exam 1 review questions

an older adult experiencing delirium suffers from a leg fracture caused by a fall. Which intervention would the nurse follow to prevent future falls?

- minimizing sedating medications -modifying the home environment -manage foot and footwear problems

the nurse plans to help a client get out of bed for the first time after surgery. Which assessments would the nurse make before having the client sit on the side of the bed? SATA

-presence of sage foot wear -status of comfort and pain -appearance of would and skin -patency of urinary catheter

which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and CPR?

BLS

which adverse hemodynamic effects typically occur when a client develops tachycardia? SATA

Decreased ventricular filling time lower cardiac output weaker pulse quality

which action would the nurse take first after noting a flat line on a clients cardiac monitor?

assess the clients pulse

which action would the nurse anticipate taking when a client develops third degree artrioventricular block with a heart rate of 30 bpm?

obtain the transcutaneous pacemaker

in which area would the nurse place the stethoscope when taking an apical pulse?

mitral area

which initial nursing intervention would the nurse take for a older adult with delirium who begins action out while in the dayroom?

giving the client one simple direction at a time in a firm, low pitched voice

which nursing action is priority when a client with severe chest pain and diaphoresis is brought to the ED?

initiate ECG monitoring

which nursing action has the highest priority when caring for a client who has had an acute MI?

monitor for cardiac dysrhythmias

when caring for a client who has just returned after a cardiac cath using the femoral artery, the nurse notes that the pedal pulses are not palpable and the foot is cool. Which action would the nurse take?

notify the HCP immediately

the nurse is caring for a client with a pneumothorax and chest tube. Which assessment finding indicated that the chest tube has been effective?

return of breath sounds

which diagnostic test result will the nurse review after noticing large U waves on the ECG for a client who was just admitted to the cardiac unit?

serum potassium

which action would the nurse do immediately when the nurse finds the RR is 8 bpm in a client who is on IV morphine sulfate?

stop administering the medication

the nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding indicates a comlication?

subcutaneous emphysema on the second postoperative day

The nurse is caring for a client who is 1 day post op for left hip fx repair. Which clinical finding would the nurse assess further?

sudden SOB

which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity?

teach the client coughing and deep breathing exercises

immediately after a thoracentesis, a clients right lung collapsed. A chest tube is inserted and is attached to a three chamber closed drainage system. The nurse assess the fluid in the system and recognizes that which finding indicated that the chest tube is functioning properly?

the fluid rises in the tube of the water-seal chamber during inspiration

how will the nurse document these sounds heard during auscultation of the lungs?

wheezes

a clients cardiac monitor indicated v tach. The nurse assess the client and identifies an increase in apical pulse rate from 100-150 bpm. Which action is indicated?

adminsiter amiodrarone

when caring for a client who has just arrived in the ED with possible acute coronary syndrome, which prescribed action would the nurse take first?

ask the client about level of intensity of the chest pain

when a client in the coronary care unit develops v tach, which action will the nurse take first?

assess client pulse and BP

the nurse is providing Post op care to a cleint on the second day after the client had a coronary artery bypass surgery. when assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. Which action would the nurse take?

assess for obstructions in the chest tube

a clients respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. The nurse would take which immediate action?

assess the clients response to the intervention

when a clients cardiac monitor shows V tach, which action would the nurse take first?

check for a pulse

which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy?

observe for fluctuations of the fluid in the water-seal chamber

the nurse is caring for a client whose mechanical ventilator settings include the use of PEEP. This treatment improves oxygenation primarily thought which mechanism of action?

opening collapsed alveoli and keeping them open

which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube?

palpate around the tube insertion site for crepitus

which nursing intervention would be of most benefit to the client with a compromised airway the nurse noticed while performing resuscitation during the primary survey?

preparing for endotracheal intubation and mechanical ventilation

when a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the clients left ventricular pressure?

pulmonary artery wedge pressure

The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice would the nurse perform?

assessment

when admitting a client with ACS on the tele unit after cardic cath and PCI, which action would the nurse take first?

attach the cardiac monitor

when a client reports a sudden onset of chest pain that feels like a pressure or weight on the chest, which action would the nurse take first?

check BP and HR

which client in the ED would the nurse assess first?

client with chest pressure and ST segment elevation on the ecg

which clinical manifestation would the nurse expect when assessing a client with atelectasis?

crackles at the bases

the nurse finds that an older adult has a new onset of decreased consciousness, fatigue, and hallucinations. Which condition would the nurse suspect in the client?

delirium

the nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds?

diminished breath sounds

a toddler in the PICU is on a ventilator. the nurse asks what would be done when condensation collects in the ventilator tubing. How would the nurse manage respond?

empty the fluid and reconnect the tubing to the ventilator

which assessment would be most useful in monitoring the client, who had a total hip replacement, for hemorrhage?

examining the bedding under the client

which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?

full re-expansion of the lungs seen on chest x-ray

when the nurse obtains vital signs of BP 90/60, pulse 96 bpm, and RR 10 bpm for a post op client who is receiving hydromorphone by a PCA pump, which nursing action would be priority?

give naloxone IV per protocol

the nurse is caring for a client with an endotracheal tube. What is the most effective way for the nurse to loosen respiratory secretions?

humidify the prescribed oxygen