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NCM 103 END TERM EXAMINATION 1st Semester SY 2016-2017
INSTRUCTIONS : Use black pen. pen. Read carefully carefully and analyze analyze your answer answer.. Circle the letter that corresponds to your your correct answer. answer. Erasures are not allowed. !ls. write your na"e at the #E$T upper corner% 1. &hich one of the followin' is NOT a function of the Upper airway( A. For For ce!r!"ce ce!r!"ce mec#! mec#!"$sm "$sm s%c# s%c# !s co%&#$" co%&#$"& & '. Tr!"s(ort &!ses to t#e o)er !$r)!*s C. +!rm$"&, F$tr!t$o" !" %m$$/c!t$o" o $"s($re !$r D. rotect t#e o)er !$r)!* rom ore$&" m!ter
2. This is the paranasal sinus found between the eyes and the nose that e)tends backward into the skull A. E#tmo$ E#tmo$ '. S(#e"o$
C. M!$ M!$! !r* r* D. Fro"t!
3. *ene +e ,onne -atrouchuacheuluiki wants to chan'e her surna"e to so"ethin' shorter/ The court denied her re0uest which depresses her and 1nd herself bin'e eatin'. She accidentally accidentally aspirate a lar'e piece of nut and it passes the carina. !robabilty wise/ &here will the nut 'o( A. R$&#t m!$" stem ro"c#%s '. 4e 4ett m! m!$" stem r ro"c o"c#%s #%s
C. 'e $so&e $" et)ee" t#e c!r$"! D. 'e o oc5e c5e * * t#e t#e co cos se e($& ($&ot ottt$s
. &hich cell secretes "ucus that help protect the lun's by trappin' debris in the respiratory tract( A. T*(e I ("e%moc*tes '. T*(e II ("e%moc*tes
C. oet ces D. A$(ose ces
8. Refers to the e)tra air that can be inhaled beyond the nor"al tidal 2olu"e A. I"s($r!tor* reser9e reser9e 9o%me '. E($r!tor* reser9e 9o%me
C. F%"ct$o"! res$%! res$%! c!(!c$t* D. Res$%! 9o%me
6. Casssandra/ 3 44 year old 'rade 3'nostic/ 3sked you/ how "any spikes of bones are there in "y ribs( 5our best response is which of the followin'(
A. +e #!9e 13 (!$rs o r$s C!ss!"r! '. +e #!9e 12 (!$rs o r$s C!ss!"r! C. %m!"s #!9e 16 (!$rs o r$s, !" t#!t )!s "ote * es!$%s $" 183 D. %m!"s #!9e ; (!$rs o r$s. o )#$c# !re
7. &hich of the followin' is considered as the "ain "uscle of respiration( A. 4%"&s '. I"tercost! M%sces
C. D$!(#r!&m D. ector!$s m!=or
;. 3ll but one of the followin' is a purpose of stea" inhalation A. M%co*t$c '. +!rm !" #%m$$* !$r
C. Am$"$ster me$c!t$o"s D. romote ro"c#oco"str$ct$o"
>. &hen should a nurse suction a client( A. As es$re '. As "eee C. E9er* 1 #o%r D. E9er* #o%rs
10. Ernest 3rnold 6a"ilton/ a 78 year old 3"erican client was "obbed by teen 'an'sters near New york/ Cubao. 6e was rushed to 9ohn 6opio :edical Center and was Unconscious. 5ou are his nurse and you are to suction his secretions. In which position should you place :r. 6a"ilton( A. $&# o)ers '. Sem$ o)ers
C. ro"e D. S$e *$"&
11. There are four catheter sizes a2ailable for use/ which one of these should you use for :r. 6a"ilton( A. Fr. 1;
C. Fr. 10
'. '. Fr. 12
D. Fr. 8
12. &hich of the followin' is the initial si'n of hypo)e"ia in an adult client( A. T!c#*("e! !" T!c#*c!r$!
C. T!c#*c!r$! !" F!r$"& o N!res
'. T!c#*c!r$! !" Irr$t!$$t*
D. C*!"os$s !" !or
13. &hich of the followin' o)y'en deli2ery "ethod can deli2er ;88< O)y'en at ;= #!:( A. N!s! C!""%!
C. No" Rere!t#er m!s5
'. S$m(e F!ce m!s5
D. !rt$! Rere!t#er m!s5
1. Roberto San 3ndres/ 3 new nurse in the hospital is about to ad"inister o)y'en on patient with Respiratory distress. 3s his senior nurse/ you should inter2ene if Roberto will> A. ?ses 9e"t%re m!s5 $" o*&e" !m$"$str!t$o" '. %t ! "o" rere!t#er m!s5 $" t#e (!t$e"t eore o(e"$"& t#e o*&e" so%rce C. ?se ! (!rt$! rere!t#er m!s5 to e$9er o*&e" D. C#ec5 or t#e octor@s orer or O*&e" !m$"$str!t$o"
18. &hich of the followin' will alert the nurse as an early si'n of hypo)ia( A. C$e"t $s t$re !" *s("e$c
C. T#e c$e"t@s #e!rt r!te $s 80 'M
'. T#e c$e"t $s co%&#$"& o%t oo s$e to s$e
D. C$e"t $s re%e"t* t%r"$"& rom
16. :i'uelito de balboa/ 3n O$& presents at the ad"ission with an 3>! +ia"eter ratio of 4>;/ &hich of the followin' associated 1ndin' should the nurse e)pect( A. !"c*to(e"$! '. A"em$!
C. F$"&ers !re C%-$5e D. em!tocr$t o c$e"t $s ecre!se
17. The best "ethod of o)y'en ad"inistration for client with CO!+ uses> A. C!""%!
C. No" rere!t#er m!s5
'. S$m(e F!ce m!s5
D. e"t%r$ m!s5
1;. :an' +a'ul/ a =8 year old chronic s"oker was brou'ht to the E.R because of di?culty in breathin'. !leural e@usion was the dia'nosis and CTT was ordered. &hat does C.T.T Stands for( A. C#est t%e t#or!cotom*
C. Cose t%e t#or!cotom*
'. C#est t%e t#or!costom*
D. Cose t%e t#or!costm*
1>. &here will the CTT be inserted if we are to drain Auids accu"ulated in :an' da'ulBs pleura( A. 2" ICS
C. 8t# ICS
'. t# ICS
D. ;t# ICS
20. There is a continuous bubblin' in the water sealed draina'e syste" with suction. 3nd oscillation is obser2ed. 3s a nurse/ what should you do( A. Co"s$er t#$s !s "orm! /"$"&s '. Not$* t#e (#*s$c$!" ress$"&
C. C#ec5 or t%e e!5 D. re(!re ! (etro!t%m &!%Be
21. 3n elderly client with pneu"onia "ay appear with which of the followin' sy"pto"s 1rst( A. Atere me"t! st!t%s !" e#*r!t$o" '. e9er !" c#$s C. emo(t*s$s !" *s("e! D. e%ret$c c#est (!$" !" co%&# 22. &hich of the followin' pathophysiolo'ical "echanis"s that occurs in the lun' parenchy"a allows pneu"onia to de2elop( A. Ateect!s$s C. E%s$o" '. 'ro"c#$ect!s$s D. I"
26. 3 client with acute asth"a showin' inspiratory and e)piratory wheezes and a decreased e)piratory 2olu"e should be treated with which of the followin' classes of "edication ri'ht away( !. 'et!-!re"er&$c oc5ers c. I"#!e stero$s . 'ro"c#o$!tors . Or! stero$s 27. 3 ;GDyearDold co"es into the e"er'ency depart"ent with acute asth"a. 6is respiratory rate is HH breathsF"inute/ and he appears to be in acute respiratory distress. &hich of the followin' actions should be taken 1rst( !. T!5e ! % me$c!t$o" #$stor* . $9e ! ro"c#o$!tor * "e%%$Ber c. A((* ! c!r$!c mo"$tor to t#e c$e"t . ro9$e emot$o"! s%((ort to t#e c$e"t. 2;. 3 =DyearDold client with a H8Dyear history of s"okin' one to two packs of ci'arettes a day has a chronic cou'h producin' thick sputu"/ peripheral ede"a/ and cyanotic nail beds. Jased on this infor"ation/ he "ost likely has which of the followin' conditions( !. A%t res($r!tor* $stress s*"rome ARDS . Ast#m! c. C#ro"$c ostr%ct$9e ro"c#$t$s . Em(#*sem! 2>. The ter" Kblue bloaterL refers to which of the followin' conditions( !. A%t res($r!tor* $stress s*"rome ARDS . Ast#m! c. C#ro"$c ostr%ct$9e ro"c#$t$s . Em(#*sem! 30. The ter" Kpink pu@erL refers to the client with which of the followin' conditions( !. ARDS c. C#ro"$c ostr%ct$9e ro"c#$t$s . Ast#m! . Em(#*sem! 31. 3 77DyearDold client has "arked dyspnea at rest/ is thin/ and uses accessory "uscles to breathe. 6eBs tachypneic/ with a prolon'ed e)piratory phase. 6e has no cou'h. 6e leans forward with his ar"s braced on his knees to support his chest and shoulders for breathin'. This client has sy"pto"s of which of the followin' respiratory disorders( !. ARDS c. C#ro"$c ostr%ct$9e ro"c#$t$s . Ast#m! . Em(#*sem! 32. ItBs hi'hly reco""ended that clients with asth"a/ chronic bronchitis/ and e"physe"a ha2e !neu"o2a) and Au 2accinations for which of the followin' reasons( !. A c$e"ts !re recomme"e to #!9e t#ese 9!cc$"es . T#ese 9!cc$"es (ro%ce ro"c#o$!t$o" !" $m(ro9e o*&e"!t$o". c. T#ese 9!cc$"es #e( re%ce t#e t!c#*("e! t#ese c$e"ts e(er$e"ce. . Res($r!tor* $"ect$o"s c!" c!%se se9ere #*(o$! !" (oss$* e!t# $" t#ese c$e"ts. 33. E)ercise has which of the followin' e@ects on clients with asth"a/ chronic bronchitis/ and e"physe"a( !. It e"#!"ces c!r$o9!sc%!r /t"ess. . It $m(ro9es res($r!tor* m%sce stre"&t#.
c. It re%ces t#e "%mer o !c%te !tt!c5s. . It )orse"s res($r!tor* %"ct$o" !" $s $sco%r!&e. 3. Clients with chronic obstructi2e bronchitis are 'i2en diuretic therapy. &hich of the followin' reasons best e)plains why( !. Re%c$"& <%$ 9o%me re%ces o*&e" em!". . Re%c$"& <%$ 9o%me $m(ro9es c$e"ts@ mo$$t*. c. Restr$ct$"& <%$ 9o%me re%ces s(%t%m (ro%ct$o". . Re%c$"& <%$ 9o%me $m(ro9es res($r!tor* %"ct$o". 38. 3 7GDyearDold client appears thin and cachectic. 6eBs short of breath at rest and his dyspnea increases with the sli'htest e)ertion. 6is breath sounds are di"inished e2en with deep inspiration. These si'ns and sy"pto"s 1t which of the followin' conditions( !. ARDS c. C#ro"$c ostr%ct$9e ro"c#$t$s . Ast#m! . Em(#*sem! 36. 3 client with e"physe"a should recei2e only ; to #F"inute of o)y'en/ if needed/ or he "ay lose his hypo)ic dri2e. &hich of the followin' state"ents is correct about hypo)ic dri2e( !. T#e c$e"t oes"@t "ot$ce #e "ees to re!t#e. . T#e c$e"t re!t#es o"* )#e" #$s o*&e" e9es c$m !o9e ! cert!$" (o$"t. c. T#e c$e"t re!t#es o"* )#e" #$s o*&e" e9es $( eo) ! cert!$" (o$"t. . T#e c$e"t re!t#es o"* )#e" #$s c!ro" $o$e e9e $(s eo) ! cert!$" (o$"t. 37. Teachin' for a client with chronic obstructi2e pul"onary disease CO!+% should include which of the followin' topics( !. o) to #!9e #$s )$e e!r" to $ste" to #$s %"&s )$t# ! stet#osco(e rom +!M!rt. . o) to $"cre!se #$s o*&e" t#er!(*. c. o) to tre!t res($r!tor* $"ect$o"s )$t#o%t &o$"& to t#e (#*s$c$!". . o) to reco&"$Be t#e s$&"s o !" $m(e"$"& res($r!tor* $"ect$o". 3;. &hich of the followin' respiratory disorders is "ost co""on in the 1rst 4H to H hours after sur'ery( !. Ateect!s$s c. "e%mo"$! . 'ro"c#$t$s . "e%mot#or! 3>. &hich of the followin' "easures can reduce or pre2ent the incidence of atelectasis in a postDoperati2e client( !. C#est (#*s$ot#er!(* c. Re%c$"& o*&e" re%$reme"ts . Mec#!"$c! 9e"t$!t$o" . ?se o !" $"ce"t$9e s($rometer 0. E"er'ency treat"ent of a client in status asth"aticus includes which of the followin' "edications( !. I"#!e et!-!re"er&$c !&e"ts c. I.. et!-!re"er&$c !&e"ts . I"#!e cort$costero$s . Or! cort$costero$s +r. 9ones prescribes albuterol sulfate !ro2entil% for a patient 1.
with newly dia'nose asth"a. &hen teachin' the patient about this dru'/ the nurse should e)plain that it "ay cause> A. N!s! co"&est$o" '. Ner9o%s"ess
C. 4et#!r&* D. *(er5!em$!
2.:iria"/ a colle'e student with acute rhinitis sees the ca"pus nurse
because of e)cessi2e nasal draina'e. The nurse asks the patient about the color of the draina'e. In a acute rhinitis/ nasal draina'e nor"ally is> A. Yeo) C. Ce!r '. ree" D. r!*
3.3 "ale adult patient hospitalized for treat"ent of a pul"onary e"bolis"
de2elops respiratory alkalosis. &hich clinical 1ndin's co""only acco"pany respiratory alkalosis( A. N!%se! or 9om$t$"& C. !%c$"!t$o"s or t$""$t%s '. Aom$"! (!$" or $!rr#e! D. 4$&#t#e!e"ess or (!rest#es$! .Jefore ad"inisterin' ephedrine/ Nurse Tony assesses the patientBs history. Jecause of ephedrineBs central ner2ous syste" CNS% e@ects/ it is not reco""ended for> A. !t$e"ts )$t# !" !c%te !st#m! !tt!c5 C. !t$e"ts %"er !&e 6 '. !t$e"ts )$t# "!rcoe(s* D. Eer* (!t$e"ts 8.3 fe"ale patient su@ers adult respiratory distress syndro"e as a conse0uence of shock. The patientBs condition deteriorates rapidly/ and endotracheal intubation and "echanical 2entilation are initiated. &hen the hi'h pressure alar" on the "echanical 2entilator/ alar" sounds/ the nurse starts to check for the cause. &hich condition tri''ers the hi'h pressure alar"( A. $"5$"& o t#e 9e"t$!tor t%$"& '. A $sco""ecte 9e"t$!tor t%e C. A" e"otr!c#e! c% e!5 D. A c#!"&e $" t#e o*&e" co"ce"tr!t$o" )$t#o%t resett$"& t#e o*&e" e9e !!rm 6.3 "ale adult patient on "echanical 2entilation is recei2in' pancuroniu" bro"ide !a2ulon%/ 8.8; "'Fk' I.,. as needed. &hich assess"ent 1ndin' indicates that the patient needs another pancuroniu" dose( A. 4e& mo9eme"t '. F$"&er mo9eme"t C. 4$( mo9eme"t D. F$&#t$"& t#e 9e"t$!tor 7.On auscultation/ which 1ndin' su''ests a ri'ht pneu"othora)( A. '$!ter! $"s($r!tor* !" e($r!tor* cr!c5es '. Ase"ce o re!t#s so%" $" t#e r$&#t t#or! C. I"s($r!tor* )#eeBes $" t#e r$&#t t#or! D. '$!ter! (e%r! r$ct$o" r%. ;.Rhea/ confused and short breath/ is brou'ht to the e"er'ency depart"ent by a fa"ily "e"ber. The "edical history re2eals chronic bronchitis and hypertension. To learn "ore about the current respiratory proble"/ the doctor orders a chest )Dray and arterial blood 'as 3J*% analysis. &hen re2iewin' the 3J* report/ the nurses sees "any abbre2iations. &hat does a lowercase KaL in 3J* 2alue present( A. Ac$-!se !!"ce '. Arter$! 'oo C. Arter$! o*&e" s!t%r!t$o" D. A9eo$ >.3 "ale patient is ad"itted to the health care facility for treat"ent of chronic obstructi2e pul"onary disease. &hich nursin' dia'nosis is "ost i"portant for this patient( A. Act$9$t* $"toer!"ce re!te to !t$&%e '. A"$et* re!te to !ct%! t#re!t to #e!t# st!t%s C. R$s5 or $"ect$o" re!te to ret!$"e secret$o"s D. Im(!$re &!s ec#!"&e re!te to !$r A. Co"tr!!ter! s$e $" ! s$m(e ("e%mot#or! '. Aecte s$e $" ! #emot#or! C. Aecte s$e $" ! te"s$o" ("e%mot#or! D. Co"tr!!ter! s$e $" #emot#or! 81.3fter under'oin' a left pneu"onecto"y/ a fe"ale patient has a chest tube in place for draina'e. &hen carin' for this patient/ the nurse "ust> A. Mo"$tor <%ct%!t$o"s $" t#e )!ter-se! c#!mer '. C!m( t#e c#est t%e o"ce e9er* s#$t C. E"co%r!&e co%&#$"& !" ee( re!t#$"& D. M$5 t#e c#est t%e e9er* 2 #o%rs
82.&hen carin' for a "ale patient who has ust had a total laryn'ecto"y/ the
nurse should plan to> A. E"co%r!&e or! ee$"& !s soo" !s (oss$e '. De9eo( !" !ter"!t$9e comm%"$c!t$o" met#o C. ee( t#e tr!c#eostom* c% %* $" A. C!r$o&e"$c (%mo"!r* eem! '. Res($r!tor* !5!os$s C. I"cre!se (%mo"!r* c!($!r* (erme!$$t* D. Re"! !$%re 86.$or a fe"ale patient with chronic obstructi2e pul"onary disease/ which nursin' inter2ention would help "aintain a patent airway( A. Restr$ct$"& <%$ $"t!5e to 1,000 m (er !* '. E"orc$"& !so%te e rest C. Te!c#$"& t#e (!t$e"t #o) to (erorm co"troe co%&#$"& D. Am$"$ster$"& (rescr$e se!t$9es re&%!r* !" $" !r&e !mo%"ts 87.Nurse #ei carin' for a client with a pneu"othora) and who has had a chest tube inserted notes continues 'entle bubblin' in the suction control cha"ber. &hat action is appropriate( A. Do "ot#$"&, ec!%se t#$s $s !" e(ecte /"$"& '. Imme$!te* c!m( t#e c#est t%e !" "ot$* t#e (#*s$c$!" C. C#ec5 or !" !$r e!5 ec!%se t#e %$"& s#o% e $"term$tte"t D. I"cre!se t#e s%ct$o" (ress%re so t#!t t#e %$"& ecomes 9$&oro%s 8;.Nurse :aureen has assisted a physician with the insertion of a chest tube. The nurse "onitors the client and notes Auctuation of the Auid le2el in the water seal cha"ber after the tube is inserted. Jased on this assess"ent/ which action would be appropriate( A. I"orm t#e (#*s$c$!" '. Co"t$"%e to mo"$tor t#e c$e"t C. Re$"orce t#e occ%s$9e ress$"& D. E"co%r!&e t#e c$e"t to ee(-re!t#e 8>.Nurse Reynolds carin' for a client with a chest tube turns the client to the side/ and the chest tube accidentally disconnects. The initial nursin' action is to> A. C! t#e (#*s$c$!" '. !ce t#e t%e $" otte o ster$e )!ter C. Imme$!te* re(!ce t#e c#est t%e s*stem D. !ce ! ster$e ress$"& o9er t#e $sco""ect$o" s$te 60.3 nurse is assistin' a physician with the re"o2al of a chest tube. The nurse should instruct the client to> A. E#!e so)* '. St!* 9er* st$ C. I"#!e !" e#!e %$c5* D. erorm t#e !s!9! m!"e%9er 61.&hile chan'in' the tapes on a tracheosto"y tube/ the "ale client cou'hs and tube is dislod'ed. The initial nursin' action is to> A. C! t#e (#*s$c$!" to re$"sert t#e t%e '. r!s( t#e rete"t$o" s%t%res to s(re! t#e o(e"$"&
C. C! t#e res($r!tor* t#er!(* e(!rtme"t to re$"sert t#e tr!c#eotom* D. Co9er t#e tr!c#eostom* s$te )$t# ! ster$e ress$"& to (re9e"t $"ect$o" 62.Nurse Oli2er is carin' for a client i""ediately after re"o2al of the
endotracheal tube. The nurse reports which of the followin' si'ns i""ediately if e)perienced by the client( A. Str$or '. Occ!s$o"! ($"5-t$"&e s(%t%m C. A e) !s$!r %"& cr!c5es o" t#e r$&#t D. Res($r!tor* r!te 2 re!t#sGm$" 63.3n e"er'ency roo" nurse is assessin' a "ale client who has sustained a blunt inury to the chest wall. &hich of these si'ns would indicate the presence of a pneu"othora) in this client( A. A o) res($r!tor* r!te '. D$m$"$s#e re!t# so%"s C. T#e (rese"ce o ! !rre c#est D. A s%c5$"& so%" !t t#e s$te o $"=%r* 6.Nurse Reese is carin' for a client hospitalized with acute e)acerbation of chronic obstructi2e pul"onary disease. &hich of the followin' would the nurse e)pect to note on assess"ent of this client( A. *(oc!("$! '. A #*(er$" A. D*s("e! '. C#est (!$" C. A oo*, (ro%ct$9e co%&# D. A co%&# )$t# t#e e(ector!t$o" o m%co$ s(%t%m 67.3 nurse perfor"s an ad"ission assess"ent on a fe"ale client with a dia'nosis of tuberculosis. The nurse re2iews the result of which dia'nosis test that will con1r" this dia'nosis( A. 'ro"c#osco(* '. S(%t%m c%t%re C. C#est -r!* D. T%erc%$" s5$" test 6;.3 nurse is carin' for a "ale client with e"physe"a who is recei2in' o)y'en. The nurse assesses the o)y'en Aow rate to ensure that it does not e)ceed> A. 1 4Gm$" '. 2 4Gm$" C. 6 4Gm$" D. 10 4Gm$" 6>.3 nurse instructs a fe"ale client to use the pursedDlip "ethod of breathin' and the client asks the nurse about the purpose of this type of breathin'. The nurse responds/ knowin' that the pri"ary purpose of pursedDlip breathin' is to> A. romote o*&e" $"t!5e '. Stre"&t#e" t#e $!(#r!&m C. Stre"&t#e" t#e $"tercost! m%sces D. romote c!ro" $o$e e$m$"!t$o" 70.3 nurse is carin' for a "ale client with acute respiratory distress syndro"e. &hich of the followin' would the nurse e)pect to note in the client(
A. !or '. 4o) !rter$! !O2 C. Ee9!te !rter$! !O2 D. Decre!se res($r!tor* r!te 71.3 nurse is preparin' to obtain a sputu" speci"en fro" a "ale client. &hich
of the followin' nursin' actions will facilitate obtainin' the speci"en( A. 4$m$t$"& <%$ '. !9$"& t#e c$e"t t!5e ee( re!t#s C. As5$"& t#e c$e"t to s($t $"to t#e coect$o" co"t!$"er D. As5$"& t#e c$e"t to ot!$" t#e s(ec$me" !ter e!t$"& 72.Nurse 9oy is carin' for a client after a bronchoscopy and biopsy. &hich of the followin' si'ns/ if noticed in the client/ should be reported i""ediately to the physician( A. Dr* co%&# '. erm!t%r$! C. 'ro"c#os(!sm D. 'oo-stre!5e s(%t%m 73.3 nurse is suctionin' Auids fro" a "ale client 2ia a tracheosto"y tube. &hen suctionin'/ the nurse "ust li"it the suctionin' ti"e to a "a)i"u" of> A. 1 m$"%te '. 8 seco"s C. 10 seco"s D. 30 seco"s 7.3 nurse is suctionin' Auids fro" a fe"ale client throu'h an endotracheal tube. +urin' the suctionin' procedure/ the nurse notes on the "onitor that the heart rate is decreasin'. &hich if the followin' is the appropriate nursin' inter2ention( A. Co"t$"%e to s%ct$o" '. Not$* t#e (#*s$c$!" $mme$!te* C. Sto( t#e (roce%re !" reo*&e"!te t#e c$e"t D. E"s%re t#!t t#e s%ct$o" $s $m$te to 18 seco"s 78.3 "ale adult client is suspected of ha2in' a pul"onary e"bolus. 3 nurse assesses the client/ knowin' that which of the followin' is a co""on clinical "anifestation of pul"onary e"bolis"( A. D*s("e! '. 'r!*("e! C. 'r!*c!r$! D. Decre!se res($r!t$o"s 76.3 sli'htly obese fe"ale client with a history of aller'yDinduced asth"a/hypertension/ and "itral 2al2e prolapse is ad"itted to an acute care facility for electi2e sur'ery. The nurse obtains a co"plete history and perfor"s a thorou'h physical e)a"ination/ payin' special attention to the cardio2ascular and respiratory syste"s. &hen percussin' the clientBs chest wall/ the nurse e)pects to elicit> A. Reso"!"t so%"s. '. *(erreso"!"t so%"s. C. D% so%"s. D. F!t so%"s. 77.3 "ale client who wei'hs ;= lb G.H k'% is recei2in' a"inophylline 3"inophyllin% H88 "' in =88 "l% at =8 "lFhour. The theophylline le2el is reported as 7 "c'F"l. The nurse calls the physician who instructs the nurse to chan'e the dosa'e to 8.H= "'Fk'Fhour. The nurse should> A. H%est$o" t#e orer ec!%se $t@s too o). '. H%est$o" t#e orer ec!%se $t@s too #$&#. C. Set t#e (%m( !t 8 mG#o%r. D. Sto( t#e $"%s$o" !" #!9e t#e !or!tor* re(e!t t#e t#eo(#*$"e me!s%reme"t. 7;.The nurse is teachin' a "ale client with chronic bronchitis about breathin' e)ercises. &hich of the followin' should the nurse include in the teachin'( A. M!5e $"#!!t$o" o"&er t#!" e#!!t$o". '. E#!e t#ro%&# !" o(e" mo%t#.
C. ?se $!(#r!&m!t$c re!t#$"&. D. ?se c#est re!t#$"&. 7>.&hich phrase is used to describe the 2olu"e of air inspired and e)pired
with a nor"al breath( A. Tot! %"& c!(!c$t* '. Force 9$t! c!(!c$t* C. T$! 9o%me D. Res$%! 9o%me ;0.3 "ale client abruptly sits up in bed/ reports ha2in' di?culty breathin' and has an arterial o)y'en saturation of <. &hich "ode of o)y'en deli2ery would "ost likely re2erse the "anifestations( A. S$m(e m!s5 '. No"-rere!t#er m!s5 C. F!ce te"t D. N!s! c!""%! ;1.3 fe"ale client "ust take strepto"ycin for tuberculosis. Jefore therapy be'ins/ the nurse should instruct the client to notify the physician if which health concern occurs( A. Im(!$re coor $scr$m$"!t$o" '. I"cre!se %r$"!r* re%e"c* C. Decre!se #e!r$"& !c%$t* D. I"cre!se !((et$te ;2.3 "ale client is askin' the nurse a 0uestion re'ardin' the :antou) test for tuberculosis. The nurse should base her response on the fact that the> A. Are! o re"ess $s me!s%re $" 3 !*s !" eterm$"es )#et#er t%erc%os$s $s (rese"t. '. S5$" test oes"@t $ere"t$!te et)ee" !ct$9e !" orm!"t t%erc%os$s $"ect$o". C. rese"ce o ! )#e! !t t#e $"=ect$o" s$te $" 2 !*s $"$c!tes !ct$9e t%erc%os$s. D. Test st$m%!tes ! ree"e res(o"se $" some c$e"ts !" re%$res ! seco" test $" 3 mo"t#s. ;3.3 fe"ale adult client has a tracheosto"y but doesnBt re0uire continuous "echanical 2entilation. &hen weanin' the client fro" the tracheosto"y tube/ the nurse initially should plu' the openin' in the tube for> A. 18 to 60 seco"s. '. 8 to 20 m$"%tes. C. 30 to 0 m$"%tes. D. 8 to 60 m$"%tes. ;.Nurse Oli2er obser2es constant bubblin' in the waterDseal cha"ber of a closed chest draina'e syste". &hat should the nurse conclude( A. T#e s*stem $s %"ct$o"$"& "orm!* '. T#e c$e"t #!s ! ("e%mot#or!. C. T#e s*stem #!s !" !$r e!5. D. T#e c#est t%e $s ostr%cte. ;8.3 black client with asth"a seeks e"er'ency care for acute respiratory distress. Jecause of this clientBs dark skin/ the nurse should assess for cyanosis by inspectin' the> A. 4$(s. '. M%co%s memr!"es. C. N!$ es. D. E!roes. ;6.$or a "ale client with an endotracheal ET% tube/ which nursin' action is "ost essential( A. A%sc%t!t$"& t#e %"&s or $!ter! re!t# so%"s '. T%r"$"& t#e c$e"t rom s$e to s$e e9er* 2 #o%rs C. Mo"$tor$"& ser$! oo &!s 9!%es e9er* #o%rs D. ro9$$"& re%e"t or! #*&$e"e ;7.The nurse assesses a "ale clientBs respiratory status. &hich obser2ation indicates that the client is e)periencin' di?culty breathin'( A. D$!(#r!&m!t$c re!t#$"& '. ?se o !ccessor* m%sces
C. %rse-$( re!t#$"& D. Co"troe re!t#$"& ;;.3 fe"ale client is under'oin' a co"plete physical e)a"ination as a
re0uire"ent for colle'e. &hen checkin' the clientBs respiratory status/ the nurse obser2es respiratory e)cursion to help assess> A. 4%"& 9$r!t$o"s. '. oc! so%"s. C. 're!t# so%"s. D. C#est mo9eme"ts. ;>.3 "ale client co"es to the e"er'ency depart"ent co"plainin' of sudden onset of diarrhea/ anore)ia/ "alaise/ cou'h/ headache/ and recurrent chills. Jased on the clientBs history and physical 1ndin's/ the physician suspects le'ionnairesB disease. &hile awaitin' dia'nostic test results/ the client is ad"itted to the facility and started on antibiotic therapy. &hat is the dru' of choice for treatin' le'ionnairesB disease( A. Er*t#rom*c$" Er*t#roc$" '. R$!m($" R$!$" C. Am!"t!$"e S*mmetre D. Am(#oter$c$" ' F%"&$Bo"e >0.3 "ale client with chronic obstructi2e pul"onary disease CO!+% is reco2erin' fro" a "yocardial infarction. Jecause the client is e)tre"ely weak and canBt produce an e@ecti2e cou'h/ the nurse should "onitor closely for> A. e%r! e%s$o". '. %mo"!r* eem!. C. Ateect!s$s. D. O*&e" to$c$t*. >1.The nurse in char'e is teachin' a client with e"physe"a how to perfor" pursedDlip breathin'. The client asks the nurse to e)plain the purpose of this breathin' techni0ue. &hich e)planation should the nurse pro2ide( A. It #e(s (re9e"t e!r* !$r)!* co!(se. '. It $"cre!ses $"s($r!tor* m%sce stre"&t#. C. It ecre!ses %se o !ccessor* re!t#$"& m%sces. D. It (roo"&s t#e $"s($r!tor* (#!se o res($r!t$o". >2.3fter recei2in' an oral dose of codeine for an intractable cou'h/ the "ale client asks the nurse/ K6ow lon' will it take for this dru' to work(L 6ow should the nurse respond( A. I" 30 m$"%tes '. I" 1 #o%r C. I" 2.8 #o%rs D. I" #o%rs >3.3 "ale client su@ers adult respiratory distress syndro"e as a conse0uence of shock. The clientBs condition deteriorates rapidly/ and endotracheal ET% intubation and "echanical 2entilation are initiated. &hen the hi'hDpressure alar" on the "echanical 2entilator sounds/ the nurse starts to check for the cause. &hich condition tri''ers the hi'hDpressure alar"( A. $"5$"& o t#e 9e"t$!tor t%$"& '. A $sco""ecte 9e"t$!tor t%e C. A" ET c% e!5 D. A c#!"&e $" t#e o*&e" co"ce"tr!t$o" )$t#o%t resett$"& t#e o*&e" e9e !!rm >.3 fe"ale client with chronic obstructi2e pul"onary disease CO!+% takes anhydrous theophylline/ 488 "' !.O. e2ery hours. +urin' a routine clinic 2isit/ the client asks the nurse how the dru' works. &hat is the "echanis" of action of anhydrous theophylline in treatin' a nonre2ersible obstructi2e airway disease such as CO!+( A.It m!5es t#e ce"tr! res($r!tor* ce"ter more se"s$t$9e to c!ro" $o$e !" st$m%!tes t#e res($r!tor* r$9e. '. It $"#$$ts t#e e"B*me (#os(#o$ester!se, ecre!s$"& e&r!!t$o" o c*c$c !e"os$"e mo"o(#os(#!te, ! ro"c#o$!tor. C. It st$m%!tes !e"os$"e rece(tors, c!%s$"& ro"c#o$!t$o".
D. It !ters $!(#r!&m mo9eme"t, $"cre!s$"& c#est e(!"s$o" !" e"#!"c$"& t#e %"&@s c!(!c$t* or &!s ec#!"&e. >8.3 "ale client with pneu"ococcal pneu"onia is ad"itted to an acute care
facility. The client in the ne)t roo" is bein' treated for "ycoplas"al pneu"onia. +espite the di@erent causes of the 2arious types of pneu"onia/ all of the" share which feature( A. I"6.3 client with *uillainDJarr syndro"e de2elops respiratory acidosis as a result of reduced al2eolar 2entilation. &hich co"bination of arterial blood 'as 3J*% 2alues con1r"s respiratory acidosis( A. (, 8.0 !CO2 30 mm & '. (, 7.0 !CO2 38 mm & C. (, 7.38 !CO2 0 mm & D. (, 7.28 !CO2 80 mm & >7.3 "ale client ad"itted to an acute care facility with pneu"onia is recei2in' supple"ental o)y'en/ 4 #F"inute 2ia nasal cannula. The clientBs history includes chronic obstructi2e pul"onary disease CO!+% and coronary artery disease. Jecause of these history 1ndin's/ the nurse closely "onitors the o)y'en Aow and the clientBs respiratory status. &hich co"plication "ay arise if the client recei2es a hi'h o)y'en concentration( A. A("e! '. A"&$"! (!$" C. Res($r!tor* !5!os$s D. Met!o$c !c$os$s >;.3t ;; p."./ a "ale client is ad"itted to the e"er'ency depart"ent. 6e has a respiratory rate of HH breathsF"inute. 6eBs an)ious/ and wheezes are audible. The client is i""ediately 'i2en o)y'en by face "ask and "ethylprednisolone +epoD"edrol% I.,. 3t ;;>8 p."./ the clientBs arterial blood o)y'en saturation is 7< and heBs still wheezin'. The nurse should plan to ad"inister> A. A(r!Bo!m X!"!. '. ro(r!"oo I"er! C. Mor(#$"e. D. A%tero ro9e"t$. >>.3fter under'oin' a thoracoto"y/ a "ale client is recei2in' epidural anal'esia. &hich assess"ent 1ndin' indicates that the client has de2eloped the "ost serious co"plication of epidural anal'esia( A. e$&#te"e !ert"ess '. I"cre!se #e!rt r!te C. N%m"ess !" t$"&$"& o t#e etrem$t$es D. Res($r!tor* e(ress$o" The nurse in char'e for"ulates a nursin' dia'nosis of 3cti2ity 100. intolerance related to inade0uate o)y'enation and dyspnea for a client with chronic bronchitis. To "ini"ize this proble"/ the nurse instructs the client to a2oid conditions that increase o)y'en de"ands. Such conditions include> A. Dr$"5$"& more t#!" 1,800 m o <%$ !$*. '. 'e$"& o9er)e$&#t. C. E!t$"& ! #$&#-(rote$" s"!c5 !t et$me. D. E!t$"& more t#!" t#ree !r&e me!s ! !*.
