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Nurs 3000 - Content After Midterm Exam Latest Update A+ Graded
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Nurs 3000 - Content After Midterm Exam LatestUpdate A+ Graded
The nurse is caring for an older-adult client who has undergone left knee arthroplasty
with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis.
Postoperatively the nurse expects which of the following interventions will be included
in the care of the affected leg?
Progressive leg exercises to obtain 90-degree flexion
Early ambulation with full weight bearing on the left leg
Three days of bed rest with left leg in extension
Two weeks of immobilizing left knee in 30 degree flexion to prevent dislocation -Answer
A: A-The client is encouraged to begin the progressive leg exercises as soon as possible
until 90 degree flexion can be achieved. Due to pain associated with this post surgically,
the client must have good pain management and are often placed on a continuous
passive motion (CPM) machine.
The nurse is caring for a client with metastatic lung cancer who has a 60-pack-per-year
history of cigarette smoking. The nurse should consider that which of the following
respiratory defenses are impaired related to tobacco use?
A. Cough reflex
B. Mucociliary clearance
C. Reflex bronchoconstriction
D. Ability to filter particles from the air
ANSWER A: B - Smoking reduces the ciliary action in the tracheobronchial tree,
leading to impaired clearance of respiratory secretions, chronic cough, and frequent
respiratory infection.
The nurse is walking a client who has metastatic lung cancer. During the ambulation,
the nurse notices that the oxygen saturation has dropped from 93% to 86%. Which of the
following nursing interventions is most appropriate for the nurse to take?
,Continue to walk the client because this is a normal response to activity.
Obtain an order for arterial blood gas determinations to confirm the oxygen saturation.
Obtain a prescription for supplemental oxygen to be used during ambulation and other
activity.
Move the oximetry probe from the finger to the earlobe for accurate monitoring during
activity. - ANSWER A: C - An oxygen saturation below 90% on exertion shows that the
client is not tolerating the exercise and should utilize supplemental oxygen.
The nurse is caring for a client who had a left total knee arthroplasty. On the third
postoperative day, the client shows signs of shortness of breath, slight chest pain, and
that "something is wrong." Temperature is 36.9°C (98.4°F), blood pressure 130/88 mm
Hg, respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the
following etiologies should the nurse first suspect related to these findings?
New-onset angina pectoris
Septic embolus from the knee joint
Pulmonary embolus from deep vein thrombosis
Pleural effusion related to positioning in the operating room - ANSWER A: C - The client
exhibits classic symptoms of pulmonary embolus: sudden onset of symptoms,
tachypnea, dyspnea and chest pain.
The nurse is caring for a client who had a left total knee arthroplasty. The client, on the
third postoperative day, shows signs of shortness of breath, slight chest pain, and that
"something is wrong." Temperature is 36.9°C (98.4°F), blood pressure 130/88 mm Hg,
respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the
following actions should the nurse take first?
Notify the health care provider.
Administer a nitroglycerine tablet sublingually.
Conduct a detailed assessment of the chest pain.
Sit the client up in bed as tolerated and administer oxygen. - ANSWER A: D - The client's
clinical presentation is indicative of pulmonary embolus, so the first action that the
nurse should take is to provide support for the client. Thus, the nurse should sit the
client up in bed as tolerated and administer oxygen before calling the physician.
The nurse is caring for a client diagnosed with pneumonia. Which of the following should
the nurse include in the plan of care to facilitate airway clearance? (Select all that
, apply.)
Maintain adequate fluid intake
Splint the chest when coughing
Maintain a high Fowler's position
Maintain a semi-Fowler's position
Instruct client to cough at end of exhalation - ANSWER A: A,B.C,E - The nurse should
instruct the client to splint the chest while coughing. This minimizes discomfort and
results in a more effective cough. Fluid intake at optimal levels thins out secretions so
they are more easily expectorated. The cough is more effective at the end of exhalation.
The client should be placed in an upright sitting position -high Fowler's-with the head
slightly flexed.
The nurse is admitting a client who was diagnosed with non-small cell carcinoma of the
lung. Which of the following risk factors should the nurse assess in the client related to
this type of cancer? (Select all that apply.)
Asbestos exposure
Cigarette smoking
Exposure to uranium
Chronic interstitial fibrosis
Geographic region in which he was born - ANSWER A: A,B,C - Cigarette smoking and
exposure to environmental carcinogens like asbestos and uranium are associated with
the development of non-small cell carcinoma. Chronic interstitial fibrosis can give rise to
adenocarcinoma of the lung. The geographic area where the client was born is not a
risk factor for this type of cancer.
The nurse is admitting a client diagnosed with pulmonary embolism. Which of the
following risk factors does the nurse look for in the client? (Select all that apply.)
Obesity
Pneumonia
Hypertension
Cigarette smoking
Long-distance flying - ANS: A,C,D,E - Most studies demonstrate obesity, heavy cigarette
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