Acute MIDTERM

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

20 mL or less

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?

80 to 110 mg/dL

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

The nurse is assessing a client with advanced gastric cancer. The nurse anticipates that the assessment will reveal which finding?

Bloating after meals

Which clinical manifestation is not associated with hemorrhage?

Bradycardia

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci (also Tonsillitis and adenoiditis)

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy.

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?

Shortness of breath

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute)

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by

Telling the client to sit upright with the head tilted forward

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

amoxicillin-clavulanic acid.

The nurse is creating a discharge plan of care for a client with a peptic ulcer. The nurse tells the client to avoid

decaffeinated coffee.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention.

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

laryngeal cancer

The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience

pain 2 to 3 hours after a meal.

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?

potassium 6.2 mEq/L

The classification of Stage IV of COPD is defined as

very severe COPD.

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

7 to 10 days

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse?

Assess the client's abdomen and vital signs.

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care?

Baking soda and water

The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery?

Blood pressure 80/50 mm Hg

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum

A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client?

Calcium channel blockers

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse

Which is the primary symptom of achalasia?

Difficulty swallowing

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics

For a client with pleural effusion, what does chest percussion over the involved area reveal?

Dullness over the involved area

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Dyspnea

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

Edema of the upper airway

A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?

Elective

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest

Which domain of perioperative nursing practice focuses on clinical processes and outcomes?

Health care systems

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

It prolongs exhalation.

Which position is used for perineal surgical procedures?

Lithotomy

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in?

Lithotomy position

A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?

Osteoporosis

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

Partial pressure of arterial oxygen (PaO2)

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it.

The client received ketamine during a surgical procedure. What intervention by the nurse will assist with an optimal recovery period?

Place the client in a darkened, quiet part of the recovery area.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

The nurse is teaching a client with peptic ulcer disease who has been prescribed misoprostol. What information from the nurse would be most accurate about misoprostol?

Prevents ulceration in clients taking nonsteroidal anti-inflammatory drugs (NSAIDs)

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

Protrusion of the upper stomach into the lower portion of the thorax.

Your client is status post total laryngectomy and cannot talk. What intervention should you make to help this client communicate?

Provide alternative methods of communication.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?

Report the infection to an immediate supervisor

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure?

Respiratory acidosis

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

Respiratory acidosis

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?

Vasomotor symptoms associated with dumping syndrome

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

alcohol abuse and smoking.

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?

diuretics

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

drink liquids only between meals.

The most common symptom of esophageal disease is

dysphagia.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits.

The nurse provides health teaching to inform the client with oral cancer that

many oral cancers produce no symptoms in the early stages.

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 85% for a patient with COPD. What stage should the nurse document the patient is in?

stage I

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?

urgent

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention?

Frequently monitoring vital signs

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority?

Impaired gas exchange

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which explanation from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is:

"Have you tried to quit smoking before?"

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly so it won't fall off while I nap."

Which nursing statement would best ease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?

A canker sore of the oral soft tissues

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

Gastroesophageal reflux disease

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage?

Hematemesis

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

Hoarseness of more than 2 week's duration

Select the nursing diagnosis that would warrant immediate health care provider notification.

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

Which is a true statement regarding the nursing considerations in administration of metronidazole?

It leaves a metallic taste in the mouth.

Immediate medical and nursing management is necessary for a patient who has ingested a corrosive substance and experienced a chemical burn. Select the first response.

Maintain a patent airway.

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

After teaching a class about agents commonly associated with the development of malignant hyperthermia, the instructor determines that additional teaching is needed when the students identify which drug as a possible cause?

Morphine

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?

Nasogastric tube insertion

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Oxygen through nasal cannula at 2 L/minute

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Place the client in the Fowler's position.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in the OR

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?

The client can develop malignant hyperthermia up to 24 hours after surgery.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

Tolerance

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

Tumor excision

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis.