High Acuity Nursing 6th Edition by Kathleen Dorman Wagner – Test Bank

Chapter 11
Question 1
Type: MCSA
A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?
1. Prolonged expiratory time
2. Increased lung compliance
3. Reduced tidal volume
4. Hyper-inflated lungs
Correct Answer: 3
Rationale 1: Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax.
Rationale 2: With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance.
Rationale 3: Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient’s tidal volume will be reduced.
Rationale 4: Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1

Question 2
Type: MCSA
A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?
1. Decreased total lung capacity
2. Progressive respiratory alkalosis
3. Increased PaCO2
4. Increased forced expiratory volume (FEV)
Correct Answer: 3
Rationale 1: The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity.
Rationale 2: Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis.
Rationale 3: In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping.
Rationale 4: Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1

Question 3
Type: MCSA
A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a “high pitched noise” in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?
1. COPD
2. Asthma
3. Emphysema
4. Pneumonia
Correct Answer: 2
Rationale 1: COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
Rationale 2: The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma.
Rationale 3: Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
Rationale 4: Pneumonia will not “suddenly appear” after exposure to cigarette smoke to cause the onset of the patient’s symptoms.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1

Question 4
Type: MCSA
The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?
1. The patient is now able to rest and sleep.
2. The patient’s condition has significantly deteriorated.
3. The patient’s condition shows some slight improvement.
4. The patient’s condition has stabilized significantly.
Correct Answer: 2
Rationale 1: These findings do not indicate that the patient is resting and now able to sleep.
Rationale 2: The patient’s condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid–base balance.
Rationale 3: These findings do not indicate that the patient’s condition is improving.
Rationale 4: These findings do not indicate significant stabilization of the patient’s condition.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-2

Question 5
Type: MCMA
A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. The patient has ventilation failure.
2. Without treatment the patient’s oxygen saturation is likely to drop rapidly.
3. The patient has decreased airflow.
4. The patient is at risk for respiratory muscle fatigue.
5. Acute respiratory failure is present.
Correct Answer: 2,4
Rationale 1: Ventilation failure is reflected by an increased PaCO2.
Rationale 2: Once the PaO2 drops below 60 mm Hg oxygen’s affinity to hemoglobin drops.
Rationale 3: When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2.
Rationale 4: As respiratory rate increases the risk of respiratory muscle fatigue also increases.
Rationale 5: Currently the patient does not have acute respiratory failure because the PaCO2 is normal.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-2

Question 6
Type: MCMA
The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. A patient who sustained a severe chest contusion.
2. A patient hospitalized for treatment of drug overdose.
3. A patient who sustained severe head trauma.
4. A patient hospitalized for treatment of pneumonia.
5. A patient diagnosed with sepsis.
Correct Answer: 4,5
Rationale 1: Chest contusion can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 2: Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 3: Head trauma can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 4: Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS.
Rationale 5: Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3

Question 7
Type: MCSA
The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing?
1. Increased lung compliance
2. Decrease in heart rate
3. Hypoxemia refractory to oxygen therapy
4. Respiratory acidosis
Correct Answer: 3
Rationale 1: Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease.
Rationale 2: The heart rate increases as the work of breathing increases.
Rationale 3: In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting.
Rationale 4: In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3

Question 8
Type: MCSA
A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?
1. Obstructed endotracheal tube
2. Increased severity of ARDS
3. Decreased cardiac output
4. Pneumothorax
Correct Answer: 4
Rationale 1: An obstructed endotracheal tube would affect both lung fields.
Rationale 2: If the disease process was worsening it would be likely that both lung fields would be involved.
Rationale 3: Decreased cardiac output would affect vital signs but not breath sounds.
Rationale 4: A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3

Question 9
Type: MCSA
The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?
1. Administer pain medication as ordered.
2. Increase intravenous fluids.
3. Evaluate the patient’s oxygen saturation.
4. Help the patient assume a more comfortable position.
Correct Answer: 3
Rationale 1: The patient’s pain should be treated but this is not the priority intervention.
Rationale 2: Intravenous fluids may be increased, but this is not the priority intervention.
Rationale 3: The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography.
Rationale 4: Positioning is not the priority intervention.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-4

Question 10
Type: MCMA
The patient’s Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Monitor daily D-dimer levels.
2. Strictly measure all intake and output.
3. Encourage ambulation.
4. Instruct the patient on use of antiembolism stockings.
5. Prevention of leg injury
Correct Answer: 3,4,5
Rationale 1: D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus.
Rationale 2: Measuring intake and output will not prevent development of thrombus.
Rationale 3: Ambulation will help to support circulation and prevent clot development.
Rationale 4: Proper use of antiembolism stocking is helpful in decreasing development of thrombus.
Rationale 5: One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-4