Adult Care 1 Quiz Review

1. Patient shakes the MDI 2. Patient takes a deep breath and blows out completely 3. Patient places the mouthpiece of the inhaler in the mouth 4. Patient inhales slowly and pushes the canister 5. Patient continues to inhale for 3 to 5 seconds and hold the breath for 5 to 10 seconds 6. Patient removes inhaler and exhales through pursed lips

The client is to use a traditional metered-dose inhaler (MDI). Place the steps of the procedure in the correct order.

"Have you been exposed to loud noises?"

The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?

A 27-year-old client with a heart rate of 120 beats/min

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?

Increased urine output

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?

Monitor the apical pulse Initiate telemetry monitoring

A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.)

Attaining independence with dressing Performing activities of daily living (ADLs)

A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? (Select all that apply.)

"Note the time of the client's first void and collect urine for 24 hours."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?

"Try warm, moist heat packs on your face."

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

Assess the client for bleeding. Monitor the daily activated partial thromboplastin time (aPTT) results. Use an IV pump for the infusion.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.)

Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)

Place warm compresses on the site.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?

Coordinate rehabilitation team activities to ensure implementation of the plan of care. Support the client's choices by acting as an advocate for the client and family.

A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse's role? (Select all that apply.)

"My shoes fit tighter by the end of the day."

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?

Client with a respiratory rate of 8 breaths/min

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?

Notify the provider and request antibiotics.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important?

"This test will assess for a hormone secreted on a circadian rhythm."

A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, "Why do I need to collect urine for 24 hours instead of providing a random specimen?" How should the nurse respond?

Increased carbohydrates Increased calorie intake Increased proteins

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's teaching? (Select all that apply.)

Checking emergency equipment each morning

A nurse works in an allergy clinic. What task performed by the nurse takes priority?

Intravenous

A postoperative client is vomiting and states, "I am having a lot of pain—about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the client?

Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.)

Applying suction while inserting the catheter

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

Providing protection against invading organisms

The student nurse learns that the most important function of inflammation and immunity is which purpose?

Hypertension and heart failure

What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client?

Coordinates holistic care Coordinates rehabilitation team activities Plans continuity of care for discharge

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? (Select all that apply.)

A multicolored lesion is present on the client's thigh.

When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider?

Consistently using appropriate hand hygiene

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?

Frequent nosebleeds Upper extremity bruising Dark stools

Which assessment findings indicate to the nurse that a client taking warfarin may have decreased Clotting? Select all that apply.

Presence of one of the "ABCDE" features

Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon?

Man who smokes and whose father died at 49 of myocardial infarction (MI)

Which client has the highest risk for cardiovascular disease?

B-type natriuretic peptide (BNP) of 760 ng/dL

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)?

Those with type 2 diabetes make insulin, but in inadequate amounts.

Which explanation best assists a client in differentiating type 1 diabetes from type 2 diabetes?

Early recognition and quarantine

Which method is the best way to prevent outbreaks of pandemic influenza?

Elevated C-reactive protein levels Smoking

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.)

HR, RR, O2 sat, and lung sounds

Which specific assessments should be done by the nurse before administration of a bronchodilator medication?

Skin integrity can be compromised easily by the application of tape or dressings.

Which statement is true about the special needs of older adults receiving IV therapy?

Change the set in about 4 hours

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?

Decreasing respiratory rate

A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention?

Admit the client to a negative-airflow room. Order specialized masks/respirators for caregiving.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)

"Nocturia could cause interruption of your sleep and cause changes in mood."

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the client's behavior, which statement by the nurse would be the most appropriate?

Teach the client to sneeze in the upper sleeve.

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

Midline catheter

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client?

Assess the client's lung sounds and oxygenation.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate?

"Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."

A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond?

Stop the infusion of intravenous fluids

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

Administer medications promptly on schedule to maintain therapeutic drug levels.

A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse?

Slower processing time Change in sleep patterns

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

Apply compression stockings. Assist with ambulation. Offer fluids frequently.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)

"Advance directives allow a client to convey his or her wishes about health care ahead of time."

A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond?

The risk for hypotension

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication?

"Because eye pressure was too high, the tissue died."

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?

Pneumothorax

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?

Call the doctor for increased pain Do not bend over from the waist. Do not lift more than 10 pounds. Use stool softeners to avoid constipation.

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.)

Be careful not to drop the hearing aid when handling Turn the hearing aid off when the client goes to bed Use a toothpick to clean debris from the device Wash device with soap and a small amount of warm water

A client has a hearing aid. what care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.)

Distraction Music therapy Premedication

A client reports increasing pain during dressing changes. Which interventions are recommended for the client? (Select all that apply.)

Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow.

A client with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? (Select all that apply.)

Change the client's gown and linens when damp. Offer cool fluids to the client frequently.

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.)

Potential for injury related to chronic confusion and physical deficits

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority?

Serum potassium level of 2.8 mEq/L

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription?

Draw aerobic and anaerobic blood cultures.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first?

11:00 a.m.

A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client should be monitored for hypoglycemia at which time?

"Tell me more about that."

A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond?

Teach family members about physical signs of impending death. Encourage the management of adverse symptoms. Encourage reminiscence by both client and family members.

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.)

Keep the client's skin dry. Obtain a pressure-relieving mattress Turn the client every 2 hours.

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Ciprofloxacin (Cipro) 400 mg IV every 12 hours

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order?

Assess the color and temperature of the left leg.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?

" I am always tired, even with 12 hours of sleep."

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism?

Collect the nasal drainage on a piece of filter paper.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Hypertension Leukemia Cocaine use

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.)

Administer oxygen to keep saturations greater than 94%. Administer prescribed albuterol (Proventil) inhaler.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)

A 55-year-old woman who is 50 pounds overweight

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

Age-related decrease in immune function Decreased cough and gag reflexes Diminished acidity of gastric secretions Thinning skin that is less protective

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.)

"I will limit my total intake of fluids."

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"I will take this medication every morning to help prevent an acute attack."

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?

"I will use the drug when I have an asthma attack."

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

Keep the light on in the bathroom at night.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?

Stop irrigation immediately.

An older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next?

Sodium

Normal plasma value is 135 to 145 mEq; It is the main cation in extracellular fluid (ECF) of the cell that maintains ECF osmolarity

Potassium

Normal plasma value is 3.5 to 5.0 mEq/L; Major cation of intracellular fluid and maintians action potentials in excitable membranes

Magnesium

Normal value is 1.8 to 2.6 mg/dL; Has more activity in the cell than in the blood

Calcium

Normal value is 9.0 to 10.5 mg/dL; Its functions include contraction of the skeletal and cardiac muscle

Edema Redness Warmth

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.)

Crackles

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds?

Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority?

Client taking glyburide (Diabeta) who is dizzy and sweaty

The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first?

Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Has cut down on caffeine

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.)

Erythromycin Ibuprofen (Advil) Furosemide (Lasix)

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (Select all that apply.)

Muscle weakness Headache Confusion Abdominal cramping

The nurse is assessing the client who presented to the emergency room with a serum sodium level of 114 mEq/L. Which findings would the nurse relate to the serum sodium level? (Select all that apply)

Increased, bounding pulses Jugular venous distention Presence of crackles in the lungs Elevated blood pressure Skin pale and cool to touch

The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate that the patient has fluid volume excess? (Select all that apply)

Hypertension

The nurse is caring for a client who has chronic pyelonephritis. What assessment finding would the nurse expect?

Correctly identifying the client prior to a blood transfusion

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

"Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Do not wear high-heeled shoes."

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.)

Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.)

"I use a tanning bed to avoid the sun's harmful rays."

The nurse is instructing a client on skin and sun protection. Which statement by the client indicates a need for further teaching?

"I can break in my shoes by wearing them all day."

The nurse is providing discharge teaching to a client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching?

"I use a bobby pin to remove earwax."

The nurse is talking to a client about ear hygiene safety. Which statement by the client indicates a need for further teaching?

"I should eat three graham crackers."

The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management?

Client who is speaking in three-word sentences and has an SpO 2 of 87% by pulse oximetry

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse?

Handwashing Preoperative checklists Six rights of drug administration

The nurse is working on a busy medical-surgical floor where many errors can occur. Which principal nursing actions best support a focus on client safety? ( Select all that apply.)

"Be sure to swallow the pill whole."

The nurse prepares to administer the following mediation to the client. Which instruction will the nurse be sure to give before the client takes the medication? MS Contin (Morphine sulfate) 15mg Extended Release PO q8h PRN severe pain

Type I - Examples include hay fever and anaphylaxis Type III - Immune complex deposits in blood vessel walls Type IV - Examples are poison ivy and transplant rejection

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)