01.The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan?
a. Clubbing of nail beds
b. Hypertension
c. Peripheral edema
d. Increased appetite
02. Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD?
a. Increased anteroposterior chest diameter
b. Underdeveloped neck muscles
c. Collapsed neck veins
d. Increased chest excursions with respiration
03. A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client?
a. Altered nutrition: Less than body requirements related to fatigue.
b. Activity intolerance related to dyspnea.
c. Weight loss related to COPD.
d. Ineffective breathing pattern related to alveolar hypoventilation.
04. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?
a. It is likely that the client is developing a secondary bacterial pneumonia.
b. The assessment findings are consistent with influenza and are to be expected.
c. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions.
d. The client has not been taking her decongestants and bronchodilators as prescribed.
05. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
a. Maintain a fluid intake of 800 ml every 24 hours.
b. Experience chills only once a day
c. Cough productively without chest discomfort.
d. Experience less nasal obstruction and discharge.
06. The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack?
a. Decreased PaCO2, increased PaO2, and decreased pH.
b. Increased PaCO2, decreased PaO2, and decreased pH.
c. Increased PaCO2, increased PaO2, and increased pH.
d. Decreased PaCO2, decreased PaO2, and increased pH.
07. A client is prescribed metaproterenol (Alupent) via a metered dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol?
a. Irregular heartbeat
b. Constipation
c. Pedal edema
d. Decreased heart rate.
08. A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to:
a. Begin mechanical ventilation
b. Place the client on oxygen
c. Give the client sodium bicarbonate
d. Monitor for pulmonary embolism.
09. If a client continues to hypoventilate, the nurse will continually assess for a complication of:
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
10. A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia?
a. Fluid volume deficit related to blood loss.
b. Impaired tissue perfusion related to thrombosis
c. Activity intolerance related to dyspnea
d. Risk for infection related to suppressed immune response.
Answer and Rational
Refrence
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