Chapter 23 (Test 3) – Flashcards
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Which action should the nurse take first in caring for a client during an acute asthma attack?
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Administer bronchodilator as ordered.
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A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
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Putting on an individually fitted mask when entering the client's room
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A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
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Flail chest
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The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
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Tension pneumothorax
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Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is
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primary drug resistance.
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A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following?
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Asbestos
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Which of the following interventions does a nurse implement for patients with empyema?
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Encourage breathing exercises
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The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation?
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Shortness of breath
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The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?
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Classes at community centers to teach about smoking cessation strategies
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A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
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Dyspnea
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A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest?
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Paradoxical chest movement
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Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?
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It is the most contagious during the second week of illness
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For a patient with pleural effusion, what does chest percussion over the involved area reveal?
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Dullness over the involved area
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A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following?
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Tense and relax muscles in lower extremities.
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A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
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Flail chest
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A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?
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"It is all right if I have a grilled cheese sandwich with American cheese."
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Nursing instruction during postural drainage should include telling the patient to:
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Change positions frequently and cough up secretions.
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A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?
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0 to 4 mm
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When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
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Hypercapnia, hypoventilation, and hypoxemia
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A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
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Impaired gas exchange
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You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
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Encourage increased fluid intake
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You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
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See if there are air leaks in the system
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You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
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Acute respiratory distress syndrome (ARDS)
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A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
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The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
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The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?
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Acute respiratory distress syndrome
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After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
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Significant