Chapter 10 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 10 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCMA

The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pressure from a right pneumothorax
2. Misplacement of the endotracheal tube
3. High pulmonary pressures
4. Partial obstruction of the endotracheal tube
5. A large infiltrate in the left lung

Correct Answer: 2,5

Rationale 1: A right pneumothorax would present with decreased sounds on the right.

Rationale 2: The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea. This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung from air. This results in decreased breath sounds on the left.

Rationale 3: High pulmonary pressures would affect both sides equally.

Rationale 4: A partially obstructed endotracheal tube would affect both sides equally.

Rationale 5: A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1

Question 2

Type: MCSA

A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs?

1. Decreased work of breathing
2. Reduced muscle activity
3. Dehydration of lung tissues
4. Decreased compliance

Correct Answer: 4

Rationale 1: A respiratory rate of 28 is evidence of increased work of breathing.

Rationale 2: It requires more muscle activity to breath at a rate of 28.

Rationale 3: Pulmonary edema results from retention of fluid in the lung tissues.

Rationale 4: Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1

Question 3

Type: MCSA

The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results?

1. Increased PaO₂ and increased PaCO₂
2. Decreased PaO₂ and normal PaCO₂
3. Normal PaO₂ and elevated PaCO₂
4. Decreased PaO₂ and increased PaCO₂

Correct Answer: 2

Rationale 1: Presence of pneumonia will not result in an increase in oxygen.

Rationale 2: In the early stages of pneumonia the alveolar surface area is reduced and the alveolar–capillary membrane begins to thicken causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO₂. Only when the condition progresses untreated will the PaCO₂ rise.

Rationale 3: PaCO₂ will rise only after the disease has progressed.

Rationale 4: Oxygen will decrease, but PaCO₂ will not rise initially.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2