Advanced Medsurg 2 Midterm

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect?

confusion

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?

"I decline the opportunity at this time."

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the AP and the nurses on the next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

"I need to talk to you about unit expectations regarding delegating and completing tasks"

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

"If I could lose about 50 pounds, I might stop having so many apneic episodes."

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate.

"Let's talk about your concerns about the new policy."

A nurse is planning to the use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

"The client was found unconscious on the floor in her home"

a nurse manager is providing an inservice program about delegation to AP with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

"The nurse should consider the AP's level of experience when making delegation decisions"

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

"delegation permits a designated individual to meet a goal on your behalf"

A nurse is caring for a client following exposure to inhalation anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (Select all that apply)

- Ciprofloxacin - Doxycycline - Amoxicillin

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary TB? (Select all that apply)

- Night sweats - Low-grade fever - Blood in the sputum

The nurse is preparing to admit the client who was diagnosed with TB. What are the interventions that the nurse is going to implement? (Select all that apply)

- Put on a N95 respirator mask when entering the room - Begin the prescribed doses of isoniazid, rifampin, pyrazinamide, and ethambutol

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? select all that apply

-Coordinator -Evaluator -Energizer

A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)

-Elevate the HOB to at least 30 -Administer pantoprazole as prescribed -Reposition the endotracheal tube to the opposite side of the mouth daily

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer?

-Rifampin -Isoniazid -Pyrazinamide

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply)

-Severe dyspnea - Decreased level of consciousness - Headache - Hypotension

The client with cellular dehydration is to receive an IV solution that will rehydrate cells. Which solution prescribed by the PCP should the nurse plan to administer?

0.45% Normal Saline

A nurse in a community health center is assessing the results of a TB skin test she performed for a client. Which of the following indicates exposure to a possible infection with TB?

15 mm induration

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?

480 mL

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who told an assistive personnel he is short of breath.

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A dependent adult admitted for the treatment of a spiral fracture

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outdoor environment

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

A typical course of treatment involves 6 to 9 months of consistent medication use.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation, the client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the client's airway

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time?

Assess the client's respiratory status

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care. Facility. Which of the following is appropriate action by the nurse manager?

Address the concern with the specific staff nurse.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing interventions?

Administer oxygen via face mask.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

Administer the abdominal thrust maneuver.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?

Albuterol via jet nebulizer

The nurse is caring for a client in the ED who has 5 fractured ribs from blunt force trauma, the client is rating a 9 out of 10 pain. When contacting the PCP, the nurse should advocate for which pain management option?

An epidural analgesic or intercostal nerve block

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

Approach the man and ask why he is making copies

The client has a vesicant solution infusing in the IV in a large peripheral vein. Which assessment finding should prompt the nurse to explore whether extravasation has occurred? (Select all that apply)

Blisters noted at the IV insertion site

A nurse on a medical unit is preparing to contact a provider about a client's condition. The client is a 6 hour postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report?

Assessment

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of over-delegation?

Assigning the most efficient AP to perform glucometer monitoring for each client

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via nasal cannula. Which of the following actions should the nurse take?

Attach a humidifier bottle to the base of the flow meter

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator pneumonia?

Brush the client's teeth with a suction toothbrush every 12 hr.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyene-Stokes respirations

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter.

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?

Cooperating

The client who is receiving TPN through a subclavian triple-lumencatheter expresses concern to the nurse about bacteria entering the bloodthrough the catheter. The nurse explains that the risk of catheter-relatedinfections can be decreased by taking which action?

Designating one port of the catheter exclusively for the TPN solution

A nurse observes for early manifestations of ARDS in a client being treated for smoke inhalation. Which signs indicates the possible onset of ARDS in this client?

Diaphoresis and low SAO2 despite oxygen administration

A nurse is teaching a client who has TB and is to start medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?

Drink at least 8 ounces of water when you take the pyrazinamide tablet.

The nurse is developing a plan of care for a client admitted with a cough, fever, dyspnea, and a diagnosis of pneumonia. Which of the following interventions should the nurse include to prevent atelectasis?

Encourage hourly use of the incentive spirometer

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions

Encouraging the client to drink 2 to 3 L of water daily

A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?

Flu-like symptoms

The nurse is caring for the client requiring positive pressure mechanical ventilation. The client has been resisting the ventilator-assisted breaths, and the client's BP has been steadily decreasing. Which intervention should the nurse implement?

Give the prescribed sedative-hypnotic medication if it is due now

A 35-year-old woman with a history of asthma comes into the emergency department with an asthma exacerbation secondary to viral pneumonia. Vital signs are temperature 38.1 heart rate 110 respiration rate slightly labored blood pressure 148 / 90. Lung sounds have pronounced wheezing and all lung fields. Her ABG on room air is: pH 7.45, CO2 35, HCO3 23, PaCO2 53. What is the interpretation of the blood gases?

Hypoxic

A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?

Identify the problem.

A nurse on a medical surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Increased anteroposterior diameter of the chest

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate of 18 to 44

A nurse is caring for a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Increasing dyspnea

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

Lethargy

A nurse is caring for a patient who was admitted with DKA. Her blood gases are pH 7.20, CO2 35, HCO3 15. What is the interpretation of the blood gases?

Metabolic Acidosis

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Movement of the ET tube into the right main bronchus

A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom?

No one

The nurse is caring for the client whose condition has progressed from an acute lung injury from near-drowning to ARDS. Which intervention should the nurse question with the HCP?

Normal saline 1000 mL bolus followed by 250 mL/hr

The nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of following findings should the nurse expect?

PaCO2 50 mmHg

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86 to 110 and becomes irregular. Which of the following actions should the nurse take?

Perform pre oxygenation prior to suctioning

A nurse id planning care for a client who has acute respiratory distress syndrome (ADRS). Which of the following interventions should the nurse include in the plan of care?

Place in a prone position

The nurse is assessing the lung sounds of a client with pneumonia who is having pain during inspiration and expiration. Which information about lung sounds should the nurse document when hearing loud gabbing sounds over the lung fields?

Pleural friction rub

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

Propanolol

A nurse is creating a plan of care for a client who is in the late stages of inhalation anthrax. Which of the following is appropriate to include in the plan of care?

Provide respiratory support.

A nurse is caring for a patient who has COPD and was admitted to the unit with an acute exacerbation. The physician orders a blood gas, and the results are pH 7.27, CO2 50, HCO3 33. What are the interpretations of the blood gas?

Respiratory Acidosis

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. pH 7.22PaCO2 68 mm HgBase excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L. Which of the following is an appropriate analysis of the ABGs?

Respiratory acidosis

A nurse is caring for a client who has an ABG result of pH 7.30, CO2 50. The nurse should identify that the client is experiencing which of the following acid base imbalances?

Respiratory acidosis

A nurse is caring for a patient who has started on oxygen therapy via a non-rebreather at 100% O2. IV fluids steroids and albuterol continuous nebulizer are also initiated along with empiric antibiotics. Within 30 minutes her blood pressure heart rate and respiration rate has normalized with improvement of her PaO2 at 81. He is transferred to the ICU step down for further monitoring 6 hours after admission the patient becomes increasingly shortness of breath begins wheezing and vital signs increases her ABG's are pH 7.31, CO2 55, HCO3 27, PaCO2 48. What is the interpretation of these blood gases?

Respiratory acidosis

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Right supervision

A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?

Secure new tracheostomy ties before removing old ones.

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement?

Sit in front of the group for the meeting and then stand for the announcement.

A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

Sodium bicarbonate 100 mEq diluted in 1 L of D5W

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Suppresses respiratory effort

A charge nurse has assigned a group of clients to a LPN. The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the nurse take?

Talk with the clients who have reported the LPNs lack of care

When planning delegation tasks to AP, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

The AP has the knowledge and skill to perform the task

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

The nurse separates the client's labia with her dominant hand.

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?

Transporting a school-age client who is in traction to another department.

A client who had a central venous access device suddenly develops dyspnea, chest pain, tachycardia, and hypotension. This occurs after the nurse attached new injection caps after a central line dressing change. Which of the following actions should the nurse be taking first?

Turn the client onto the left side with the head of the bed lowered

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

Visual acuity

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

Widen QRS complexes

A nurse and an AP are providing care for four clients who were admitted to the med-surg unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

a client who has lumbro sacral spinal tumor

(i think this is an NGN) A nurse is assessing a client who is experiencing significant stress due to septicemia.Drag words from the choices below to fill in each blank in the following sentence.

administer oxygen therapy, obtain the lactate level, and monitor temperature.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

agitation

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

barrel

A nurse is working with an AP to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

check to see if the elbow restraint is in place for an infant who is postop from a surgical correction of cleft palate

A nurse in the emergency department is caring for a client who was injured in a motor vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges during expiration. The nurse should identify this finding as which of the following?

flail chest

The charge nurse is on a team with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

give positive feedback directly to the AP

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect

intercostal retractions

a nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. the nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication?

red colored urine

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 min into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

stop the infusion

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

stridor

a nurse manager is talking with a staff nurse who was unable to sleep the night after experiencing unsuccessful client resuscitation. which of the following responses should the nurse manager make

tell me what your concerns are

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

wear a mask when providing care to the client.