Solutions - Chapter 50 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care?
1.  Percussion and postural drainage should be done before lunch.
2.  The order should be coughing, percussion, positioning, and then suctioning.
3.  A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
4.  Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.
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1ACT. What factors may have led the medical staff to suspect that Ms. Singh had more than a very bad cold? Would you have come to the same conclusion?
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1Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
Pneumonia occurs when microorganisms get into the lower respiratory tract and overwhelm the body’s defenses. Name at least two normal defense mechanisms present in the upper airway that help prevent microorganisms getting into the lower respiratory tract.
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1TYK. A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition?
1.  Hypoxia
2.  Hypoxemia
3.  Dyspnea
4.  Cyanosis
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2ACT. The care plan appropriately focuses on the acute care of this client. Once she is significantly improved, the nurse will perform discharge teaching. What areas should be included?
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2Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
Microorganisms can travel past the upper respiratory tract defense mechanisms. What defense mechanisms are present in the lower respiratory tract that may help the client?
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2TYK. To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following?
1.  Coughing exercises 1 hour before meals and deep breathing 1 hour after meals
2.  Forceful coughing as many times as tolerated
3.  Huff coughing every 2 hours or as needed
4.  Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day
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3Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
The microorganisms have quickly multiplied and overpowered the clients defense mechanisms. The client has pneumonia and the alveoli are filled with infectious fluid. How will this affect gas exchange at the respiratory or alveolar/ capillary membrane?
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3TYK. The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?
1. Tells the client to raise two fingers to indicate pain or distress.
2.  Changes the twill tape holding the tracheostomy in place.
3. Cleans the incision site.
4. Checks the tightness of the ties and knot.
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4ACT. It appears that the client’s sputum has not been cultured. In caring for this client, what infection control guidelines would be needed?
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4TYK. Which action by the nurse represents proper nasopharyngeal/ nasotracheal suction technique?
1. Lubricate the suction catheter with petroleum jelly before and between insertions.
2. Apply suction intermittently while inserting the suction catheter.
3. Rotate the catheter while applying suction.
4. Hyperoxygenate with 100% oxygen for 30 minutes before and after suctioning.
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5ACT. Ms. Singh’s oxygen order is for a face mask at 6 L/min. She repeatedly pulls it off and you find it lying in the sheets. How might you intervene?
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5TYK. Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
1. “I should breathe out as fast and hard as possible into the device.”
2.  “I should inhale slowly and steadily to keep the balls up.”
3.  “I should use the device three times a day, after meals.”
4. “The entire device should be washed thoroughly in sudsy water once a week.”
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7TYK. The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has
1. Anemia.
2. An infection.
3. A fractured rib.
4. A tumor of the medulla.
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8TYK. Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively?
1.  Dyspnea
2.  Hyperpnea
3.  Orthopnea
4.  Acapnea
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9TYK. A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following?
1.  Promote bronchodilation.
2.  Help the client to cough.
3.  Prevent respiratory infection.
4.  Decrease inflammation in the airways.
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