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TEST BANK FOR ADULT HEALTH NURSING REVIEWED QUESTIONS AND ANSWERS
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TEST BANK FOR ADULT HEALTH NURSING REVIEWED QUESTIONS AND ANSWERS
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TEST BANK FOR ADULTHEALTH NURSING REVIEWED
QUESTIONS AND ANSWERS
1. Amnursemobtainsmthemhealthmhistorymofmamclientmwhomismrecentlymdiagnosedmwithmlungmcancermandmide
ntifiesmthatmthemclientmhasmam60pack-
yearmsmokingmhistory.mWhichmactionmismmostmimportantmformthemnursemtomtakemwhenminterviewingmthism
client?
a. Tellmthemclientmthatmhemneedsmtomquitmsmokingmtomstopmfurthermcancermdevelopment.
b. Encouragemthemclientmtombemcompletelymhonestmaboutmbothmtobaccomandmmarijuanamuse.mc.mMaint
ainmamnonjudgmentalmattitudemtomavoidmcausingmthemclientmtomfeelmguilty.
d.mAvoidmgivingmthemclientmfalsemhopemregardingmcancermtreatmentmandmprognosis.m-
mCORRECTmANSWERm-mANS:mC
Smokingmhistorymincludesmthemusemofmcigarettes,mcigars,mpipemtobacco,mmarijuana,mandmothermcontrolled
msubstances.mBecausemthemclientmmaymhavemguiltmormdenialmaboutmthismhabit,massumemamnonjudgmentalm
attitudemduringmtheminterview.mThismwillmencouragemthemclientmtombemhonestmaboutmthemexposure.mAskmt
hemclientmwhethermanymofmthesemsubstancesmaremusedmnowmormweremusedminmthempast.mAssessmwhetherm
themclientmhasmpassivemexposuremtomsmokeminmthemhomemormworkplace.mIfmthemclientmsmokes,maskmformho
wmlong,mhowmmanympacksmpermday,mandmwhethermhemormshemhasmquitmsmokingm(andmhowmlongmago).mDo
cumentmthemsmokingmhistoryminmpack-
yearsm(numbermofmpacksmsmokedmdailymmultipliedmbymthemnumbermofmyearsmthemclientmhasmsmoked).mQu
ittingmsmokingmmaymnotmstopmfurthermcancermdevelopment.mThismstatementmwouldmbemgivingmthemclientm
falsemhope,mwhichmshouldmbemavoided,mbutmismnotmasmimportantmasmmaintainingmamnonjudgmentalmattitu
de.
DIF:mApplying
2. Amnursemassessesmamclientmaftermanmopenmlungmbiopsy.mWhichmassessmentmfindingmismmatchedmwit
hmthemcorrectmintervention?
a. Clientmstatesmhemismdizzy.mNursemappliesmoxygenmandmpulsemoximetry.
b. Clientsmheartmratemism55mbeatsmin.mNursemwithholdsmpainmmedication.
c. Clientmhasmreducedmbreathmsounds.mNursemcallsmphysicianmimmediately.
,d. Clientsmrespiratorymratemism18mbreathsmmin.mNursemdecreasesmoxygenmflowmrate.m-
mCORRECTmANSWERm-mANS:mC
Ampotentiallymseriousmcomplicationmaftermbiopsymismpneumothorax,mwhichmismindicatedmbymdecreasedm
ormabsentmbreathmsounds.mThemphysicianmneedsmtombemnotifiedmimmediately.mDizzinessmaftermthemproc
eduremismnotmanmexpectedmfinding.mIfmthemclientsmheartmratemism55mbeatsmmin,mnomreasonmismknownmtom
withholdmpainmmedication.mAmrespiratorymratemofm18mbreaths
3. Amnursemassessesmamclientsmrespiratorymstatus.mWhichminformationmismofmhighestmprioritymformthemnu
rsemtomobtain?ma.mAveragemdailymfluidmintake
b. Neckmcircumference
c. Heightmandmweight
d. Occupationmandmhobbiesm-mCORRECTmANSWERm-ANS:mD
Manymrespiratorymproblemsmoccurmasmamresultmofmchronicmexposuremtominhalationmirritantsmusedminmamc
lientsmoccupationmandmhobbies.mAlthoughmitmwillmbemimportantmformthemnursemtomassessmthemclientsmflui
dmintake,mheight,mandmweight,mthesemwillmnotmbemasmimportantmasmdeterminingmhismoccupationmandmho
bbies.
Determiningmthemclientsmneckmcircumferencemwillmnotmbemanmimportantmpartmofmamrespiratorymassess
ment.mTestmBankm-mMedical-
SurgicalmNursing:mConceptsmformInterprofessionalmCollaborativemCarem9em214
DIF:mApplying
4. Amnursemismcaringmformanmoldermadultmclientmwhomhasmampulmonaryminfection.mWhichmactionmshoul
dmthemnursemtakemfirst?
a. Encouragemthemclientmtomincreasemfluidmintake.
b. Assessmthemclientsmlevelmofmconsciousness.
c. Raisemthemheadmofmthembedmtomatmleastm45mdegrees.md.mProvidemthemclientmwithmhumidifiedmox
ygen.m-mCORRECTmANSWERm-ANS:mB
Assessingmthemclientsmlevelmofmconsciousnessmwillmbemmostmimportantmbecausemitmwillmshowmhowmthemcli
entmismrespondingmtomthempresencemofmtheminfection.mAlthoughmitmwillmbemimportantmformthemnursemtomen
couragemthemclientmtomturn,mcough,mandmfrequentlymbreathemdeeply;mraisemthemheadmofmthembed;mincreas
emoralmfluidmintake;mandmhumidifymthemoxygenmadministered,mnonemofmthesemactionsmwillmbemasmimportan
tmasmassessingmthemlevelmofmconsciousness.mAlso,mthemclientmwhomhasmampulmonaryminfectionmmaymnotmbe
mablemtomcoughmeffectivelymifmanmareamofmabscessmismpresent.
,DIF:mApplying
5. Amnursemismprovidingmcaremaftermauscultatingmclientsmbreathmsounds.mWhichmassessmentmfindi
ngmismcorrectlymmatchedmtomthemnursesmprimarymintervention?
a. Hollowmsoundsmaremheardmovermthemtrachea.mThemnursemincreasesmthemoxygenmflowmrate.
b. Cracklesmaremheardminmbases.mThemnursemencouragesmthemclientmtomcoughmforcefully.
c. Wheezesmaremheardminmcentralmareas.mThemnursemadministersmanminhaledmbronchodilator.md.mVesicular
msoundsmaremheardmovermthemperiphery.mThemnursemhasmthemclientmbreathemdeeply.m-
mCORRECTmANSWERm-ANS:mC
Wheezesmaremindicativemofmnarrowedmairways,mandmbronchodilatorsmhelpmtomopenmthemairmpassages.mHol
lowmsoundsmaremtypicallymheardmovermthemtrachea,mandmnominterventionmismnecessary.mIfmcracklesmaremhe
ard,mthemclientmmaymneedmamdiuretic.mCracklesmrepresentmamdeepminterstitialmprocess,mandmcoughingmforc
efullymwillmnotmhelpmthemclientmexpectoratemsecretions.mVesicularmsoundsmheardminmthemperipherymaremno
rmalmandmrequiremnomintervention.
DIF:mApplying
6. Amnursemobservesmthatmamclientsmanteroposteriorm(AP)mchestmdiametermismthemsamemasmthemlateral
mchestmdiameter.mWhichmquestionmshouldmthemnursemaskmthemclientminmresponsemtomthismfinding?
a. Aremyoumtakingmanymmedicationsmormherbalmsupplements?
b. Domyoumhavemanymchronicmbreathingmproblems?
c. Howmoftenmdomyoumperformmaerobicmexercise?
d. Whatmismyourmoccupationmandmwhatmaremyourmhobbies?m-mCORRECTmANSWERm-ANS:mB
ThemnormalmchestmhasmamlateralmdiametermthatmismtwicemasmlargemasmthemAPmdiameter.mWhenmthemAPmdia
metermapproachesmormexceedsmthemlateralmdiameter,mthemclientmismsaidmtomhavemambarrelmchest.mMostmco
mmonly,mbarrelmchestmoccursmasmamresultmofmamlong-
termmchronicmairflowmlimitationmproblem,msuchmasmchronicmobstructivempulmonarymdiseasemormseveremch
ronicmasthma.mItmcanmalsombemseenminmpeoplemwhomhavemlivedmatmamhighmaltitudemformmanymyears.mThere
fore,manmAPmchestmdiametermthatmismthemsamemasmthemlateralmchestmdiametermshouldmbemrecheckedmbutmi
smnotmasmindicativemofmunderlyingmdiseasemprocessesmasmanmAPmdiametermthatmexceedsmthemlateralmdiam
eter.mMedications,mherbalmsupplements,mandmaerobicmexercisemaremnotmassociatedmwithmambarrelmchest.m
Althoughmoccupationmandmhobbiesmmaymexposemamclientmtomirritantsmthatmcanmcausemchronicmlungmdisord
ersmandmbarrelmchest,
, TestmBankm-mMedical-
SurgicalmNursing:mConceptsmformInterprofessionalmCollaborativemCarem9em215maskingmaboutmch
ronicmbreathingmproblemsmismmoremdirectmandmshouldmbemaskedmfirst.
DIF:mApplying
7. Amnursemismassessingmamclientmwhomismrecoveringmfrommamlungmbiopsy.mWhichmassessmentmfindingmre
quiresmimmediatemaction?
a. Increasedmtemperature
b. Absentmbreathmsounds
c. Productivemcough
d. Incisionalmdiscomfortm-mCORRECTmANSWERm-ANS:mB
Absentmbreathmsoundsmmaymindicatemthatmthemclientmhasmampneumothorax,mamseriousmcomplicationmaf
termamneedlembiopsymormopenmlungmbiopsy.mThemothermmanifestationsmaremnotmlifemthreatening.
DIF:mApplying
8. Amnursemismcaringmformamclientmwhomismscheduledmtomundergomamthoracentesis.mWhichminterventionms
houldmthemnursemcompletempriormtomthemprocedure?
a. Measuremoxygenmsaturationmbeforemandmaftermam12-minutemwalk.
b. Verifymthatmthemclientmunderstandsmallmpossiblemcomplications.
c. Explainmthemprocedureminmdetailmtomthemclientmandmthemfamily.
d. Validatemthatminformedmconsentmhasmbeenmgivenmbymthemclient.m-mCORRECTmANSWERm-ANS:mD
Amthoracentesismismanminvasivemproceduremwithmmanympotentiallymseriousmcomplications.mVerifyingmthat
mthemclientmunderstandsmcomplicationsmandmexplainingmthemproceduremtombemperformedmwillmbemdonemb
ymthemphysicianmormnursempractitioner,mnotmthemnurse.mMeasurementmofmoxygenmsaturationmbeforemand
maftermam12-mminutemwalkmismnotmamproceduremuniquemtomamthoracentesis.
DIF:mApplying
9. Amnursemassessesmamclientmaftermamthoracentesis.mWhichmassessmentmfindingmwarrantsmimmediatemactio
n?
a. Themclientmratesmpainmasmam5-10matmthemsitemofmthemprocedure.
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