NRN Theory 161 Health Promotion (Mod 9) Comfort (Mod 10) Oxygenation (Mod ?)

A client is ordered pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client states that they are in pain and wants the medication. What is the most appropriate action by the nurse? Hold the pain medication at this time. Administer the pain medication. Encourage the client to use alternative pain relief measures. Reassess the need for pain medication in 30 minutes

Administer the pain medication. Explanation: Pain is present whenever the client perceives that they are in pain. The client is ordered the medication, the client's vital signs are within acceptable range, and the client states that they are in pain. Therefore, the nurse should administer the pain medication as ordered

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following? Orthopnea Paroxysmal nocturnal dyspnea Dyspnea on exertion Hyperpnea

Orthopnea Explanation: Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler's position. Dyspnea on exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night

The nurse is assessing a woman with Class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure? Elevated blood pressure Audible wheezes Persistent rales in the bases of the lungs Low blood pressure

Persistent rales in the bases of the lungs Explanation: The earliest warning sign of cardiac decompensation is persistent rales in the bases of the lungs

What type of nonpharmacologic pain relief measure uses electrical stimulation to inhibit transmission of painful impulses? acupressure acupuncture TENS hypnosis

TENS Explanation: TENS (transcutaneous electrical nerve stimulator) is a noninvasive alternative technique that involves electrical stimulation to inhibit transmission of painful impulses

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

True Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis

Postoperatively, a patient with a radical neck dissection should be placed in which position? Supine Fowler's Prone Side-lying

Fowler's Explanation: The patient should be placed in the Fowler's position to facilitate expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively

The nurse recognizes which of the following statements is true of chronic pain? It disappears with treatment. It is always present and intense. It may cause depression in clients. It can be easily described by the client

It may cause depression in clients. Explanation: Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation

The wife of a patient with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the patient is likely showing the effects of which of the following? Drug interactions Addiction Tolerance. Physical dependence

Tolerance. Explanation: This patient is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathological finding and does not necessarily indicate physical dependence. Tolerance does not indicate addiction or a heightened risk of addiction. The phenomenon noted is not indicative of a drug interaction.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Height, level of orientation, support systems Degree of responsiveness, respiratory rate, fundus location Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness

Blood pressure, pulse, reports of dizziness Explanation: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

Which of the following is considered to be the most potent neuromodulators? Efferent Enkephalins Endorphins Efferent

Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? Secondary prevention Primary prevention Residual prevention Tertiary prevention

Tertiary prevention Explanation: Tertiary prevention and healthcare deals with rehabilitation of the client. Teaching the client to walk with a walker is tertiary prevention

What is a dynamic state in which a person constantly adapts to changes in the internal and external environment? Infirmity Health Wellness Holism

Health Explanation: Health is a dynamic state in which a person constantly adapts to changes in the internal and external environment

A nurse caring for patients with diabetes knows that the following is a characteristic of a chronic illness: It causes reversible alterations in A&P. It requires a short period of care or support. It requires special patient education for rehabilitation. It is a temporary change.

It requires special patient education for rehabilitation. Explanation: Chronic illness is a broad term that encompasses many different physical and mental alterations in health, with one or more of the following characteristics: it is a permanent change; it causes, or is caused by, irreversible alterations in normal anatomy and physiology; it requires special patient education for rehabilitation; and it requires a long period of care or support

A patient with sickle cell anemia has a Normal blood smear High hematocrit Low hematocrit Normal hematocrit

Low hematocrit Explanation: The patient with sickle cell anemia has a low hematocrit and sickled cells on the smear. The patient with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear

You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize? Nonrebreather mask Nasal cannula Venturi mask Simple mask

Nonrebreather mask Explanation: Nonrebreather mask is the only device that can deliver FIO2 of 100% to a patient without a controlled airway. Venturi mask delivers a maximum FIO2 of 55%. Nasal cannula delivers a maximum FIO2 of 44%. Simple mask delivers a maximum FIO2 of 60%

Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura? Sepsis Air embolism Pneumothorax Fluid overload

Pneumothorax Explanation: A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention? Observe vitals every two hours. Notify the doctor immediately. Elevate the head of the bed. Administer epinephrine

Notify the doctor immediately. Explanation: The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

The nurse working in the recovery room is caring for a patient who had a radical neck dissection. The nurse notices that the patient has a coarse, high-pitched sound on inspiration. Which of the following is the appropriate intervention by the nurse? Administering a breathing treatment Lowering the head of the bed Documenting the presence of stridor Notifying the physician

Notifying the physician Explanation: The presence of stridor, a coarse, high-pitched sound on inspiration, in the immediate postoperative period following radical neck dissection indicates obstruction of the airway and requires that the nurse report it immediately to the physician

The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms? Obtain baseline vital signs and oxygen saturation Prepare the client for a bronchoscopy Gather equipment and begin oxygen therapy Perform a head-to-toe assessment

Obtain baseline vital signs and oxygen saturation Explanation: Alteration in oxygenation can lead to an altered mental status. The nurse should first obtain baseline vital signs and oxygen saturation to assess the client?s needs. If required after obtaining baseline data, the client may require oxygen therapy and a complete assessment. There is no indication that the client needs a bronchoscopy at this time

The nurse is caring for a client utilizing a Patient Controlled Analgesia (PCA) pump that is programmed to allow a bolus dose every 10 minutes. The client is sleeping with visitors at the bedside. Which of the following instructions should the nurse give the client's visitors? ?Push the button on the pump every 10 minutes.? ?Remind the client to push the button more often than every 10 minutes.? ?Only the client should push the pump button.? ?Push the pump button when you think the client is in pain

Only the client should push the pump button.? Explanation: The nurse should instruct the visitors that only the client should push the button on the pump to administer the bolus pain medication. Unauthorized family members or caregivers (instead of the client) who administer PCA by pushing the dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death. The client should push the pump?s button only when feeling the sensation of pain

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients? The developing neurological system of children transmits less pain than in older patients. A numeric scale should be used to assess pain if the child is older than 5 years of age. Pain assessment may require multiple methods in order to ensure accurate pain data. Pharmacologic pain relief should be used only as an intervention of last resort

Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all patients above a certain age; the assessment tool should reflect the patient's specific circumstances, abilities, and development

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Partial pressure of arterial carbon dioxide (PaCO2) Bicarbonate (HCO3-) Partial pressure of arterial oxygen (PaO2)

Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate? Placing the client in the supine position Placing the client in high Fowler's position Placing the client in Sims' position Placing the client in Trendelenburg position

Placing the client in high Fowler's position Explanation: High Fowler's position — the posture assumed by the client when the head of the bed is elevated to 90 degrees — promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing

A nurse is immunizing children against measles. This is an example of what level of preventive care? Primary Secondary Tertiary

Primary Explanation: Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Immunizations are an example of primary health promotion. Secondary health promotion and illness prevention focus on screening for early detection of disease with prompt diagnosis and treatment of any found. Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning

Your community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. What level(s) of health promotion is this an example of? All three levels Tertiary Primary Secondary

Primary Explanation: Primary health promotion and illness prevention is directed toward promoting health and preventing the development of disease process or injury. Primary level activities include immunization clinics, providing poison-control information, and teaching about using seat belts and child-safety seats

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply. ?The lungs in emphysema, unlike a used balloon, are stiff and noncompliant.? ?Emphysema, like a new balloon, takes less effort to empty air out of the alveoli.? ?Respirations of the client with emphysema can be compared to a balloon that has been blown up before.? "Balloons represent compliancy; the new balloons are difficult to expand, as in emphysema, leading to decreased compliancy." ?The extra effort it takes to blow up a new balloon can explain why the client with emphysema is short of breath

Respirations of the client with emphysema can be compared to a balloon that has been blown up before.? ?Emphysema, like a new balloon, takes less effort to empty air out of the alveoli.? Explanation: The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity leading to decreased compliance

The nurse recognizes that the client who makes the decision to accept a new diagnosis and follow the prescribed treatment plan is in which of the following stages of an illness? Stage 2-Assuming the sick role Stage 1-Experiencing symptoms Stage 3-Assuming a dependent role Stage 4-Achieving Recovery

Stage 3-Assuming a dependent role Explanation: Stage 3 is characterized by the client's decision to accept the diagnosis and follow the treatment plan. Stage 1 is the beginning of symptoms, while stage 2 is where a client describes him or herself as being sick and seeks validation from others. Stage 4 is recovery and rehabilitation and is the final stage of the illness

A nurse refers an HIV-positive patient to a local support group. This is an example of what level of preventive care? Secondary Primary Tertiary

Tertiary Explanation: Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Referring an HIV-positive client to a local support group would be an example of tertiary preventative care. Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Secondary health promotion and illness prevention focus on screening for early detection of disease with prompt diagnosis and treatment of any found

A nurse is preparing a 7-year-old for abdominal computed tomography (CT) scanning with intravenous contrast. What statement would be most appropriate to explain the injection of the contrast dye to the child? "The radiologist is going to inject dye into your IV. You won't feel a thing." "The doctor is going to put a special medicine in your tube so that she will be able to see your stomach better." "The doctor is going to proceed by administering contrast medium into your vein to see what is wrong with you." "You are going to have medicine injected into your IV so that the doctor will be able to see your internal organs better

The doctor is going to put a special medicine in your tube so that she will be able to see your stomach better." Explanation: When explaining to a child about a procedure that will be performed, the nurse should use terminology that the child will understand. The word "dye" can be misinterpreted as "die" and should be avoided to prevent scaring the child

The nurse is caring for a client with a dysrhythmia with a prescription for oxygen therapy. The client is concerned and asks the nurse, ?Why am I getting oxygen when I came in with a heart problem?" What appropriate response would the nurse give this client? ?Let me check the prescription, you may not need oxygen therapy.? ?The dysrhythmia causes nerve damage so oxygen is given to rebuild the heart?s muscles.? ?It?s a precaution in case your heart becomes stressed; the oxygen will help your heart rest.? ?The dysrhythmia interferes with the heart?s circulation, leading to changes in oxygenation.?

The dysrhythmia interferes with the heart?s circulation, leading to changes in oxygenation.? Explanation: Dysrhythmias affect the heart?s rate, rhythm, or both. This disturbance can affect the heart?s pumping action, leading to alterations in oxygenation. The oxygen is not given to rebuild the heart?s muscle or give the heart a chance to rest. The client needs the oxygen therapy to aid in oxygenation, so it is inappropriate for the nurse to check the prescription

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching? "The feeling of the heart skipping a beat is common." "We need to avoid a tub bath for the next 3 days." "Strenuous activity should be limited for the next 3 days." "We need to watch for changes in skin color or difficulty breathing.

The feeling of the heart skipping a beat is common." Explanation: Reports of heart "fluttering" or "skipping a beat" should be reported to the doctor as this can be a sign of a complication. The tub bath statement is appropriate because tub baths should be avoided for about 3 days. The strenuous activity statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported

The newly hired graduate nurse is caring for a client with a chest tube. The nurse mentor would intervene if which actions are being performed by the graduate? Select all that apply. The graduate is stripping the tubing every hour. The graduate tapes all connections securely. The graduate keeps a bottle of sterile saline at the bed site. The graduate tapes the tubing for the client?s trip to the x-ray department. The graduate positions collection device below the tube insertion site.

The graduate is stripping the tubing every hour. The graduate tapes the tubing for the client?s trip to the x-ray department. Explanation: The chest tube should not be stripped because it creates excessive negative pressure that can damage delicate lung tissue. The chest tubing should not be clamped when the client leaves the unit: Instead disconnect the suction tubing from the drainage system to allow the unit to continue to collect drainage by gravity. The collection device should be kept below the chest tube insertion site and all connections should be securely tape to prevent air from entering the pleural space. In the event the chest tube becomes separated from the collection device, a sterile bottle of water or saline should be kept to submerge the tubing into

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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.

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. Reasoning: Guidelines to determine suction catheter depth include the following: 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. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the patient, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. 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. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

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. Explanation: Guidelines to determine suction catheter depth include the following: 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. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the patient, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: prepare to ventilate the child. return the child to class. monitor the child with a pulse oximeter in her office. contact the child's parent or guardian

prepare to ventilate the child. Explanation: The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian

Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the health care provider (HCP) based on the interpretation that these findings may lead to which condition? respiratory arrest bronchial pneumonia epiglottitis intraventricular hemorrhage

respiratory arrest Explanation: Periods of apnea lasting longer than 20 seconds, mild cyanosis, and a heart rate of <100 bpm (bradycardia) are associated with a potentially life-threatening event and subsequent respiratory arrest. The neonate needs further evaluation by the HCP . Pneumonia is associated with tachycardia, anorexia, malaise, cyanosis, diminished breath sounds, and crackles. Intraventricular hemorrhage is associated with prematurity. Assessment findings include bulging fontanels and seizures. Epiglottitis is a bacterial form of croup. Assessment findings include inspiratory stridor, cough, and irritability. It occurs most commonly in children age 3 to 7 years

Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." "If the care provider has recommended the procedure, it's likely that the benefits outweigh the risks." "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress." "Some women don't have any problem giving birth to large babies. You might want to get a second opinion.

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress." Explanation: Transient tachypnea of the newborn (TTN) involves the development of mild respiratory distress in a newborn. TTN results from a delay in absorption of fetal lung fluid after birth. As the fetus passes through the birth canal during birth, some of the fluid is expelled as the thoracic area is compressed. TTN is commonly seen in newborns born by cesarean birth. It typically occurs after birth with the greatest degree of distress occurring approximately 36 hours after birth. TTN commonly disappears spontaneously around the third day

A client states that he is pain and requests the ordered pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? Administer the pain medication. Contact the client's physician. Hold the pain medication. Reassess the client's pain in 30 minutes

Administer the pain medication. Explanation: Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's physician needs to be notified at this time

A nurse working in the ICU understands that illnesses affect both the client as well as the family members. What are some things that often cause stress in family members due to a hospitalization of a family member? Select all that apply. Decrease in social interactions Increase in social interactions Alterations in roles Economic problems Alterations in lifestyle

Alterations in roles Economic problems Alterations in lifestyle Decrease in social interactions Explanation: A chronic illness can create stress for both client and family because of life long alterations in role or lifestyle, frequent hospitalizations, economic problems, and decreased social interactions among family members

Which of the following assessment factors would indicate a need for oropharyngeal suctioning? Oxygen saturation levels of 95% and diaphragmatic breathing patterns Auscultation of crackles in the lower lobes of the lungs Thin sputum, weak cough, and enlargement of the tonsils Breathing rate of 36 breaths/min and noisy, gurgling respirations

Breathing rate of 36 breaths/min and noisy, gurgling respirations Explanation: An increase in the breathing rate indicates hypoxia in the body. The signs of noisy, gurgling respirations indicate airway interference and the need for suctioning. Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first? Clear the neonate's airway with suction or gravity. Contact the neonatal resuscitation team. Raise the neonate's head and pat the back gently. Start mouth-to-mouth resuscitation

Clear the neonate's airway with suction or gravity. Explanation: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.

A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case? Use a nasal strip. Drink liberal amounts of fluids. Receive annual immunizations. Avoid strenuous exercises

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 31.9 mmol/L (575 mg/dL), vomiting, and shortness of breath. This client has experienced which of the following phenomena? Morbidity Risk factor Infection Exacerbation

Exacerbation Explanation: This client has experienced a significant exacerbation of his chronic disease (diabetes mellitus), which has manifested as an acute threat to his health. Morbidity is an epidemiological statistic of the frequency of a disease. His problem does not have an infectious etiology and while risk factors underlie his present condition, they are not the essence of his current state.

After studying concepts of health and wellness, the nursing student realizes that many different things influence a client's personal perception of health. Which of the following influences should the student list as factors that impact how a client defines health? Select all that apply. Community Culture Family Society Music

Family Culture Community Society Explanation: Each client defines health in terms of his or her own values and beliefs. The person's family, culture, community, and society also influence this personal perception of health

The nurse practitioner is discussing health promotion with a group of senior nursing students. What would be the best example of secondary health promotion? Family counseling Workplace health and safety seminar Immunizations Weight loss program

Family counseling Explanation: Secondary health promotion and illness prevention focuses on screening for early detection of disease with prompt diagnosis and treatment of those found; this includes emotional issues, making family counseling the correct answer. Work place health and safety would be considered a primary health promotion activity, as would a weight loss clinic and an immunization clinic

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? Nasal strip Oxygen analyzer Nasal cannula Flowmeter

Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client

As the nurse enters the room to teach the client about self-care at home, the client states, ?I am glad you are here. I need some pain medicine. I can't stand it anymore.? What is the best action of the nurse? Redirect client to learning about self-care and begin teaching. Give written materials to client and retrieve pain medication. Assess client understanding of self-care and administer medication. Have client rate pain level and reschedule the teaching session

Have client rate pain level and reschedule the teaching session. Explanation: The client is not ready or able to learn and is reporting a need that first must be met. Assessing the client?s knowledge of self-care or redirecting the subject only delays the care that must be done before the client is able to learn. Although providing written materials is an excellent supplement to a teaching session, it does not replace teaching the client. It is best to address the physical needs before attempting to educate the client

When providing care to a client, the nurse demonstrates understanding of which health model by integrating knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness? Health belief model High-level wellness model Holistic health model Clinical model

Health belief model Explanation: According to the health belief model, a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. According to the clinical model, health is defined narrowly as the absence of signs and symptoms of disease or injury. The holistic model views individuals as ever-changing systems of energy and the interaction of a person's mind, body, and spirit within the environment. The high-level wellness model is the recognition of health as an ongoing process toward a person's highest potential of functioning

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply. ?I will adjust the oxygen flow according to my needs.? ?I will secure my tank by placing it flush against the wall." ?I will keep the oxygen tank away from direct sunlight or heat.? ?I will only use an electrical instead of gas stove.? ?I will not allow smoking within 10 feet of my oxygen.?

I will not allow smoking within 10 feet of my oxygen.? ?I will keep the oxygen tank away from direct sunlight or heat.? Explanation: Supplemental oxygen increases the risk of fire, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It?s more important to follow the prescription, than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electrical stoves

The nurse in a free clinic when caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model? It focuses on what people believe to be true about their health. It focuses on factors that predispose a person to infectious diseases. It focuses on how people interact with their environments. It focuses on how health is a constantly changing state

It focuses on what people believe to be true about their health. Explanation: The Health Belief Model focuses on what people perceive or believe to be true about themselves in relation to their health. The Health Promotion Model focuses on how people interact with their environments, as they pursue health. The Health Illness Continuum Model focuses on health as a constantly ever-chaining state, while The Agent-Host-Enviornemnt Model explains how certain factors place a person at risk for an infectious disease.

The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? It expands the lungs with breaths. It keeps alveoli from collapsing with breaths. It removes fluid from the lungs. It allows oxygen to move in the lungs

It keeps alveoli from collapsing with breaths. Explanation: The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs

A nursing student knows that there are three most common symptoms of asthma. Choose the three that apply. Crackles Wheezing Cough Dyspnea

Cough Wheezing Dyspnea Explanation: The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances, cough may be the only symptom

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? Oxygen tent Nasal cannula Ambu bag Oxygen mask

Ambu bag Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube

The father of a 2-year-old phones the emergency department on a Sunday night and informs the nurse that his son put a bead in his nose. What is the most appropriate recommendation by the nurse? "Try removing the bead at home as soon as possible. You might try using a pair of tweezers." "Ask your child to blow his nose several times; this should dislodge the bead." "You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." "Be sure to take your child to the pediatrician in the morning so the pediatrician can remove the bead in the office."

"You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." Explanation: The bead should be removed by a health care professional as soon as possible to prevent the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an object from the nose as they may push the object further increasing the risk for aspiration. Two-year-old children are not skilled at blowing their nose and may breathe in, further increasing the risk of aspiration

A nurse is performing pain assessments on patients in a physician's office. Which patients would the nurse document as having acute pain? (Select all that apply.) A patient who has diabetic neuropathy A patient who is having an MI A patient who fell and broke an ankle A patient who presents with the signs and symptoms of appendicitis A patient who has rheumatoid arthritis A patient who has bladder cancer

A patient who is having an MI A patient who presents with the signs and symptoms of appendicitis A patient who fell and broke an ankle Explanation: The client having an MI, presenting with signs and symptoms of appendicitis, and having a broken ankle would be having acute pain. Diabetic neuropathy, rheumatoid arthritis, and bladder cancer would have chronic pain

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? Hemoglobin levels Arterial blood gas Pulmonary function Hematocrit values

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids

Which assessment finding would be most consistent with advanced emphysema? Dependent edema Barrel-shaped chest Epigastric pain Aortic bruit

Barrel-shaped chest Explanation: Barrel chest occurs as result of overinflation of the lungs. In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The apprearance of a such a client with advanced emphysema is easily detected.

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? Checking the cuff pressure every 6 to 8 hours Ensuring that humidified oxygen is always introduced through the tube Deflating the cuff routinely Deflating the cuff prior to tube removal

Deflating the cuff routinely Explanation: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube

Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Eat one large meal at noon Eat smaller meals that are high in protein Contact the physician for Ensure Snack on high-carbohydrate foods frequently

Eat smaller meals that are high in protein Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which of the following concepts? Focus on the altered functioning. Focus on why the client has the illness. Focus on what can no longer be. Focus on what is possible.

Focus on what is possible. Explanation: When a client has a chronic illness, the nurse needs to make every effort to promote health with a focus of care that emphasizes what is possible rather than what can no longer be. The others should not be a focus at this time

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? High respiratory rate Low pulse rate High temperature Low blood pressure

High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

What is defined as the recognition of health as an ongoing process toward a person's highest potential of functioning? Agent-host-environment Illness High-level wellness Health belief model

High-level wellness Explanation: High-level wellness is defined as recognizing health as an ongoing process toward a person's highest potential of functioning

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 technique? Calculate the pressure of carbon dioxide dissolved in plasma Monitor the amount of oxygen saturation in the blood Monitor the pressure of oxygen dissolved in plasma Calculate the percentage of hemoglobin saturated with oxygen

Monitor the amount of oxygen saturation in the blood Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma

A postoperative patient who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. What drug has the potential to reverse the respiratory-depressant effect of an opioid? Atropine Naloxone Diphenhydramine Epinephrine

Naloxone Explanation: Naloxone (Narcan) is an opioid antagonist that reverses the respiratory-depressant effect of an opioid

The nurse is administering oxycodone to a client. To which category of analgesics does this belong? Adjuvant Multipurpose Nonsteroidal anti-inflammatory Opioid

Opioid Explanation: Opioids analgesics were formerly called narcotic analgesics and are used to manage moderate to severe pain. These include morphine, codeine, oxycodone, meperidine, hydromorphone, and methadone

A 6-year-old will be hospitalized for a surgical procedure. How can the nurse best ease the stress of hospitalization for this child? Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital. Tell the parents to bring toys for the child from home. Have another child talk with the child to be hospitalized. There is no way to adequately prepare a child for an impending hospitalization

Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital. Explanation: The best way to ease the stress of hospitalization is to ensure that the child has been well prepared for the hospital experience

A client experiencing symptoms of cold is referred to the specialist for diagnosis and consultation. Consultation and diagnostic tests are included in which level of the health care system? Primary care Secondary care Tertiary care Extended care

Secondary care Explanation: Consultation and diagnostic tests are included in the secondary level of health care. The first contact with a general physician is the primary care, and the reference to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. Extended care is care provided to clients who no longer require acute hospital care

A nurse is caring for a client who was administered opioid narcotics. The client complains of constipation. Which of the following is another potential side effect of opioid narcotics? Anxiety Diarrhea Insomnia Sedation

Sedation Explanation: Opioids and opiates cause sedation, nausea, constipation, and respiratory depression, which is the main side effect to watch for with narcotics. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

Nurses promote the needs of patients as an integral part of each person's human dimension. Which needs are being met when a nurse recommends a senior citizen community center for an older patient who is living alone? Emotional needs Spiritual needs Intellectual needs Sociocultural needs

Sociocultural needs Explanation: The factors influencing a person's health-illness status, health beliefs, and health practices relate to the person's human dimensions. Each dimension interrelates with each of the others and influences the person's behaviors in both health and illness. Nursing assessments of strengths and weaknesses in each dimension are used to develop a plan of care that is individualized and holistic. Sociocultural needs are strongly influenced by a person's economic level, lifestyle, family, and culture. The question asked about an older client and a recommendation from the nurse regarding visiting a senior citizen community center. This is an example of sociocultural needs. Emotional needs address how the mind affects body functions and responds to body conditions. Long-term stress affects body systems, and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change the body's responses to illness. The intellectual dimension encompasses cognitive abilities, educational background, and past experiences. Spiritual beliefs and values are assessed when addressing spiritual needs

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? The nurse develops a specific schedule for coughing. The nurse reminds the client to combine coughing and deep breathing. The nurse has the client lying in bed in semi-Fowler?s position. The nurse encourages the client to cough before meals

The nurse has the client lying in bed in semi-Fowler?s position. Explanation: The client should be sitting upright with feet flat on the floor to be most effective. As part of the client?s plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective

What is the difference between respiration and ventilation? Ventilation is the process of getting oxygen to the cells. Ventilation is the exchange of gases in the lung. Ventilation is the process of gas exchange. Ventilation is the movement of air in and out of the respiratory tract.

Ventilation is the movement of air in and out of the respiratory tract. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells. Therefore, options A, C, and D are incorrect

When assessing a patient with left-sided heart failure, what would be noted on auscultation of lungs? Stridor Wheezes with wet lung sounds High-pitched sound Labor

Wheezes with wet lung sounds Explanation: If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound and wheezes and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal high pitch sound

The nursing instructor is teaching the students about acute and chronic illnesses and informs them that health promotion and illness prevention is vital because ___________. people do not like to be sick and feel bad. chronic illnesses can cause pain and suffering. chronic illnesses are the leading health problem in the world. the treatment of chronic illnesses is very expensive

chronic illnesses are the leading health problem in the world. Explanation: Because chronic illnesses are the leading health problem in the world, health promotion and illness prevention activities are vital to nursing care. It is true that treating chronic illnesses can be expensive, they do cause pain and suffering, and people do not like to be sick, but these are not the most important reason for promoting health and preventing illnesses

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: bounding pulse. hepatomegaly. femoral pulse weaker than brachial pulse. narrow pulse.

femoral pulse weaker than brachial pulse. Explanation: A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as sonorous wheezes. sibilant wheezes. crackles. pleural friction rub.

pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration

Modafinil has been ordered for a client diagnosed with narcolepsy. The nurse understands that this medication: is an antianxiety agent. promotes wakefulness. is a mood stabilizer. is a central nervous system (CNS) depressant.

promotes wakefulness. Explanation: Although modafinil's mechanism of action isn't fully known, this drug promotes wakefulness. It's indicated for treatment of individuals with narcolepsy, obstructive sleep apnea, or shift work type sleep-wake disorder. It would increase anxiety and elevate mood. CNS depressants and antianxiety agents would worsen the symptoms of narcolepsy. Mood stabilizers aren't indicated for narcolepsy

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease? It persists for a long time. It is a sequela of acute illness. It takes a long time to cure. It has a gradual onset and lasts for a long time

t has a gradual onset and lasts for a long time. Explanation: Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population

A child is being discharged with albuterol nebulizer treatments. The nurse should instruct the parents to watch for: urine retention. bradypnea. tachycardia. constipation

tachycardia. Explanation: Albuterol is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases. Signs and symptoms of albuterol toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, and dizziness. Unusually slow respirations, urine retention, and constipation aren't associated with albuterol toxicity

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? Determination of the cause Positioning to prevent complications Maintenance of a patent airway Assessment of pupillary light reflexes

Maintenance of a patent airway Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is Chronic pain Acute pain Referred pain Limited pain

Referred pain Explanation: Pain from the abdominal, pelvic, or back may be referred to areas far distant from the site of tissue damage

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? 28 breaths/min and audible 18 breaths/min and inhaled through the mouth 16 breaths/min and deep in character 20 breaths/min and shallow in character

28 breaths/min and audible Explanation: Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status

A nurse caring for an 11-month-old infant with tenacious secretions is preparing to suction the infant's nasopharynx. The nurse using the wall unit suction machine would set the valve at which appropriate pressure before suctioning? 150 mm Hg 130 mm Hg 60 mm Hg 100 mm Hg

100 mm Hg Explanation: High pressure can cause trauma, hypoxemia, and atelectasis. The correct pressure on the wall unit for an infant is 80?125 mm Hg. The neonate?s wall unit pressure is 60 to 80 mm Hg; the adult?s wall unit pressure is 100?150 mm Hg.

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult? 50 to 100 mm Hg 100 to 120 mm Hg 150 to 200 mm Hg 10 to 60 mm Hg

100 to 120 mm Hg Explanation: The appropriate suction pressure for a wall unit for an adult is 100 to 120 mm Hg. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis

After sedating a patient, the nurse assesses that the patient is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this patient? 4 3 1 2

3 Explanation: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary, 2 = occasionally drowsy but easy to arouse; requires no action, 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose, 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone

The nurse is teaching a client how to manage their post-operative pain through a Patient Controlled Analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client states which of the following? ?The pump is programmed to limit the chance of over-medicating.? ?This will allow me to control my own pain medication.? ?I give myself the pain medication by pushing the button.? ?I should only take medication when my pain is intense

?I should only take medication when my pain is intense.? Explanation: PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients over-medicating themselves.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply) Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed Administer prescribed pain medication 15 to 30 minutes before chest tube removal Ask the client to bear down, then slowly withdraw the chest tube Teach the client about relaxation exercises to be used during chest tube removal

Administer prescribed pain medication 15 to 30 minutes before chest tube removal Teach the client about relaxation exercises to be used during chest tube removal Explanation: After the chest tube is removed, the plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure. Occlusive dressing versus a semipermeable dressing should be utilized.

A nurse measuring the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a patient's arterial blood gets a weak signal from the pulse oximeter. What would be the appropriate intervention in this situation? Use a blood pressure cuff to increase circulation to the site. Check vital signs and patient condition. If extremity is hot, place a cold compress on the site. Shine available light on the equipment to facilitate accurate reading

Check vital signs and patient condition. Explanation: If a nurse finds an absent or weak signal, he or she should check vital signs and patient condition. If satisfactory, check connections and circulation to site. Hypotension makes an accurate recording difficult. Equipment (restraint, blood pressure cuff) may compromise circulation to the site and cause venous blood to pulsate, giving an inaccurate reading. If the extremity is cold, the nurse should cover it with a warm blanket. Bright light can interfere with the operation of light sensors and cause an unreliable report

The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal? Respiratory rate of 18 breaths per minute Vesicular breath sounds audible over peripheral lung fields Resonance on percussion of lung fields Fine crackles to the bases of the lungs bilaterally

Fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

The nurse assesses a patient 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? Hyperventilation Hypoxia Perfusion Atelectasis

Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli

A nurse is assessing a client's pain. The nurse notes which of the following database findings that is indicative of acute pain? Decreased respiratory rate Decreased pulse rate Pupil constriction Increased blood pressure

Increased blood pressure Explanation: The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? Simple mask Face tent Nasal cannula Non-rebreather mask

Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and are critically ill.

A 6-month-old infant who was born premature is being seen for a follow-up examination. The child is to receive an intramuscular injection monthly through the winter and spring season. Which drug would the nurse expect to be ordered? Nedocromil Zanamivir Palivizumab Amantadine

Palivizumab Explanation: Palivizumab is a monoclonal antibody used for prevention of serious lower respiratory syncytial virus (RSV) disease. RSV bronchiolitis occurs most often in infants and toddlers, with a peak incidence around 6 months of age. Infants born prematurely are more at risk. The peak occurrence of bronchiolitis is in the winter and spring. Nedocromil decreases the frequency and intensity of allergic reactions. Amantadine is used to treat and prevent influenza A. Zanamivir is used to treat and prevent influenza A

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Urinary Respiratory Gastrointestinal Skin

Respiratory Explanation: Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority

The nurse is planning a diet for a patient with COPD. Which recommended nutritional guidelines would the nurse consider? (Select all that apply.) The diet should contain 12% to 20% protein. The diet should consist of 40% to 55% carbohydrates. The diet should contain 45% to 50% fat to counter malnutrition. Obese patients should not be encouraged to lose weight to prevent malnutrition. The diet should be rich in antioxidants and vitamin A, C, and B. The patient should follow a high-protein and low-calorie diet.

The diet should consist of 40% to 55% carbohydrates. The diet should be rich in antioxidants and vitamin A, C, and B. The diet should contain 12% to 20% protein. Explanation: Patients who have COPD require a high-protein/high-calorie diet to counter malnutrition. Obese patients with COPD should be encouraged to lose weight using a calorie-controlled diet. Diets for COPD patients should be 40% to 55% carbohydrates, 30% to 40% fat, and 12% to 20% protein. A diet rich in antioxidants, vitamins A and C, and the B vitamins is important to maintain health and fight off infection

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge 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 newly hired nurse assesses the client?s pain and administers pain medication. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. The newly hired nurse adjusts the bed to a comfortable working position

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care

Parents are told their infant has a hypoplastic left heart. How would the nurse explain this condition to the family? There are no surgeries that can help the child live with this heart defect. The infant will have immediate surgery to completely correct the heart defect. This is a problem where the right side of the heart did not develop properly. This is a problem where the left side of the heart did not develop properly

This is a problem where the left side of the heart did not develop properly. Explanation: This is a problem where the left side of the heart did not develop properly. There is a three-step palliative surgery that can be implemented or the child will need a heart transplant

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? The gate control mechanism opens so all the stimuli pass through to the brain. This is a technique to prevent the painful stimuli from entering the brain. The gate control mechanism is located at the pain site. Pain perception is decreased if anxiety is present.

This is a technique to prevent the painful stimuli from entering the brain. Explanation: Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location

What have the models of health promotion and illness prevention been used for? To define a medical framework for the care of the disabled. To formulate care plans for the disabled population. To create a forum for improving rehabilitative care. To help healthcare providers understand health-related behaviors

To help healthcare providers understand health-related behaviors. Explanation: Several models of health promotion and illness prevention have been used to help healthcare providers understand health-related behaviors and adapt care to people from diverse economic and cultural backgrounds. The models include the health belief model, the health promotion model, the health-illness continuum model, and the agent-host-environment model. These models do not define a medical framework in the care of the disabled; these models do not create a forum for improving rehabilitative care; and these models do not formulate care plans for use with the disabled.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? fetal heart rate declining late with contractions and remaining depressed a shallow deceleration occurring with the beginning of contractions fetal baseline rate increasing at least 5 mm Hg with contractions variable decelerations, too unpredictable to count

fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing? epinephrine albuteral norepinephrine surfactant

surfactant Explanation: Surfactant is a protein that keeps small air sacs in the lungs from collapsing. Its use was introduced in 1990 and continues today, especially for premature babies and those who have respiratory distress syndrome. The other medications are not given to help premature babies breathe