Fundamentals of Nursing Practice Quiz 17

Answer: C – Orthopnea

Explanation: Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea.

Answer: D – Decrease inflammation in the airways.

Explanation: Glucocorticoids are prescribed because of their anti-inflammatory effect, are not achieved with glucocorticoids.The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care? 1.Percussion and postural drainage should be done before lunch.

Answer: A – Percussion and postural drainage should be done before lunch.

Explanation: Postural drainage result in expectoration of large amounts of mucus. Client sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.

Answer: B – Inspiratory volume will be increased.

Explanation: An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. Patients who use an incentive spirometer may or may not be receiving oxygen.

Answer: C – Increases circulation

Explanation: Heat increases the skin surface temperature, promoting vasodilation, which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction, which decreases blood flow to the area. Both heat and cold relax muscles and thus minimize muscle spasms.

Answer: B – Osteoporosis.

Explanation: Implementing the practitioners order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength, These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls.

Answer: B – help maintain open airways.

Explanation: Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse.

Answer: B – Determine if the patient can make any verbal sounds.

Explanation: When a person is choking on food, the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction, the person will be able to make sounds because some air can pass from the lungs through the vocal chords. In this situation the person’s own efforts open parentheses gagging and coughing) should be allowed to clear the airway.

Answer: B – Assist the client to Fowlers position.

Explanation: The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients dyspnea. Fowler’s position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea, The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing.

Answer: B – Weak, rapid pulse.

Explanation: All other options are indicated of fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit.