EXAM 2 - FN

The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)?

A client who requires assistance with ambulation every 4 hours

The nurse is providing dietary instructions to a client with a diagnosis of hyperphosphatemia. The nurse determines that the client understands the instructions if the client states the importance of eliminating which item from the diet?

Fish

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

Perform a focused respiratory assessment.

The nurse is preparing to administer an oral medication to an infant. In which position should the nurse place the infant?

Semi-Fowler's

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome?

"Cushing's syndrome is caused by excessive amounts of cortisol."

The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective?

"It helps to use magical thinking with the preschool-age group."

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

"The enema will be given while I am sitting on the toilet."

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN?

A client with a spinal cord injury requiring urinary catheterization every 6 hours

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift

The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

A heart rate that is 90 beats per minute and irregular

A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?

Administer the eye drop first, followed by the eye ointment.

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?

Allow the inner cannula to dry after washing it with sterile water.

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identity by performing which action? Asking the patient his name and birthdate

Asking the patient his name and birthdate

A client's nasogastric feeding tube has become clogged. The nurse should take which action first?

Aspirate the tube.

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation?

Assess the vomit, looking for the pill.

A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication?

Doses administered as needed for pain relief

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system?

Ensure the water level in the water seal chamber is at the 2cm level.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding?

Fowler's on the right side

The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?

Get up slowly when changing positions.

The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A:

Green leafy vegetables

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Impaired tissue perfusion

The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next?

Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.

A client is diagnosed with a moderate case of acute ulcerative colitis. The nurse doing dietary teaching should give the client examples of foods to eat that represent which therapeutic diet?

Low fiber without milk

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

Maintain inflation of the alveoli.

The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action should the nurse perform when administering this test to the client?

Make a circular mark around the injection site after administration of the tuberculin test.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?

Monitoring blood pressure

The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery?

Obturator in case tube becomes dislodged.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action?

Occlude the nasolacrimal duct with a finger after instilling the drops.

The nurse is assisting a primary health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

Perform the Valsalva maneuver.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client?

Remove the water pitcher from the bedside.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked sausage

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily.

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first?

Suction the client through the endotracheal tube.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

The chest tube may be obstructed.

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical nurse, and 2 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

The client with an abdominal wound requiring frequent wound irrigations

The nurse has instructed a client in the foods that are best to consume on a low-fat diet. The nurse determines that the client understands this diet if the client indicates which food item is lowest in fat?

dry toast and strawberry jelly

is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?

every 30 minutes

The nurse has provided dietary instructions to a client regarding food items that are high in vitamin B complex. The client demonstrates understanding of the dietary instructions by stating the importance of including which food item in the diet?

grains

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the primary health care provider (PHCP) immediately?

stridor

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation?

the chest tube is functioning as expected

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection?

vastus lateralis

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hr. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment?

"Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching?

"I should remove the chest tube site dressing as soon as I get home."

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron?

Apricots

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply.

1. Coffee 2. Chocolate 3. Peppermint 4. Fried chicken

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

"It will enter the right main bronchus if inserted too far."

The nurse is providing dietary instructions to a client regarding a high-protein diet. The nurse should instruct the client to consume which food item that is highest in protein content?

1 cup of cottage cheese

The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting? Select all that apply.

1. Intranasal spray 2.Oral transmucosal lozenge 3.72-hour transdermal patch 4.Effervescent buccal oralets

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply.

1. Place the client on a cardiac monitor. 2. Notify the primary health care provider (PHCP). 3. Review the client's medications to determine whether any contain or retain potassium.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

1. The acuity level of the clients 2. Client needs and workers' needs and abilities

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply.

1.Warfarin 2.Glimepiride 3.Amlodipine

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

10 Seconds

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.4 mmol/L)

A client has a prescription to receive purified protein derivative, 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines?

26-gauge 5/8-inch needle parallel to the skin bevel side up

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position?

Left-sided lateral Sims' position

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

Bloody

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?

Bronchospasm

The nurse should determine that tracheal suctioning is needed if which is noted?

Congested breath sounds in the lung fields

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak because the bubbling should be intermittent.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

Check the client's status.

The nurse has assisted the primary health care provider (PHCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Continue to monitor the client.

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. What should the nurse do?

Dispose of 0.2 mL before administering the drug; verify the waste with another nurse.

A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation?

Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration.

A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy?

Dislodgment of the epidural catheter because the catheter is not sutured in place

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate?

Notify the primary health care provider (PHCP).

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy vegetables

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

Summer squash

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs during suctioning.

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action?

Assess tube placement.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?

Assessing for the return of the gag reflex

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Audible stridor

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?

Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

Cream of wheat, blueberries, coffee

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply.

Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?

Pull back on the tube and wait until the respiratory distress subsides.

The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action?

Pull back on the tube, and wait until the client is breathing easily.

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Pulmonary function studies

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?

Rhonchi are ausculated

The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics?

The drainage is bloody.

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended?

The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track.

A medication order reads: "K-Dur, 20 mEq po BID." When and how does the nurse correctly give this drug?

Twice a day by the oral route

The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate?

document the findings

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

left-Sim's

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

malaise

The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings?

It is at the bifurcation of the right and left main bronchi.

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Test the stomach contents for a pH indicating acidity.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply.

1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.

1.Monitor the client's temperature. 2.Use sterile technique when suctioning. 3.Use the closed-system method of suctioning. 4.Monitor sputum characteristics and amounts.

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube?

Asking the client to swallow as the tube is being advanced

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff on the tube.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation?

Tap water

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented?

The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

Dorothy Holmes is a 62-year-old client who sustained a closed, nondisplaced, complete fracture of the left femur when she slipped on the ice and fell. She is admitted to the orthopedic unit from the emergency department. Dorothy's medical history includes hypertension, for which she takes lisinopril 30 mg orally and a garlic tablet daily; atrial fibrillation, for which she takes apixaban 5 mg orally twice daily; and osteoarthritis. She is scheduled to have surgery the following morning. The primary health care provider writes the following admitting prescriptions: Before surgery, what additional prescription should the nurse inquire about with the primary health care provider?

The need for a prothrombin time (PT) and international normalized ratio (INR) test

Dorothy asks the nurse why Buck's traction is being applied before surgery. Which statement best answers her question?

To decrease muscle spasms and provide comfort

The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client demonstrates understanding of the instructions by stating the need to include which food item in the diet?

milk

The school nurse is providing a nutritional counseling session to a group of adolescents. The school nurse should instruct the adolescents that which item is a good source of vitamin C?

sweet potatoes

The nurse is assisting the primary health care provider (PHCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action?

Document the accurate functioning of the tube.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Document the findings

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

Hyperoxygenate the client.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

Instruct the client to avoid coughing and deep breathing.

The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription should the nurse question?

Isosorbide mononitrate 30 mg via PEG tube daily

Dorothy has surgery and goes back to her room on the orthopedic unit. The postanesthesia care unit nurse reports that Dorothy underwent general anesthesia and that she received 2 mg of midazolam IV preoperatively and a total of 10 mg of morphine sulfate IV in the recovery room over the previous 2 hours. The last dose of morphine sulfate was 3 mg IV administered 30 minutes ago for pain rated at a 7 on a 1 to 10 scale; the medication reduced the pain to a 5. Vital signs are as follows: temperature, 97.9° F; pulse, 68 beats per minute; respirations, 12 breaths per minute; blood pressure, 118/68 mm Hg; and oxygen saturation, 92% on room air. When the orthopedic nurse assesses Dorothy, she complains of pain of a 4 and then falls back to sleep. If needed, which prescribed medication would be the best choice to administer to Dorothy at this time?

Ketorolac 30 mg IV because it is a nonsteroidal anti-inflammatory medication and will not cause further sedation or affect respirations.

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the primary health care provider at standard doses and frequencies would the nurse question?

Meperidine hydrochloride by intramuscular route

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure?

Oil-soluble lubricant

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?

Place the client in high-Fowler's position.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

Stop and reoxygentate