ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 23 Questions
Question 1 of 5
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication?
Correct Answer: B
Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
Question 2 of 5
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
Correct Answer: A
Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
Question 3 of 5
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
Correct Answer: A
Rationale: The purified protein derivative (PP
D) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
Question 4 of 5
The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?
Correct Answer: D
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patients ABGs would most likely be abnormal and shortness of breath would be expected.
Question 5 of 5
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action?
Correct Answer: D
Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.