Chapter 25 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 25  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process?
1. Beginning of the gas exchange process
2. Neutralizing the air
3. Filtering the air
4. Separating the air
Correct Answer: 3
Rationale 1: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through the anatomical dead space, but these structures do not participate in gas exchange.
Rationale 2: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through this space, but it is not neutralized.
Rationale 3: The trachea is part of the anatomical dead space. It traps particulate matter to keep it from entering the lungs.
Rationale 4: The anatomical dead space includes the structures from the nose to the terminal bronchioles. The air is not separated in these structures.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-1

Question 2
Type: MCSA
During an assessment, a patient begins to cough. How would the nurse evaluate this finding?
1. The patient has a cold.
2. The patient is nervous.
3. Something other than air was entering the larynx.
4. The patient is not fully conscious.
Correct Answer: 3
Rationale 1: A cough does not indicate the presence of a cold. Additional assessment would be necessary.
Rationale 2: A cough is not sufficient assessment data to determine that a patient is nervous.
Rationale 3: If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs.
Rationale 4: The protective reflex of coughing may not be present if the person is unconscious. A cough is not enough data to determine level of consciousness.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-5

Question 3
Type: MCSA
A patient is diagnosed with a low iron count. The nurse would be alert for which finding associated with this condition?
1. Increased carbon dioxide in the blood
2. Nausea
3. Anxiety
4. Poor tissue oxygenation
Correct Answer: 4
Rationale 1: Low iron would not increase carbon dioxide levels in the blood.
Rationale 2: Nausea is not generally associated with low iron count.
Rationale 3: Anxiety is not generally associated with low iron count.
Rationale 4: Oxygen is carried in the blood either bound to hemoglobin or dissolved in the plasma. Oxygen is not very soluble in water, so almost all oxygen that enters the blood from the respiratory system is carried to the cells of the body by hemoglobin.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-1

Question 4
Type: MCMA
During the palpation of a patient’s chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with which condition?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Emphysema
2. Pneumothorax
3. Flail chest
4. Heart failure
5. Influenza
Correct Answer: 2,3
Rationale 1: Bilateral chest expansion is decreased in emphysema.
Rationale 2: Thoracic expansion is altered on the affected side in patients with pneumothorax.
Rationale 3: One side of the chest would not expand at the correct time if the patient has a flail chest.
Rationale 4: Heart failure does not result in a change in chest expansion.
Rationale 5: Thoracic expansion is not affected by influenza.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-5