NCLEX-RN Exam 1 Set three

The home care nurse instructs a client on how to administer enoxaparin (Lovenox) subcutaneously. Which statement, if made by the client, indicates an understanding of how to administer this medication?

"A syringe that has a small ⅝-inch needle is used to administer the injection."

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply.

1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response.

The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)?

2 inches

What are the assessment findings associated with FVE?

Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

A client who had surgery 3 days earlier is receiving heparin sulfate by subcutaneous injection every 12 hours. In planning for the client's morning care, the priority nursing intervention is which action?

Assist the client to shave using an electric razor.

Dissecting aortic aneurysms usually are accompanied by what type of pain?

Back pain

A client is scheduled for a dose of ramipril (Altace). The nurse should check which measurement before administering the medication?

Blood Pressure

The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)?

Each rescue breath should be given over 1 second and should produce a visible chest rise.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value?

Elevated U Waves Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves.

A client receiving parenteral nutrition through a central intravenous (IV) line is scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging the antibiotic solution?

Ensure a separate IV access for the antibiotic.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

Expiration date

What does hyperkalemia cause?

Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias.

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. The nurse notifies the health care provider of these findings because they can be indicative of which problem?

Infections of a central venous catheter site can lead to septicemia.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?

It can develop into ventricular fibrillation at any time. Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN?

Monitoring temperature because the most common complication is infection.

What are the nursing interventions for cardiac tamponade?

Place on CCU Admin fluids Prepare for ECHO Prepare for pericardiocentesis

The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?

Prolonged QT Interval

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?

Protomine Sulfate

What is pulmonary edema characterized by

Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles.

PE presents suddenly with what s/s?

Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain.

How Pulseless ventricular tachycardia is treated

Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as vasopressin, epinephrine, amiodarone, lidocaine, and magnesium sulfate

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation?

Requires nasogastric suctioning Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia.

What two sounds are not associated with pulmonary edema?

Rhonchi and diminished breath sounds are not associated with pulmonary edema.

A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm?

Apply adhesive patch electrodes to the chest and move away from the client.

What are some common food sources high in magnesium?

Peas and cauliflower are high in magnesium.

When can acute cardiac tamponade occur?

When small volume (20-50ml) of fluid accumulate rapidly in the pericardium

The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first?

Activate the emergency response system.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results?

Activated partial thromboplastin time of 60 seconds

A client receiving total parenteral nutrition experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the total parenteral nutrition?

Air embolism

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?

Decreased oozing of blood from puncture sites and gums

When is debrillation used?

Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. *Joules 150-200 Joules*

A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs/symptoms?

Hypotension and dizziness Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in the bed on the unaffected side

How does Addison's disease and Diuretics affect Potassium?

The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

The nurse is monitoring a client who is taking propranolol (Inderal LA). Which assessment data indicates a potential serious complication associated with this medication?

The development of audible expiratory wheezes Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. b-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma.

What are some common food sources for Potassium

The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes.

A client is brought into the emergency department in ventricular fibrillation (VF). The advanced cardiac life support (ACLS) nurse prepares to defibrillate by placing conductive gel pads on which part of the chest?

The right of the sternum just below the clavicle and to the left of the precordium

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication?

Thrombolytics act to dissolve thrombi that have already formed.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client?

To promote rapid volume expansion

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?

Ventricular Fibrilation

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?

Ventricular dysrhythmias

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?

Ventricular tachycardia Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes.

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?

White blood cell count

What are good sources of phosphorus

Nuts, cauliflower, and peas are good food sources of phosphorus.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

Peas, Raisins, Potatoes, Cantaloupe and strawberries

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

How is ventricular tachycardia treated?

Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?

15 minutes

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority?

Call the HCP Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery.

What are signs of FVD

Weight loss, flat neck veins, Decreased CVP

A client who began medication therapy with prazosin hydrochloride (Minipress) 1 week earlier arrives at the health care clinic for follow-up evaluation and care. The nurse interprets that the client is experiencing the expected benefit of therapy if which is noted?

Decreased blood pressure

The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium?

Decreased blood pressure Rationale: Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F orally. Which action should the nurse take?

Delay hanging the blood and notify the health care provider (HCP).

The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply.

Diarrhea Blurred vision Nausea and vomiting

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction?

Diphenhydramine (Benadryl)

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

"Have you ever had a transfusion before?"

A hypertensive client has been prescribed clonidine hydrochloride (Catapres-TTS), a transdermal patch. The nurse provides written instructions to the client on the use of the patch. Which statement by the client indicates the need for further instruction?

"I need to change the patch every 24 hours."

The nurse provides discharge instructions to a client who is taking warfarin sodium (Coumadin). Which statement, by the client, reflects the need for further teaching?

"I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which statement, by the client, indicates the need for further education?

"I'll continue my nicotinic acid from the health food store." Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided.

A client is prescribed nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

"Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing."

A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The health care provider prescribes determination of the serum digoxin level to rule out digoxin toxicity. The nurse checks the results, knowing that which value is the therapeutic serum level (range) for digoxin?

0.5 to 2 ng/mL

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?

0.9% sodium chloride

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the 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 (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit

The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse compresses at least how many times?

100

A nurse has a prescription to transfuse a unit of packed red blood cells to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the IV infusion, the nurse should select an angiocatheter of which size?

20 gauage

A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery?

360 J

The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific health care provider (HCP) prescription?

50 to 100 joules

A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply.

6 and 8 Rationale: The normal LAP is 1 to 10 mm Hg; therefore, options 1 and 2 are correct. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic or diastolic pressure.

The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child?

6-8

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis.

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm?

Atrial fibrillation

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first?

Auscultate the client's apical pulse and obtain a blood pressure. Rationale: Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first.

The nurse is developing a plan of care for a client who is receiving total parenteral nutrition (TPN). The nurse identifies assessments to be made to help identify complications related to the infusion of the TPN solution. The care plan should include monitoring of which assessment item(s)?

Blood glucose levels

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure?

Bed rest with head elevation no greater than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer the flat position) until hemostasis is adequately achieved.

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism?

Blood pressure of 198/110 mm Hg Rationale: Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the HCP before initiating therapy.

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

Blood warming device

When does cardiogenic shock occur?

Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock.

What does circulatory overload cause?

Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension.

A client with hypertension has begun taking spironolactone (Aldactone). The nurse teaches the client to limit intake of which food?

Citrus Fruits Rationale: Spironolactone (Aldactone) is a potassium-retaining diuretic that causes hyperkalemia as the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas.

A client with atrial fibrillation secondary to mitral stenosis is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium (Coumadin) 7.5 mg at 5:00 pm daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT) = 32 seconds; internationalized normalized ratio (INR) = 1.3. The nurse should plan to take which action based on the client's laboratory results?

Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. When a client is receiving warfarin (Coumadin) for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharging them, which intervention should be done?

Confirm that the rhythm is actually ventricular fibrillation.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

Crackles

The nurse is planning to administer hydrochlorothiazide to a client. The nurse understands that which is a concern related to the administration of this medication?

Hypokalemia, hyperglycemia, sulfa allergy Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

Increased Blood Pressure Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body.

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method?

Jaw thrust Rationale: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present.

A client is diagnosed with an ST-segment elevation myocardial infarction (STEMI) and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?

Monitor for signs of bleeding

The nurse is performing an assessment on a client who has been receiving parenteral nutrition at 125 mL/hour. On assessment, the nurse notes the presence of bilateral crackles in the lungs and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds in 5 days. Which nursing action would be most appropriate for this client?

Notify HCP

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?

Place the client on the left side in Trendelenburg's position. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

Prepare for transcutaneous pacing. Rationale: Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client.

The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan for preparation and administration of the potassium?

Preparing the medication for bolus administration

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

Processed oat cereals

What will you see on assessment for cardiac tamponade?

Pulsus paradoxus Increased CVP JVD with clear lungs Distant, muffled heart sounds Decrease cardiac output Narrowing pulse pressure

What is stridor?

Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action?

Remove the dressing. Rationale: Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape.

The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first?

Responsiveness of the client

Fat emulsion is prescribed for the client receiving parenteral nutrition. The nurse is preparing to administer the fat emulsion and notes the presence of fat globules in the solution. What should the nurse do?

Return the solution to the pharmacy.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

Septicemia Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock.

The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?

Start chest compressions. Rationale: The next nursing action would be to start chest compressions. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.

A client with hypertension has a new prescription for a medication called moexipril (Univasc). The nurse plans to provide written directions that tell the client to take the medication at which time?

Take 1 hour before meals