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EXAM 3: NUR242/ NUR 242 MEDICAL -SURGICAL
NURSING EXAM | QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES| 100%
CORRECT| GRADE A - GALEN
What assessment findings does the nurse expect to see when a COPD client arrives? (Select all that apply.)
Answer: COPD Pt 1/4 1. Which assessment finding does the
nurse expect to see when the client arrives? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance B,C,D,E SOB, use of accessory muscles, tripod position, barrel chest
What does the nurse do next when a COPD client arrives in acute respiratory distress with respirations of 32 and O2 saturation of 82% on 2 L/min via nasal cannula?
Answer: COPD pt 2/4 2. When the client arrives to the unit, she
is assessed and is in acute respiratory distress. Her respirations are labored with a respiratory rate of 32. Oxygen saturation is 82% on O2 at 2 L/min via nasal cannula. What does the nurse do next? Call rapid response tream O2 sat should be at least 90% on 2 L per NC
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Which order will the nurse implement immediately for a COPD client in acute respiratory distress when the provider arrives with the Rapid Response Team?
Answer: COPD Pt 3/4 3. While the Rapid Response Team is at
the bedside, the client's health care provider arrives. The provider writes several orders. Which order will the nurse implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 minutes after oxygen is increased D. Methylprednisolone sodium succinate (Solu- Medrol) 40 mg IVP B The first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The client should then be transferred to the ICU as soon as possible. Once the client arrives in the ICU, they can administer the one-time dose of Solu-Medrol.
What will the nurse include in discharge teaching for a COPD client transferred to a pulmonary stepdown unit after 3 days in the ICU, with O2 saturation of 99% on 2 L/min via nasal cannula, still slightly short of breath with exertion, and planned for home oxygen?
Answer: COPD pt 4/4 4. The client is in the ICU for 3 days and
then transferred back to a pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2L/min via nasal cannula. She denies any shortness of breath when resting during the assessment. The health care provider plans to discharge the client on home
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oxygen in the morning. What will the nurse include in this client's discharge teaching? Make sure that the client understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress.Because she is being discharged with home oxygen, home health services should be arranged.
Which client statement causes the nurse to suspect an increase in dyspnea for a COPD client who smokes 1 PPD presenting for a routine appointment?
Answer: A client with COPD who smokes 1 PPD presents for a
routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea? A. "I prop myself up at night to sleep." B. "I decided to put on some makeup today." C. "I have a productive cough in the morning." D. "I have gained weight since I was here last." A "I prop myself up at night to sleep." Clients with COPD, who smoke, may have a productive morning cough. Weight loss (not gain) often occurs when dyspnea is increased due to the increased metabolic demand. A disheveled appearance may indicate an increase in dyspnea, if the client doesn't feel well enough to perform ADLs. Sleeping propped up indicates that breathing may be worse while lying down.
Which assessment finding requires nursing intervention for a client with a chest tube following a pneumonectomy?
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Answer: The nurse is assessing a client with a chest tube
following a pneumonectomy. Which assessment finding requires nursing intervention? A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber. C. The water in the water seal chamber rises and falls with inhalation/exhalation. D. Bubbling present in the water seal chamber when the client coughs. A Bandage around the posterior tube is loose. After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose.
What is the priority nursing action for a client with a history of asthma reporting shortness of breath, with a peak flowmeter indicating a PEF reading in the red zone?
Answer: A client with a history of asthma reports shortness of
breath. The nurse observes that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Obtain vital signs. B.Administer rescue drugs. C. Notify the health care provider. D.Repeat the PEF reading to verify results. B Administer rescue drugs. A PEF reading in the red zone indicates a range that is 50% below the client's personal best PEF reading and indicates serious respiratory obstruction. The client needs to receive rescue drugs immediately, and then the health care provider should be notified.