Core Exam 3

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply) A. Apply petroleum jelly around and inside the nares B. Remove the nasal cannula during meal times C. Check the position of the cannula frequently D. Report any nasal stiffness, nausea, or fatigue E. Post "No Smoking" signs in a prominent location

C, D, E

A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this? a. Aortic b. Mitral c. Pulmonic d. Tricuspid

c. Pulmonic

The nurse provides dietary instructions to a client who needs to limit intake of sodium. The nurse instructs the client that which food items must be avoided because of their high-sodium content? (Select all that apply) A. Ham B. Apples C. Broccoli D. Soy sauce E. Asparagus F. Cantaloupe

A and D

Which is true about Afterload? (Select all that apply) A. Affected by vascular resistance (pressure) B. Affected by compliance of heart muscle fibers C. Affected by volume D. Refers to how much heart muscles need to stretch during filling E. Refers to how hard ventricles have to work during ejection

A and E

A nurse has just inserted a nasogastric tube in a client. Which of the following is the most reliable method for verifying correct tube placement? A) Radiographic confirmation of position B) Off-white fluid aspirated C) Instilling air into tube D) Confirmation that pH of the aspirate is 5.5 or less

A) Radiographic confirmation of position

A nurse is assessing a client who has recently had a bowel surgery and will be receiving an NG tube. Which of the following would most likely contraindicate the nurse placing the NG tube? A) Recent facial trauma or surgery B) Bleeding in the GI tract C) Abdominal distention D) One nare being less patent

A) Recent facial trauma or surgery

Which of the following actions should a nurse complete prior to administering a tube feeding? (Select all that apply) A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of the gastric aspirate D. Warm the formula to body temperature E. Discard any gastric residual

A, B, C

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint? (Select all that apply) A. Use of accessory muscles B. Increased respiratory depth C. Increased respiratory rate D. Decreased respiratory depth E. Decreased respiratory rate

A, B, C, D Rationale: The depth of respirations DEPENDS on the cause of difficulty breathing (*This was a question from study group. Mrs. Howard said we would not be tested on something so something so specific about the depth without more information*)

Which of the following are late signs of low oxygenation? (Select all that apply) A. Stupor B. Cyanosis C. Elevated blood pressure D. Decreased respiratory rate E. Pallor F. Increased pulse rate

A, B, D Rationale: Confusion/Stupor, Cyanosis, and Bradypnea are a few LATE signs of low oxygenation. Early signs of low oxygenation include hypertension, pallor, and tachycardia.

A client taking warfarin sodium (Coumadin) has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? (Select all that apply) A. Tea B. Turnips C. Oranges D. Cabbage E. Broccoli F. Strawberries

A, B, D, E

Which of the following findings are early indications that should alert the nurse that a client is developing hypoxia? (Select all that apply) A. Restlessness B. Tachycardia C. Bradycardia D. Confusion E. Pallor

A, B, D, E

A post-operative client has been placed on a clear liquid diet. Which items is the client allowed to consume? (Select all that apply) A. Tea B. Broth C. Gelatin D. Pudding E. Vegetable juice F. Pureed vegetables

A, B, and C

Identify reasons an NG tube would be placed in a client. Select all that apply A) To remove undesirable substances, such as poisons B) To facilitate weight loss C) To prevent hemorrhage D) To drain unwanted fluid and air from the stomach E) To deliver nutrients

A, C, D, E

A client with a colostomy is complaining of gas building up in the colostomy bag. The nurse instructs the client that which food items should be consumed to best prevent this problem? (Select all that apply) A. Yogurt B. Broccoli C. Cabbage D. Crackers E. Cauliflower F. Toasted bread

A, D, and F

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate a need for further teaching? A. "I will replace my cotton blankets with polyester ones" B. "My son will not be able to smoke when I am not around" C. "I will have my electrical appliances checked for grounding" D. "I will buy a fire extinguisher for my bedroom"

A. "I will replace my cotton blankets with polyester ones"

A client asks why Sequential Compression Devices have been prescribed. How should the nurse respond to the client? A. "They stimulate the blood return that would occur with walking" B. "They prevent lymph draining buildup in the tissues" C. "They exercise the muscles of the leg" D. "They are used instead of walking out of bed"

A. "They stimulate the blood return that would occur with walking"

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged" B. "Flushing helps make sure the tube stays in place" C. "This will help you get enough fluids" D. "Adding water makes the formula less concentrated"

A. "Water helps clear the tube so it doesn't get clogged"

The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma? A. 1/8 inch B. 1/4 inch C. 1/2 inch D. 1 inch

A. 1/8 inch

The nurse is preparing to administer oxygen to a client who has COPD and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? A. 2 to 3 liters per minute B. 4 to 5 liters per minute C. 6 to 8 liters per minute D. 8 to 10 liters per minute

A. 2 to 3 liters per minute

Selecting a BP cuff that is too small for the patient's arm will result in A. A falsely high reading B. A falsely low reading C. No effect

A. A falsely high reading

Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery? A. Atelectasis B. Bronchitis C. Pneumonia D. Pneumothorax

A. Atelectasis

Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.

A. Auscultate the aortic valve in the second intercostal space at the right sternal border. Rationale: The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

A patient tells the nurse that he does not want to develop the same heart problems that his parents experienced. Which of the following should the nurse instruct this client? A. Avoid cigarette smoking B. Limit fluid intake C. Wear elastic hose D. Limit exercise to 15 minutes a day

A. Avoid cigarette smoking Rationale: The one intervention that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking. Limiting fluids and wearing elastic hose are not known to prevent the onset of cardiovascular disease. Limiting exercise to 15 minutes a day may also not be enough exercise to prevent the onset of cardiovascular disease.

The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize about cardiac output? A. Calculated by multiplying the patient's stroke volume by the heart rate B. The average amount of blood ejected during one complete cardiac cycle C. Determined by measuring the electrical activity of the heart and the patient's heart rate D. The patient's average resting heart rate multiplied by the patient's mean arterial blood pressure

A. Calculated by multiplying the patient's stroke volume by the heart rate Rationale: Cardiac output is determined by multiplying the patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output

A Patient asks the nurse how he developed chronic obstructive pulmonary disease (COPD). Which of the following would be the best response for the nurse to make to this client? A. Cigarette smoking is the number one cause of COPD. B. COPD is caused from asthma. C. COPD is caused from working in an industrial environment. D. Once diagnosed with COPD, quitting smoking won't help the disease.

A. Cigarette smoking is the number one cause of COPD.

It is important that the nurse be knowledgeable about cardiac output in order to: A. Evaluate blood flow to peripheral tissues. B. Determine the electrical activity of the myocardium. C. Provide information on the immediate need for oxygen. D. Implement nutritional changes.

A. Evaluate blood flow to peripheral tissues.

An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea? A. Fever increases metabolic demands requiring increased oxygen need. B. Blood glucose stores are depleted and the cells do not have energy to use oxygen. C. Carbon dioxide production increases due to hyperventilation. D. Carbon dioxide production decreases due to hypoventilation.

A. Fever increases metabolic demands requiring increased oxygen need.

A terminally ill cancer patient is scheduled for an NGT feeding today. How should you position the patient? A. Fowler's B. Prone in bed C. Slightly elevated right side lying position D. Supine in bed

A. Fowler's

The client has been admitted with complaints of shortness of breath of 2 weeks duration, and has received the nursing diagnosis of "Impaired Gas Exchange." Which admission laboratory result would support the choice of this diagnosis? A. Increased hematocrit B. Decreased BUN C. Increased blood sugar D. Increased sedimentation rate

A. Increased hematocrit Rationale: When the body has impaired gas exchange, the body will automatically concentrate the RBCs, which causes Hematocrit to increase Hct is the percentagee of blood that is erythrocytes, which contain the hemoglobin that carries oxygen ESR = Inflammation

The nurse is teaching a client with newly diagnosed emphysema how to manage the disease. The client asks how pursed lip breathing helps the emphysema. The best response by the nurse is: A. It prevents the air sacs in lungs from trapping air B. It decreases the pressure in the airways C. The resistance on exhalation increases muscle strength in the diaphragm D. It helps slow the respiratory rate

A. It prevents the air sacs in lungs from trapping air Rationale: Pursed- lip breathing is a technique used by individuals with COPD where clients exhale through pursed lips. This increases airway pressure to get the O2 to the alveoli.

The nurse is preparing how to assess a client's fecal elimination status. Which activity will the nurse complete during this assessment? A. Obtain a nursing history B. Interpret results of diagnostic tests C. Perform a physical examination D. Set goals with the client

A. Obtain a nursing history

Ejection Fraction is... A. Percentage of blood in ventricles ejected during systole B. Amount of blood ejected from ventricles with each beat C. How much heart muscles need to stretch during filling D. Amount of blood ejected from ventricles in one minute

A. Percentage of blood in ventricles ejected during systole

The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? A. Raise the head of the bed to 60 degrees or higher. B. Get his oxygen saturation with a pulse oximeter. C. Take his blood pressure and respiratory rate. D. Notify the health care provider of his shortness of breath

A. Raise the head of the bed to 60 degrees or higher.

The nurse caring for a client with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from the client's diet? A. Spinach B. Custard C. Scrambled eggs D. Mashed potatoes

A. Spinach

A client's nasogastric (NG) tube stops draining. Which should the nurse implement *first* to maintain client safety? A. Verify the tube placement B. Instill 30 to 60 mL of fluid C. Clamp the tube for 2 hours D. Retract the tube by 2 inches

A. Verify the tube placement

Which of the following is the BEST method in assessing for the correct placement of the NGT? A. X-Ray B. Immerse tip of the tube in water to check for bubbles produced C. Aspirating gastric content to check if the content is acidic D. Instilling air in the NGT and listening for a gurgling sound at the epigastric area

A. X-Ray

The nurse is slowly advancing an NG tube when the patient begins to gasp & is unable to vocalize. Which of the following has likely occurred? A) The client is experiencing a nasovagal reaction B) The NG tube is in the client's airway C) The NG tube is curled in the back of the client's throat D) The client is forcefully resisting the procedure

B) The NG tube is in the client's airway

A patient is exhibiting signs of hypoxia and is showing an oxygen saturation reading of 85%. Which of the following are appropriate nursing interventions? A. Encourage the patient to exercise to help open the airway B. Remain with the client to help reduce anxiety. C. Encourage deep breathing D. Encourage the patient to take quick, shallow breaths E. Place patient in a Semi-Fowler's or Fowler's position if possible. F. Increase oxygen flow and reassess in 30 minutes

B, C, E

Which of the following is true about the sinoatrial node? (Select all that apply) A. It is located between atria and ventricles B. It is called the "Pacemaker" of the heart C. It has an intrinsic heart rate of 60 to 100 beats per minute D. It has an intrinsic heart rate of 40 to 60 beats per minute E. It is part of the conduction system

B, C, E

Which is true about Preload? (Select all that apply) A. Affected by vascular resistance (pressure) B. Affected by compliance of heart muscle fibers C. Affected by volume D. Refers to how much heart muscles need to stretch during filling E. Refers to how hard ventricles have to work during ejection

B, C, and D

Stroke volume is.... A. Percentage of blood in ventricles ejected during systole B. Amount of blood ejected from ventricles with each beat C. How much heart muscles need to stretch during filling D. Amount of blood ejected from ventricles in one minute

B. Amount of blood ejected from ventricles with each beat

Which of the following assessment findings would suggest to the nurse that a Patient is at risk for alterations in perfusion? A. Blood pressure 110/68 mmHg B. Apical heart rate 80; radial beats per minute 68 C. Respiratory rate 20 per minute D. Temperature 98.8°F

B. Apical heart rate 80; radial beats per minute 68 Rationale: The number of radial beats per minute is 12 beats slower than the apical rate of 80 per minute. This indicates weak contractions of the left ventricle and could lead to alterations in perfusion. The other assessment findings are within normal limits.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow B. Assist the client into Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases

B. Assist the client into Fowler's position

A patient with cardiogenic shock receives a nursing diagnosis of decreased cardiac output. With the appropriate interventions, the anticipated outcome is for the patient to achieve: A. Baseline activity level. B. Baseline cardiac function. C. Decreased afterload. D. Reduced anxiety.

B. Baseline cardiac function.

Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer? A. Inhales slowly B. Breathes through the nose C. Removes the mouthpiece to exhale D. Forms a tight seal around the mouthpiece with the lips

B. Breathes through the nose

Which assessment is *most important* for the nurse to make before advancing a client from liquid to solid food? A. Bowel sounds B. Chewing ability C. Current appetite D. Food preferences

B. Chewing ability Rationale: Because of the risk for aspiration

The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? A. Apply pressure over the stoma B. Clean the stoma and pat dry C. Dilate the stoma D. Scrub the stoma

B. Clean the stoma and pat dry

While suctioning a client in ICU, the nurse notices that the activity brings about deep breathing and coughing maneuvers by the client. This is considered a good action because: A. Deep breathing has no effect on the lungs or the ability of the client to cough. B. Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs. C. Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action. D. Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action.

B. Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.

The nurse is caring for a client in the short procedure unit following a bronchoscopy using moderate (conscious) sedation. Prior to discharging the client the nurse verifies that the client has achieved which of the following priority outcomes? A. Verbalizes symptoms to report to physician following discharge B. Demonstrates an intact gag reflex C. Remains afebrile D. Reports being thirsty and asks for oral fluids

B. Demonstrates an intact gag reflex Rationale: An intact gag reflex indicates that topical sedation has lost its effect and the client is able to swallow, a major safety consideration prior to discharging the client from the healthcare facility. Priority is critical for this question.

A client is admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a *priority* measure to assist the client with breathing? A. Repositions side to side every 2 hours B. Elevates the head of the bed 60º C. Auscultates the lung fields every 4 hours D. Encourages deep breathing exercises every 2 hours

B. Elevates the head of the bed 60º

A postoperative client with emphysema is receiving oxygen at 2L/min via nasal cannula when the client reports shortness of breath. The spouse asks the nurse to increase the oxygen intake to help the client breathe easier. Which response by the nurse is appropriate? A. Switch oxygen to 100% non-rebreather mask B. Explain to spouse that high concentration of oxygen may depress breathing C. Ask spouse to leave the room to let client sleep D. Administer a dose of pain medication ordered PRN that can be given at this time

B. Explain to spouse that high concentration of oxygen may depress breathing Rationale: Carbon dioxide level is one of the primary stimuli for breathing in clients with chronic obstructive pulmonary disease (COPD), emphysema, who adjust to higher than normal carbon dioxide levels. Abrupt elevation of O2 level will depress the stimulus for breathing and can produce respiratory arrest.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy

B. Frequent change of position

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should she recommend? A. Macaroni and cheese B. Fresh fruit and whole wheat toast C. Bread pudding and yogurt D. Roasted chicken and white rice

B. Fresh fruit and whole wheat toast

As the NG tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? A. Remove the tube and attempt reinsertion B. Give the client a few sips of water C. Use firm pressure to pass the tube from the glottis D. Have the client tilt the head back to open the passage

B. Give the client a few sips of water

The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places. *priority* on discussing which risk factor with this client? A. Age older than 30 years B. High-fat and low-fiber diet C. Distant relative with colorectal cancer D. Personal history of ulcerative colitis and/or gastrointestinal polyps

B. High-fat and low-fiber diet

A nurse is caring for a client who is at risk high for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck her chin when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals

B. Instruct the client to tuck her chin when swallowing Rationale: Allows food to pass down the esophagus more easily

Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute? A. Arterial blood gas (ABG) and breath sounds B. Level of consciousness and a pulse oximetry value. C. Breath sounds and reflexes D. Pulse oximetry value and heart sounds

B. Level of consciousness and a pulse oximetry value.

A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema. A. Hold the solution for a short time B. Lie in the left lateral position C. Lie in the right lateral position D. Take fast breaths through the nose

B. Lie in the left lateral position

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb above heart level B. Lowering the limb so it is dependent C. Massaging the limb after application of cold compresses D. Placing the limb in a plane horizontal to the body

B. Lowering the limb so it is dependent

Which of the following if done by the nurse, is correct during NGT Insertion? A. Use an oil based lubricant B. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the xiphoid process C. Soak the NGT in a basin of ice water to facilitate easy insertion D. Check the placement of the tube by introducing 10 cc of sterile water and auscultating for bubbling sound

B. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the xiphoid process

The nurse is making a home visit to a 70 year old client with emphysema. The nurse would call the client's primary care provider if which of following was present? A. Increased anterior-posterior diameter of the chest B. More frequent cough with change in the character and color of secretions C. Pursed-lip breathing D. Circumoral (area of the face and mouth) cyanosis

B. More frequent cough with change in the character and color of secretions Rationale: A new cough producing yellow secretions may indicate a superimposed infection and predispose the client to respiratory failure. Need to differentiate between normal changes expected with the disorder and changes that are not a part of the normal course of the disease.

A Patient with chronic obstructive lung disease is prescribed oxygen 24% 2 L/ min. The nurse realizes the best way to provide oxygen to this client would be with a: A. Nonrebreather mask. B. Nasal cannula. C. Face mask. D. Venturi mask.

B. Nasal cannula. Rationale: The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

The nurse is planning the care of a client who has a need for frequent suctioning. What should the nurse delegate to the UAP? A. Both oral and tracheal suctioning B. Only oral suctioning C. Only tracheal suctioning D. Neither suctioning

B. Only oral suctioning Rationale: You cannot delegate a sterile procedure to a UAP

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of COPD. What is the nurses next action? A. Fill the humidifier with normal saline B. Pad the tubing where it contacts the clients ears C. Set the oxygen delivery to 5L D. Secure the cannula with ties around the client's head

B. Pad the tubing where it contacts the clients ears Rationale: Because of skin breakdown The humidifier would be filled with distilled water, not normal saline 5L is too much (especially for starting out)

The nurse is caring for a client with a diagnosis of pneumonia. Over the past 24 hours the nurse observes that the client has been requiring increasing amounts of supplemental oxygen to maintain the same level of oxygenation. The best intervention at this time is to: A. Call the healthcare provider requesting an order for an arterial blood gas (ABG) B. Perform a focused pulmonary physical assessment. C. Call the physician and ask for an order for a bronchodilator D. Administer the standing diuretic order two hours early

B. Perform a focused pulmonary physical assessment. Rationale: Increased oxygen requirements can result from fluid accumulation as in heart failure and require diuresis, focused pulmonary physical assessment needs to be performed to identify problems prior to notifying the physician for orders.

The nurse is caring for a client with pulmonary mycobacterium tuberculosis (TB). When the family comes to visit for the first time, what would be the best statement for the nurse to make to the family? A. Please wear a gown so you don't get a skin infection from the droplets B. Please keep the door to the room closed at all times, except when entering or exiting C. Please wear the gloves and gown so you do not come in contact with any blood the patient may cough up D. If you have been living with the patient and don't have symptoms, you will not contract TB

B. Please keep the door to the room closed at all times, except when entering or exiting Rationale: Mycobacterium TB is transmitted via airborne droplets exhale by the patient, so use of a negative pressure room is essential to reduce the risk of infection to other patients.

What should the nurse do if the patient becomes unable to breathe while placing an NG tube? A. Continue placement of NG tube B. Pull back on tube C. Momentarily stop the advancement of the tube to allow patient to breathe, then continue D. Remove and withhold further placement of NG tube because the patient is unable to handle it

B. Pull back on tube

The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. Which position should the nurse use to administer the feeding? A. Supine B. Semi-Fowler's or Fowler's C. Trendelenburg's D. Lateral Recumbent

B. Semi-Fowler's or Fowler's

The nurse considers which of the following to be the priority item in discharge teaching for a client who has chronic bronchitis? A. Fluid restriction B. Smoking cessation C. Avoidance of crowds D. Side effects of drug therapy

B. Smoking cessation Rationale: Cigarette smoking is the primary etiology of chronic bronchitis so cessation is a priority for the client. It could also be second hand smoke or the environment. Remember that smoking is the key ongoing risk factor to lung tissue to place this as highest priority for discharge teaching.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which description describes this assessment finding? A. Waves of loud gurgles auscultated in all four quadrants B. Soft gurgling or clicking sounds auscultated in all four quadrants C. Low-pitched swishing sounds auscultated in one or two quadrants D. Very high-pitched loud rushes auscultated, especially in one or two quadrants

B. Soft gurgling or clicking sounds auscultated in all four quadrants Rationale: Normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest x-ray D. Initiate oxygen therapy

B. Stop the feeding

Which of the following describes systolic pressure? A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation phases of the heart B. The pressure exerted by the blood during the heart's contraction phase C. The pressure exerted by the blood during the heart's relaxation phase

B. The pressure exerted by the blood during the heart's contraction phase

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting sitting on the toilet. Which would be the nurse's best response? A. The sitting position decreases the contractions of the pelvic floor B. The sitting position increases the downward pressure on the rectum, making it easier to pass stool C. The sitting position increases the pressure within the abdomen D. The sitting position inhibits the urge to urinate, allowing one to defecate

B. The sitting position increases the downward pressure on the rectum, making it easier to pass stool

The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first? A. Place the client in high-fowler's position B. Turn off the tube feeding C. Assess the client's lung sounds D. Assess the client's bowel sounds

B. Turn off the tube feeding

The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? A. Diaphragmatic breathing B. Use of accessory muscles C. Pursed-lip breathing D. Controlled breathing

B. Use of accessory muscles

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A. Face tent B. Venturi mask C. Nonrebreather mask D. Nasal cannula

B. Venturi mask

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A. Nasal cannula B. Venturi mask C. Simple face mask without inflated reservoir bag D. Plastic face mask with inflated reservoir bag

B. Venturi mask Rationale: The Venturi mask delivers the most precise oxygen concentration out of all the oxygen delivery systems

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the container has been open B. Verify placement of the NG tube C. Confirm that the client does not have diarrhea D. Make sure the client is alert and oriented

B. Verify placement of the NG tube

The nurse is planning teaching for a client that focuses on objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching? (Select all that apply) A. Age B. Gender C. Obesity D. Smoking E. Hypertension

C, D, E

Which of the following are early signs of low oxygenation? (Select all that apply) A. Stupor B. Cyanosis C. Elevated blood pressure D. Decreased respiratory rate E. Pallor F. Increased pulse rate

C, E, F Rationale: Stupor, Cyanosis, and Bradypnea are a few LATE signs of low oxygenation. Early signs of low oxygenation include hypertension, pallor, and tachycardia.

A nurse is giving a nothing per orem instructions to a malnourished client with diarrhea and frequent abdominal pain episodes which is about to receive a Total Parenteral Nutrition. Which statement made by the nurse is the most appropriate? A. "It will help in your weight loss". B. "It can assure you that you feel better after receiving TPN". C. "It will decrease your diarrhea and your bowel can rest". D. "It will give you less time in the hospital".

C. "It will decrease your diarrhea and your bowel can rest".

The registered nurse is planning the client assignments for the day. Which of the following is an appropriate assignment for the unlicensed assistive personnel (UAP)? A. A client requiring colostomy irrigation B. A client receiving continuous tube feedings C. A client requiring stool specimen collections D. A client who has difficulty swallowing food and fluids

C. A client requiring stool specimen collections Rationale: Colostomy irrigations and tube feedings are not done by UAPs. The client who has difficulty swallowing food and fluids is at high risk for aspiration.

A client receiving total parenteral nutrition (TPN) complains of nausea, excessive thirst, and increased frequency of voiding. The nurse should *initially* assess which client data? A. Rectal temperature B. Last serum potassium C. Capillary blood glucose D. Serum BUN and creatinine

C. Capillary blood glucose

The nurse prepares a client who is being discharged from the hospital to receive oxygen therapy at home. Which should the nurse include in client teaching about oxygen safety? A. Hold the oxygen tank on your lap when traveling B. Light candles a few feet away from the oxygen tank to avoid fires C. Check the oxygen level of the tank on a regular basis D. Report low oxygen levels in the tank to the health care provider (HCP)

C. Check the oxygen level of the tank on a regular basis

A client who has undergone GI surgery is permitted to have a clear liquid diet on the second post-op day. Which should should the nurse order from the kitchen for the client? A. Apricot nectar B. Cranberry juice C. Chicken broth D. Cherry popsicle

C. Chicken broth Rationale: Nectar is not clear liquid After GI surgery, patients should not consume anything red because it could be mistaken as a GI bleed

Which is not a clear liquid diet? A. Hard candy B. Gelatin C. Coffee with Coffee mate D. Bouillon

C. Coffee with Coffee mate

The home care nurse assesses a client with COPD who is complaining of increased dyspnea. The client is on home oxygen via a concentrator at 2L per minute, and the client's respiratory rate is 22 breaths/minute. Which action should the nurse take? A. Determine the need to increase the oxygen B. Reassure the client that there is no need to worry C. Conduct further assessment of the client's respiratory status D. Call emergency services to take the client to the emergency department

C. Conduct further assessment of the client's respiratory status Rationale: Oxygen may not be increased without the approval of the health care provider. Telling the client there is "no need to worry" is inappropriate. Calling emergency services is a premature action.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum easily after nebulization C. Decreased independent ability to cough D. Lung sounds clear only after coughing

C. Decreased independent ability to cough

A nurse is assessing a patient's respiratory status. The nurse would become *most* concerned with which assessment finding? A. Equal bilateral chest expansion B. Respiratory rate of 22 breaths per minute C. Diminished breath sounds on the affected side D. Few scattered wheezes, unchanged from baseline

C. Diminished breath sounds on the affected side

The nurse is caring for a 68 year old client who is scheduled for discharge later that day. An arterial blood gas (ABG) done the previous morning reveal a PaO2 of 87mmHg. The client has a respiratory rate of 22 clear lungs and reports no shortness of breath. What would be the nurse's response? A. Call healthcare provided reporting the PaO2 B. Monitor client more closely because a physiologic abnormality is beginning C. Do nothing because a PaO2 of 87 is normal in an older adult D. Call family to tell them to anticipate discharge being cancelled

C. Do nothing because a PaO2 of 87 is normal in an older adult Rationale: The PaO2 normally drops as the individual ages and can be as low as 83 in a 90yr.old So the client's assessment is normal. Since the client reports no distress, no need to call the physician.

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? A. Notify the physician. B. Administer a tap water enema. C. Encourage the client to ambulate at least three times per day. D. Apply moist heat to the client's abdomen.

C. Encourage the client to ambulate at least three times per day. Rationale: Ambulation stimulates peristalsis

The nurse is preparing to administer an intermittent tube feeding through an NG tube and assesses for residual volume. What is the purpose of the nurse assessing the residual volume before administering tube feeding? A. Confirm proper NG tube placement B. Determine the client's nutritional status C. Evaluate the adequacy of gastric emptying D. Assess the client's fluid and electrolyte status

C. Evaluate the adequacy of gastric emptying Rationale: Confirmation of proper NG tube placement MUST be done by X-Ray This does not assess nutritional status or fluid/electrolyte status

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? A. Decreased Cardiac Output related to difficulty breathing B. Impaired Gas Exchange related to use of bronchodilators C. Fatigue related to impaired oxygen transport system D. Ineffective Airway Clearance related to fatigue

C. Fatigue related to impaired oxygen transport system

A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health? A. Place pillows under the unaffected knee for support B. Position the bed to flex the knees at least 20º C. Have the client alternately flex and extend the feet several times a day D. Keep the client in a prone position at least 20 times a day

C. Have the client alternately flex and extend the feet several times a day Rationale: Keeps the blood moving; Doing this simulates walking

A client diagnosed with COPD who is receiving oxygen at 1.5 L per minute via nasal cannula is complaining of shortness of breath. Which action should the nurse take? A. Increase the oxygen to 3L per minute via nasal cannula B. Lower the head of the bed C. Have the client breathe through pursed lips D. Encourage the client to breathe more rapidly

C. Have the client breathe through pursed lips

The nurse is reviewing the results of laboratory tests conducted on a patient admitted with a respiratory disorder. The laboratory finding that is the most significant for this patient would be: A. Blood pH 7.40. B. Serum sodium 140 mg/dL. C. Hemoglobin level 8.3. D. Oxygen saturation 96%.

C. Hemoglobin level 8.3. Rationale: The hemoglobin level affects the amount of oxygen that can be carried in the blood. The low level suggests the client does not have enough red blood cells to provide adequate oxygen for the body. The blood pH of 7.40 is within normal limits. Serum sodium does not impact the oxygen capacity of the body. Oxygen saturation of 96% is within normal limits.

The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action? A. Inhale deeply B. Exhale slowly C. Hold in a deep breath D. Pause between breaths

C. Hold in a deep breath

A client has just undergone an upper gastrointestinal (GI) series. Upon the client's return to the unit, what health care provider's prescriptions does the nurse expect to note as a part of routine post-procedure care? A. Bland diet B. NPO status C. Mild laxative D. Decreased fluids

C. Mild laxative

Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? A. Venturi mask B. Nasal cannula C. Nonrebreather mask D. Simple face mask

C. Nonrebreather mask

A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms A. Inhaling too slowly B. Exhaling too slowly C. Not resting adequately between breaths D. Not forming a tight seal around the mouth piece

C. Not resting adequately between breaths

A client with pneumonia has anorexia caused by the effort required for eating while dyspneic and decreased taste sensation. Which action by the nurse would be most helpful in increasing the client's appetite? A. Keep fresh water at the bedside B. Provide three large meals daily C. Provide mouth care before meals D. Encourage drinking fluids up to three liters per day

C. Provide mouth care before meals

A nurse, explaining the cardiac circulation to cardiac rehabilitation clients, wants to include the oxygenation of the heart muscle. Which of the following structures carries deoxygenated blood to the lungs? A. Right main coronary vein B. Pulmonary vein C. Pulmonary artery D. Great cardiac vein

C. Pulmonary artery

The client is admitted with a possible Deep Vein Thrombosis. Nursing interventions should be designed to prevent which complication: A. Myocardial infarction B. Renal Failure C. Pulmonary embolism D. Pneumonia

C. Pulmonary embolism

S2 is produced when the.... A. Atria contract vigorously B. Ventricular walls vibrate C. Pulmonic and Aortic valves close D. Mitral and Tricuspid valves open

C. Pulmonic and Aortic valves close

A patient with a tricuspid valve disorder will have impaired blood flow between the A. Vena cava and right atrium. B. Left atrium and left ventricle. C. Right atrium and right ventricle. D. Right ventricle and pulmonary artery.

C. Right atrium and right ventricle. Rationale: The tricuspid valve is located between the right atrium and the right ventricle.

The nurse is reviewing laboratory data for a client who is receiving TPN. Which laboratory value should be immediately brought to the physician's attention A. BUN of 60 B. Prealbumin of 15 C. Serum glucose of 328 D. Potassium of 3.5

C. Serum glucose of 328

When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? A. Record the number of stools per day B. Maintain strict intake and output records C. Sterile technique for dressing change at IV site D. Monitor for cardiac arrhythmias

C. Sterile technique for dressing change at IV site

To help the client prevent postoperative pulmonary complications preoperatively, the nurse should: A. Ask the physician to order nebulizer treatments B. Teach the client to do leg exercises C. Teach the client to use a flow-oriented incentive spirometer D. Tell the client that if he does not cough, he may need to be suctioned

C. Teach the client to use a flow-oriented incentive spirometer

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A. Restricting fluid intake to 1,000 ml/day B. Enforcing absolute bed rest C. Teaching the client how to perform controlled coughing D. Administering prescribed sedatives regularly and in large amounts

C. Teaching the client how to perform controlled coughing

A client with emphysema should receive only 1 to 3 L/minute of oxygen, if needed, or he may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive? A. The client doesn't notice he needs to breathe. B. The client breathes only when his oxygen levels climb above a certain point. C. The client breathes only when his oxygen levels dip below a certain point. D. The client breathes only when his carbon dioxide level dips below a certain point.

C. The client breathes only when his oxygen levels dip below a certain point.

Which of the following should the nurse expect to see on a meal tray for a client on a low-residue diet? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C. Vanilla custard Rationale: Low-residue diets consist of foods that are low in fiber and easy to digest (dairy products and eggs, such as custard and yogurt are appropriate for this diet)

A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." C. "If I have trouble breathing at night, I'll use two to three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which finding would indicate that the oxygen level was adequate? A. A PaO2 of 45mmHg B. A PaO2 of 50 mmHg C. A PaO2 of 60 mmHg D. A PaO2 of 80 mmHg

D. A PaO2 of 80 mmHg

Cardiac Output is... A. Percentage of blood in ventricles ejected during systole B. Amount of blood ejected from ventricles with each beat C. How much heart muscles need to stretch during filling D. Amount of blood ejected from ventricles in one minute

D. Amount of blood ejected from ventricles in one minute

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the client's degree of effective gas exchange? A. Blood glucose B. Serum potassium C. Serum sodium D. Arterial blood gases

D. Arterial blood gases

The nurse is caring for a client diagnosed with right middle lobe pneumonia. The nurse should perform which of the following interventions to mobilize secretions? A. Administer antibiotics as ordered B. Limit fluids to prevent heart failure from developing as a complication C. Place client in a prone position to increase alveolar expansion D. Assist client to use incentive spirometer hourly

D. Assist client to use incentive spirometer hourly Rationale: Helping the clients deep breath or use the incentive spirometer promotes maximum lung expansion, mobilizes secretions, and encourages cough

Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? A. Temperature of 99.5ºF B. Urine output of 300 cc in 4 hours C. Poor skin turgor D. Blood glucose of 350 mg/dl

D. Blood glucose of 350 mg/dl

The nurse is teaching a client with COPD how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action? A. Breathes in and then holds breath for 30 seconds B. Loosens the abdominal muscles while breathing out C. Inhales with pursed lips and exhales with the mouth open wide D. Breathes so that expiration is two to three times as long as inspiration

D. Breathes so that expiration is two to three times as long as inspiration

The nurse has administered approximately half of a cleansing enema when the client complains of pain and cramping. Which nursing action is appropriate? A. Reassuring the client that everything is normal, and continuing the flow B. Discontinuing the enema and notifying the health care provider C. Raising the enema bag so the solution can be completed quickly D. Clamping the tubing for 30 seconds, and restarting the flow at a slower rate

D. Clamping the tubing for 30 seconds, and restarting the flow at a slower rate

During tracheal suctioning, the nurse notes that the clients HR has increased from 80 to 100 bpm. based on this assessment, what action should the nurse take? A. Immediately discontinue suctioning B. Prepare to resuscitate the client C. Continue to suction until the airway is clear D. Complete the suction episode as quickly as possible

D. Complete the suction episode as quickly as possible

A client has a HR of 170 bpm. For what will the nurse assess next in the client? A. Increased CO B. Increased preload C. Decreased after load D. Decreased cardiac output

D. Decreased cardiac output

The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition? A. Ruddy skin color over legs B. Bounding pedal pulses C. Hot spots on the feet and legs D. Decreased hair on the legs

D. Decreased hair on the legs

A client with an upper GI disorder is experiencing seeping of liquid stool, anorexia, abdominal dissension, nausea, and vomiting. The nurse suspects the client is experiencing? A. Constipation B. Diarrhea C. Trapped flatus D. Fecal impaction

D. Fecal impaction

A client is receiving oxygen by non-rebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse? A. Turn the client to the left side B. Increase the percentage of oxygen being delivered C. Check for an airtight seal between the clients face and mask D. Increase the liter flow of oxygen being delivered

D. Increase the liter flow of oxygen being delivered

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold his breath briefly and bear down B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container

D. Lower the enema fluid container

If a patient is supposed to receive as much 02 as possible without being intubated, which face mask should be used? A. Venturi mask B. Face tent C. Partial rebreather D. Nonrebreather

D. Nonrebreather

A patient receiving parenteral nutrition is administered via the following routes except: A. Subclavian line. B. Central Venous Catheter. C. PICC (Peripherally inserted central catheter) line. D. PEG tube.

D. PEG tube.

The nurse instructs a preoperative client in the proper use of an incentive spirometer. What should the nurse use to determine that the client is using the incentive spirometer effectively? A. Cloudy sputum B. Shallow breathing C. Unilateral wheezing D. Productive coughing

D. Productive coughing Rationale: Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions

Before administering an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Which should the nurse implement as a result from this finding? A. Discard the aspirate and record client output B. Mix with new formula to administer the feeding C. Dilute with water and inject into the nasogastric tube D. Reinstill the aspirate through the nasogastric tube via gravity using a syringe

D. Reinstill the aspirate through the nasogastric tube via gravity using a syringe

The nurse is giving a client with COPD information related to the positions used to breathe more easily. The nurse teaches the client to assume which position? A. Sit upright in bed with the arms crossed over the chest B. Lie on the side with the head of the bed at a 45º angle C. Sit in a reclining chair tilted slightly back with the feet elevated D. Sit on the edge of the bed with the arms leaning on an over-bed table

D. Sit on the edge of the bed with the arms leaning on an over-bed table

On return from surgery, the patient is wearing intermittent sequential compression stockings that he does not want to keep on. How should the nurse explain their necessity to the patient while he is on bed rest? A. The socks keep the legs warm while the patient is not moving much. B. The socks maintain the blood flow to the legs while the patient is on bed rest. C. The socks keep the blood pressure down while the patient is stressed after surgery. D. The socks provide compression of the veins to keep the blood moving back to the heart.

D. The socks provide compression of the veins to keep the blood moving back to the heart. Rationale: Intermittent sequential compression stockings provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.

The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client? A. Shrimp, avocado, and tomato salad B. Calf's liver, potato salad, and sherbert C. Lean steak, mashed potatoes, and gravy D. Turkey breast, boiled rice, and strawberries

D. Turkey breast, boiled rice, and strawberries

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which action should the nurse implement to decrease the risk of infection? A. Assess vital signs at 4-hour intervals B. Administer prophylactic antimicrobial agents C. Check the solution's label against the prescription D. Use aseptic technique in handling the TPN solution

D. Use aseptic technique in handling the TPN solution

Which of the following measures can reduce or prevent the incidence of atelectasis in a post-operative client? A. Chest physiotherapy B. Mechanical ventilation C. Reducing oxygen requirements D. Use of an incentive spirometer

D. Use of an incentive spiromete

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are low-pitched, soft sounds heard over peripheral lung fields. b) They are loud, high-pitched sounds heard primarily over the trachea and larynx. c) They are medium-pitched blowing sounds heard over the major bronchi. d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

a) They are low-pitched, soft sounds heard over peripheral lung fields. Rationale: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a) adequate tissue perfusion. b) diminished stroke volume. c) heart failure. d) high cardiac output.

a) adequate tissue perfusion.

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more.

b) The rate will be no more than 2 to 3 L/min or less. Rationale: A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.