply. A. Warm the enema solution prior to installation. B.Position the client on the left side with the right leg flexed forward. C.Lubricate the rectal tube or nozzle. D.Slowly insert the rectal tube about 2 inches. E.Hang the enema container 24 inches above the clients anus - CORRECT ANSWERS-A. The nurse should warm the enema solution because cold fluid can cause abdominal cramping and hot fluid can injure the intestinal mucosa. B.This position allows a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon C. * lubrication prevents trauma or irritation to the rectal mucosa. D.This is an appropriate length of insertion for a child. For an adult client, the nurse should insert a tube 3 to 4 inches. E. The height of the fluid container affects the speed of installation. The maximum recommended height is 18 inches. Hanging the container higher than that could cause rapid installation and possibly painful distention of the colon While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have a client hold his breath briefly. B.Discontinue the fluid installation. C.Remind the client that cramping is common at this time. D.Lower the enema fluid container. - CORRECT ANSWERS-A. Taking slow, deep breaths is more therapeutic for easing discomfort than holding the breath. B.The nurse should stop the installation if the clients abdomen becomes a rigid and distended or if the nurse notes bleeding from the rectum.

C.This intervention is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it. D. * to relieve the clients discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the clients condition? 1.Hypoxia 2.hypoxemia 3.dyspnea 4.cyanosis - CORRECT ANSWERS-Answer: Rationale: A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. The nurse can only observe signs/symptoms of hypoxia (option one). More information is needed to validate this conclusion. Hypoxemia requires blood oxygenation saturation data to be confirmed (option two) and dyspnea is difficulty breathing (option three) To prevent postoperative complications, the nurse assist the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following? 1.Coughing exercises one hour before meals and deep breathing one hour after meals. 2.Forceful coughing as many times as tolerated. 3.Huff coughing every two hours or as needed. 4.Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day - CORRECT ANSWERS-Answer: 3 Rationale: huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as post operatively) deep breathing and coughing should be performed at the same time. Only at meal times is not sufficient (option one). Extended forceful coughing fatigues the client, especially post operatively (option two). Diaphragmatic and pursed lip breathing are techniques used for clients with obstructive airway disease (option four) The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action? 1.Tells the client to raise two fingers to indicate pain or distress. 2.Changes twill tape holding the tracheostomy and place. 3.Cleans the incision site. 4.Checks the tightness of the ties and knots - CORRECT ANSWERS-Answer: Rarionale: prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. The twill tape is not changed until after performing tracheostomy care (option two) cleaning the incision should be done after cleaning the inner cannula (option three) checking the tightness of the ties and knot is done after apply new twill tape (option four)

3.A fractured rib. 4.A tumor of the medulla - CORRECT ANSWERS-Answer: Rationale: anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Option two would depend on where the infection is located. Option three: a fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Option four: damage to the medulla would interfere with neural stimulation of the respiratory system Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breed more comfortably and effectively? 1.Dyspnea 2.Hyperpnea 3.orthopnea 4.acapnea - CORRECT ANSWERS-Answer: Rationale: respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse respond by saying that the corticosteroids will do which of the following? 1.Promote bronchodilation. 2.Help the client to cough. 3.Prevent respiratory infection. 4.Decrease inflammation in the airways - CORRECT ANSWERS-Answer: Rationale: glucocorticoids are prescribed because of their anti-inflammatory effect. Options one, two, and four are not achieved with glucocorticoids The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care? 1.Percussion and postural drainage should be done before lunch. 2.The order should be coughing, percussion, positioning, and then suctioning. 3.A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested. 4.Percussion and postural drainage should always be preceded by three minutes of 100% oxygen. - CORRECT ANSWERS-Answer: Rationale: postural drainage result in expectoration of large amounts of mucus. Client sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort The nurse teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective? 1.Supplemental oxygen use will be reduced. 2.Inspiratory volume will be increased.

3.Sputum will be expectorated. 4.Coughing will be stimulated. - CORRECT ANSWERS-1. Patients who use an incentive spirometer may or may not be receiving oxygen 2.* an incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis

3. Although sputum maybe expectorated after the use of an incentive Iran mature, this is not the primary reason for its use. 4.Although the deep breathing associated with the use of an incentive barometer may stimulate coughing, this is not the primary reason for its use. A nurse is applying to a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold? 1.Minimizes muscle spasms 2.Prevents hemorrhage. 3.Increases circulation. 4.Reduces discomfort - CORRECT ANSWERS-1. Both heat and cold relax muscles and thus minimize muscle spasms. There is no advantage to using heat over cold.
4. Heat does not prevent hemorrhage; heat causes vasodilation, which promotes hemorrhage. 3.* heat increases the skin surface temperature, promoting vasodilation, which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction, which decreases blood flow to the area.
5. Both heat and cold can reduce discomfort. Cold reduces discomfort by numbing the area, slowing the transmission of pain impulses, and increasing the pain threshold. Heat reduces the discomfort by relaxing the muscles A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioners order? 1.Emphysema. 2.Osteoporosis. 3.Cystic fibrosis. 4.Chronic bronchitis - CORRECT ANSWERS-1. These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls 2.* implementing the practitioners order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength.
6. These are appropriate interventions for a patient with cystic fibrosis cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick, tenacious secretions in the respiratory system that block the bronchioles, creating breathing difficulties
7. These are appropriate interventions for a patient with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.

C. Bradycardia is a late manifestation of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. D. Confusion is a late manifestation of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. E.Pallor is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal talking, and adventitious lung sounds A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority? A.Increase the oxygen flow. B.Assist the client to Fowlers position. C.Promote removal of pulmonary secretions. D.Attain a specimen for arterial blood gases - CORRECT ANSWERS-A. The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing. However, administering oxygen and adjusting the fraction of inspired oxygen requires the providers prescription after a careful assessment of the clients oxygenation status, there is a higher priority given the nature of the clients distress. B. * The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients dyspnea. Fowlers position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea C. The client may need suction or expectoration, as pulmonary secretions may be the cause of his difficulty breathing. However, there is a higher priority given the nature of the clients distress. D.It is important to check the clients oxygenation status, and in many nursing situations, assessment precedes action, but there is a higher priority given the nature of the clients distress. A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply. A.Apply suction while withdrawing the catheter. B.Perform suctioning on a routine basis, every 2 to 3 hours. C.Maintain medical asepsis during suctioning. D.Use a new catheter for each suctioning attempt. E.Limit suctioning to 2 to 3 attempts. - CORRECT ANSWERS-A.The nurse should apply suction pressure only while withdrawing the catheter, not while inserting it. B. The nurse should not suction routinely, because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm. C.Endotracheal suctioning requires surgical asepsis

D. * The nurse should not reuse the suction catheter unless an in-line suctioning system is in place. E.To prevent hypoxemia, the nurse should limit each section in session to 2 to 3 attempts and allow at least one minute between passes for ventilation and oxygenation. A nurses caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply. A.Apply the oxygen source loosely if the SPO2 increases during the procedure. B.Use surgical asepsis to remove and clean the inner cannula. C.Clean the outer surfaces in a circular motion from the stoma site outward. D.Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder. - CORRECT ANSWERS-A. * The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. B.The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. * this helps move mucus and contaminated material away from the stoma for easy removal. D.To help keep the skin clean and dry, the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgment with replacing the ties, so he should not replace them routinely. E.The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? 1.Increase blood pressure. 2.Week, rapid pulse. 3.Moist mucous membranes. 4.Jugular vein distention. - CORRECT ANSWERS- Answer: Rationale: all other options are indicated of fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit. A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? 1.Start an IV. 2.Review the results of serum electrolytes. 3.Offer the woman foods that are high in sodium and potassium content. 4.Administer an anti-a medic - CORRECT ANSWERS-Answer: