Exam 2 Essentials

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

The nurse is providing teaching to an older adult with arthritis and an implanted catheter. What living arrangement does the nurse anticipate in the discharge plan of care?

home nursing visits

The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication?

in the anterolateral aspect of the thigh

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

intradermal

The Z-track technique is utilized during drug administration by which route?

intramuscular

A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation?

medications that need to be infused over 20 to 60 minutes

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation?

nasal cannula

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula

Which is a sign of dyspnea specific to infants?

nasal flaring

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

nonrebreather mask

A nurse has to administer a subcutaneous injection to a client. For which client can the nurse administer a subcutaneous injection at a 90-degree angle?

obese client

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours for pain. What type of order is this considered?

p.r.n. order

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion

Which action describes buccal medication administration?

placing a medication underneath the upper lip or in the side of the mouth

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

placing the secondary infusion higher than the primary solution

When preparing to start an intravenous infusion on an adult, the nurse should:

prepare the skin with 70% alcohol and povidone-iodine.

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?

respirations are at 20 breaths per minute

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

review the client's medication, allergy, and medical history

What would be considered a "right" of drug administration? Select all that apply.

right client right drug right dose right documentation

The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client?

spacer

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client?

supine

When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug?

swallowing the medication

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

to determine the extent to which the client responded to the drugs

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to the tracheal mucosa

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?

"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask?

"Do you get all of your medications filled at the same pharmacy?"

The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse?

"Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes."

The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention?

"I am taking tadalafil in addition to nitroglycerin."

The nurse is preparing to administer medications to a client. The client asks, "Why are you using this to give me my medication?" After reviewing the image above, what is the best response by the nurse?

"I am using this machine to scan the code on your wrist to identify and verify the medications prescribed for you before you receive them."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

"I can assist you to the bathroom and back to bed."

The nurse is teaching a client with heart failure about taking digoxin safely. Which statement by the client indicates teaching was effective?

"I will call the health care provider if I develop dizziness, blurred vision, or nausea."

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes."

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier."

A client is newly prescribed a medication that must be taken on an empty stomach. Which statement by the nurse best describes why some medications should be taken before meals?

"This is because food and some drinks can affect the way your medicine works."

A client is taking numerous eye drops to prepare for cataract surgery. Which teaching about ophthalmic application will the nurse provide?

"Wait 5 minutes between instillation of different types of eye drops."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

The nurse is teaching a client about indomethacin SR. When the client asks, "What does the SR mean?" what is the appropriate nursing response?

"sustained release"

Which statements made by the nurse indicate how insulin pens simplify self-administered insulin for clients? Select all that apply.

-"The dose of insulin in an insulin pen is displayed in a window of the syringe." -"The insulin pen automatically resets the dose window to zero, following the injection." -"The cylinder of the insulin pen contains a prefilled reservoir of insulin."

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply.

-Client is able to state the date, time and location. -Mucous membranes are pink and moist. -Heart rate is 64 beats/min.

The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply.

-Ensure that air intake valves are not blocked. -Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. -Use gauze pads under elastic strap to relieve irritation to scalp or ears.

The nurse is preparing to administer a nasal spray. Place the nurse's actions in order, from first to last. Use all options.

-Identify the client using two identifiers and verify any allergies. -Offer the client a tissue and ask the client to blow the nose. -Insert the tip of the nasal spray into one nostril and close the other nostril with a finger. -Compress the nasal spray while the client breathes in through the nose. -Remove the tip of the spray from the client's nostril and release the compression. -Instruct the client to not blow the nose for 5 to 10 minutes.

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

-Measuring the client's respiratory rate -Reapplying the client's nasal cannula after a bath -Inserting the client's nasal cannula after it has become dislodged

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply.

-Mucous membranes are pink and moist. -Heart rate is 64 beats/min. -Client is able to state the date, time and location.

When administering oral medications, which practices should the nurse follow? Select all that apply.

-Perform hand hygiene before and after medication administration. -Stay at the bedside until the client has swallowed all the medications. -Verify the client's response to the medication 30 minutes after administration or as appropriate for the drug.

The nurse is preparing to draw up a medication that is supplied in a glass ampule. Place, in order, the steps the nurse will take. Use all options.

-Wrap a small gauze pad around the neck of the ampule. -Break off the top of the ampule. -Attach the filter needle to the syringe. -Withdraw the medication. -Discard the filter needle. -Attach a sterile administration device to the syringe.

The health care provider has prescribed a subcutaneous injection to a client. Which factors should the nurse consider when selecting a syringe and needle? Select all that apply.

-amount of adipose tissue -type of medication -viscosity of the drug -size of the client

A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

0.5 tablets

A client is to take Demerol 35 mg IM. You have Demerol 50 mg per ml. How many ml will you administer?

0.7 ml

The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?

1 mL syringe; ½-inch (1.25-cm), 26-gauge needle

The nurse is teaching a client with diabetes about insulin pen injection. The nurse will teach that the insulin in prefilled pens is stable for how long?

1 month

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

10 to 15 degrees

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

15-degree angle

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?

1500

The health care provider prescribes ciprofloxacin 500 mg PO q12h for a pediatric client with bronchial pneumonia. The nurse has liquid ciprofloxacin 250 mg/10 mL on hand. How many milliliters would the nurse dispense? Record your answer using a whole number.

20mL

Which gauge needle is the nurse expected to use to administer dimenhydrinate 50 mg?

22-gauge

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner?

4 L/minute O2 (66 mL/second) nasal cannula

The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear?

5 minutes

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L)

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute.

The nurse is reviewing the plan of care for several clients who have prescriptions for intravenous medications. The nurse understands that which client is at the highest risk for greater effect of the IV medication?

73-year-old client diagnosed with liver disease

Which medication interaction illustrates a synergism?

A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy.

A nurse is administering a piggyback infusion to a client with partial-thickness or second-degree burns. Which describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with an IV solution.

The client is prescribed a medication that needs to be taken on an empty stomach. The nurse inadvertently administers this medication with food. What are the ramifications of this error?

Absorption of the medication will be impaired.

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

Ambu bag

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 16 bpm

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

Apply oxygen

The client asks the nurse how to administer medication purchased over the counter for relief of arthritis pain. The nurse reviews the medication and determines that it is to be applied topically. Which instructions should the nurse provide?

Apply the medication to clean, dry skin of the affected area using gloves.

The health care provider has prescribed the use of transdermal patch. Which information should the nurse tell the client regarding application?

Apply the patch to a clean, dry, hairless location on the skin.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gas

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?

As the gauge number becomes larger, the size of the needle becomes smaller.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

Ask the client to maintain the position for some time.

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?

Assess oxygen tubing connection

A young woman has an IV infusing for magnesium sulfate to treat preterm labor. The woman develops a fever. What is the first assessment the nurse should make?

Assess the IV site for redness.

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

Assess the vaginal area.

The home care nurse visits a client with compromised lung function. The client has greenish-yellow sputum with a musty odor. Which assessment is the priority for the client?

Auscultate bilateral breath sounds.

The nurse is creating a professional development presentation about medication orders. Which teaching will the nurse include? Select all that apply.

Be extra cautious with look-alike and sound-alike drugs. The health care providers must sign all orders.

A medication order has ac written after the medication dosage. What does ac stand for?

Before meals

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?

Bronchial

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?

Bronchitis

The nurse observes a prescription written for a client for a medication that does not correlate with the client's diagnosis or comorbid factors. What is the best action for the nurse to take?

Call the provider to obtain a rationale for the use of the medication for the client

A nurse is administering an antihypertensive drug to a hospitalized client. Which action should the nurse take to identify the client prior to administration?

Check the client's ID bracelet.

An oral medication has been ordered for a client who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration?

Check the tube placement before administration.

A nurse is applying a vaginal cream to a client with a fungal infection. Which guideline is recommended for this application?

Cleanse area at vaginal orifice with washcloth and warm water.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

The nurse is preparing to administer two IV medications. What is the appropriate nursing action?

Consult a current drug reference book for IV compatibility.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

Contact the health care provider for order clarification

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?

Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?

Contract the abdominal muscles.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

Crackles

The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?

Cut a hot dog in half, then pieces

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

Deltoid

The nurse is preparing to administer two types of insulin by mixing in one syringe. What is the first action by the nurse?

Determine compatibility of the insulins by checking a drug compatibility table.

A client's eMAR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action?

Determine the compatibility of the two drugs by consulting clinical resources.

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?

Distribution

The nurse prepares to administer an antihypertensive medication at 0900 for a client who has problems swallowing and has a blood pressure of 88/50 mm Hg. Which action should the nurse perform when administering the medication?

Do not administer the medication with blood pressure 88/50 mm Hg.

A nurse is administering an intradermal injection to a client for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's best action in this situation?

Document the administration and inform the primary care provider

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?

Drink liberal amounts of fluids.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

Engage safety shield on needle guard and discard needle appropriately.

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action?

Give written instructions to the client and caregivers.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?

Immediately activate the safety needle and place the syringe and needle into a Sharps

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?

Increased oral fluid intake

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

A nurse is administering a client's analgesic by the subcutaneous route. What should guide the nurse's action?

Inject into the adipose tissue layer just below the epidermis and dermis.

The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?

Inner surface of the forearm

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract.

The nurse is caring for a client who just returned from the postanesthesia care unit and rates current pain as "9 out of 10." Which prescribed medication would provide the fastest relief from pain?

Intravenous morphine sulfate

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

To convert 0.8 grams to milligrams, the nurse should do which of the following?

Move the decimal point 3 places to the right.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?

Nasal cannula

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer

The nurse is preparing to administer the second dose of ordered antibiotics to a client and notes that the first dose of medication is still in the automated medication-dispensing system. The medication administration record (MAR) does not show that the initial dose was given. What is the appropriate nursing action?

Notify the health care provider.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

Oxygen hood

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use.

The chemotherapy client has been admitted for thrombocytopenia. Which blood product will the nurse anticipate administering?

Platelets

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion

The nurse is caring for a client with acute respiratory distress syndorme (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation?

Prone

The nurse is assessing a client who was seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation?

Provide education on taking all antibiotics for effective treatment

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Rapid respirations

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?

Record "T.O." at the end of the order

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report the needlestick to the nurse manager.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order?

Standing order

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Stay indoors as much as possible.

The nurse has confirmed the client's identity and provided a client with oral medications to take. What is the next appropriate nursing intervention?

Stay with the client while medications are taken.

A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

Stop the infusion.

A nurse is caring for a 6-year-old client on the hematology-oncology floor. During a packed red blood cell (PRBC) transfusion, the client reports of pain at the peripheral IV site. The nurse assesses the site and notices that the site is purple. What is the nurse's best course of action?

Stop the transfusion and insert peripheral IV at a new site.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

Tactfully request the provider to input the order into the computerized provider order system.

A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason?

The area is free of major blood vessels and fat.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

The client's available hemoglobin is adequately saturated with oxygen.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted?

The graduate nurse auscultates breath sounds as the client breathes through the nose.

Regarding medication administration, what must occur at the change of shifts?

The narcotics for the division are counted.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene?

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation?

The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen.

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing?

The nurse has the client lying in bed in semi-Fowler's position

The nurse is preparing to administer a transdermal medication. How should this be accomplished?

The nurse should apply the medication directly to the skin.

Which nursing strategy should the nurse employ to enhance the teaching/learning process for a client who is noncompliant with inhalers?

The nurse should provide simple written instructions with each medication.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs?

Use a bag and mask.

A nurse is administering medication to a client via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation?

Use a syringe to plunge the tube to try to dislodge the medication

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step?

Wait 10 seconds and then withdraw the needle

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

Which client would most likely require placement of an implantable port?

a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

a canister containing medication that is released when the container is compressed

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia

To which client would the nurse be most likely to administer a p.r.n. medication?

a client who is reporting pain near the surgical site

A nurse needs to administer a subcutaneous heparin injection to a client. Which injection site is most suitable for heparin?

abdomen

The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered?

all at once

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:

atelectasis.

A client has an intermittent infusion device inserted for the administration of antibiotic therapy every 6 hours. The nurse would expect to flush the device at which frequency?

before and after each medication administration

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client:

breathes through his or her mouth until all the medication has been inhaled.

Which client does the nurse recognize will require an intramuscular administration of the medication instead of an intravenous administration?

client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

confusion

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup

A nurse is administering medication to a 78-year-old female client who experienced symptoms of stroke. When administering the medication prescribed for her, the nurse should be aware that this client has an increased possibility of drug toxicity due to which age-related factor?

decline in liver function and production of enzymes needed for drug metabolism

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?

decreases the amount of air trapping and resistance

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

flow meter

A nurse needs to administer an intradermal injection to a client. What is the most common site for administering an intradermal injection?

forearm

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level