Nursing 308 Questions

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? A) Taking hourly blood pressures with mechanical cuff B) Encouraging fluid intake of at least 200mL per hour C) Position in high Fowler's with knee gatch raised D) Administering Tylenol as ordered

Answer: B: Encouraging fluid intake of at least 200ml per hour Rationale: It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Dehydration is a common cause of sickling. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

Which signs or symptoms should the nurse report immediately because they indicate thrombocytopenia secondary to cancer chemotherapy? Select all that apply. A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor

Answer: A, C, and D Rationale: Bruising is a symptom of a low platelet count. Petechiae are signs of a low platelet count. Nosebleed is a sign of a low platelet count.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? a. Cholesterol level b. Pupil size and pupillary response c. Bowel sounds d. Echocardiogram

Answer: B: Pupil size and pupillary response Rationale: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hour, when the primary concerns are cerebral hemorrhage and increased cranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems

The nurse is caring for the following clients. Which client should the nurse assess FIRST? A. the client whose partial thromboplastin time (PTT) is 38 seconds. B. The client whose hemoglobin is 14 g/dl and hematocrit is 45%. C. The client whose platelet count is 75,000 per cubic millimeter of blood. D. The client whose red blood cell count is 4.8 x 10^6/mm^3.

Answer: C Rationale: A normal range for PTT is 32 to 39 seconds. These are normal hemoglobin/hematocrit levels for either a male or female client. A PLATELET COUNT OF LESS THAN 100,000 PER CUBIC MILLIMETER OF BLOOD INDICATES THROMBOCYTOPENIA. This is a normal red blood cell count.

The nurse is assessing a client with hyponatremia. Which finding requires immediate action? A. Diminished bowel sounds B. Heightened acuity C. Muscular weakness D. Urine output of 35 mL/hr

Answer: C. Muscular weakness Rationale: Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.

A physician writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first? A. Administering sodium polystyrene sulfonate (Kayexalate) orally. B. Ensuring that a potassium-restricted diet is ordered. C. Placing the client on a cardiac monitor. D. Teaching the client about foods that are high in potassium.

Answer: C. Placing the client on a cardiac monitor Rationale: Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor

The community health nurse is instructing a group of female clients about breast self-examination. The nurse instructs the clients to perform the examination: A. At the onset of menstruation B. Every month during ovulation C. Weekly at the same time of day D. 1 week after menstruation begins

Answer: D: 1 week after menstruation begins Rationale: The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A. Confirm that the ventilator settings are correct. B. Verify that the ventilator alarms are functioning properly. C. Assess the respiratory status and pulse oximeter reading. D. Monitor the client's arterial blood gas results.

C. Assess the respiratory status and pulse oximeter reading. Rationale: Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? A. Creatinine 1.9mg/dL B. Fasting glucose, 80mg/dL C. Potassium, 3.9mEq/L D. Sodium, 140mEq/L

Correct Answer: A: Creatinine 1.9mg/dL Rationale: A creatinine of 1.9 mg/dL is outside the normal range and may indicate renal problems. A fasting glucose of 80 mg/dL, a potassium level of 3.9 mEq/L, and sodium level of 140 mEq/L are normal laboratory values.

The nurse is providing care to the client with impaired gas exchange related to anemia. Which nursing intervention has the highest priority? A. Administer antibiotics as prescribed. B. Transfuse ordered packed red blood cells. C. Teach pursed-lip breathing. D. Encourage increased fluid intake.

Correct Answer: B. Transfuse ordered packed red blood cells. Rationale: Packed red blood cells increase hemoglobin molecules, this increases sites at which oxygen can attach and improves gas exchange.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's A. Pulse rate, both apically and radially B. Blood pressure, both standing and sitting. C. Temperature D. Skin color and turgor

Correct Answer: C. Temperature Rationale: It is very important to check a patient's temperature. Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of cortico

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A) Place the solution on an IV pump at the prescribed rate. B) Monitor blood glucose every six (6) hours. C) Weigh the client weekly, first thing in the morning. D) Change the IV tubing every three (3) days. E) Monitor intake and output every shift.

Correct Answers: A, B, E A. TPN is a hypertonic solution with enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too-rapid infusion. B. TPN contains 50% dextrose solution; therefore, the client is monitored to ensure to pancreas is adapting to the high glucose. E. Intake and output are monitored to observe for fluid balance.

The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug? a. Rales and distended neck viens b. Red discoloration of the urine and an output of 75 ml the previous hour c. Nausea and vomiting d. Elevated BUN and dry, flaky skin

A. Rales and Distended Neck Veins Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck viens are clinical manifestations of CHF. A reddish discoloration to the urine is a harmless side effect, an elevated BUN and dry flaky skin are not specific to this drug, so B, C, and D are incorrect.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? A. Give 20 mEq of potassium chloride. B. Initiate continuous cardiac monitoring. C. Arrange a consultation with the dietician. D. Teach about the side effects of diuretics.

B. Initiate continuous cardiac monitoring Rationale: Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricularectopy or other life-threatening dysrhythmias. Potassium chloride should be given after cardiac monitoring is initiated so that the effects of potassium replacement on the cardiac rhythm can be monitored. Arranging a consultation with the dietician and teaching about side effects of diuretics should be implemented when the client is stable.

The nurse is instructing the client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? A. "I will take off my stockings one to three times a day for 30 minutes." B."My stockings are too loose." C."These stockings will prevent blood clots." D."These stockings help promote blood flow."

C. "These stockings will prevent blood clots." Rationale: Anti embolism stockings alone will not prevent deep venous thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT.

The RN evaluates a care plan developed by a nursing student. Which of the following interventions are inappropriate? A. Encourage the client to drink 4-6 glasses of fluid a day B. Place client in high Fowler's position C. Increase the prescribe oxygen flow rate when short of breath D. Provide high-calorie, 6 small feeding diet each day?

Correct Answer: C. Increase the prescribed oxygen flow rate when short of breath. Rationale: Increasing the oxygen will suppress the neurological breathing response.

An older client presents to the emergency department (ED) with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. A bronchodilator would not be beneficial for this client B. A bronchodilator would help decrease the bronchospasm C. It would clear up the density in the base of the client's lungs D. It will decrease the client's pain on inspiration

Correct: A bronchodilator would help decrease bronchospasm Rationale: A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client

A nurse is conducting heath screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder? A. 25 yr old woman who jogs B.36 yr old man who has asthma C. 70 yr old man who consumes excess alcohol D. A sedentary 65 yr old woman who smokes

D. A sedentary 65 year old woman who smokes

As you are administering penicillin intravenously, you determine that the patient becomes hypotensive and with a bounding, rapid pulse rate. What is the first thing that you would do? A. Decrease the rate of the intravenous medication flow. B. Increase the rate of the intravenous medication flow. C. Call the doctor. D. Stop the intravenous flow.

D. Stop the intravenous flow Rationale: This patient is experiencing the signs and symptoms of anaphylactic shock which is a severe life threatening allergic response that is often associated with a penicillin allergy or hypersensitivity. The first thing you should do is stop the intravenous flow and respond to this medical emergency which can lead to death. After this you should call the doctor about this episode and inform the doctor of the patient's current medical status.

You are caring for a patient with multiple-trauma. Of all of these injuries and conditions, is the most serious? A. A deviated trachea B. Gross deformity of a lower extremity C. Hematuria D. Decreased bowel sounds

A. A Deviated Trachea Rationale: A deviated trachea is a serious life threatening condition. A deviated trachea is a symptom of tension pneumothorax which can be life threatening. All of the other symptoms will need to be addressed and treated, however, it is the deviated trachea that is the most severe and of the greatest priority.

A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: A. Administer the morphine B. Obtain a 12-lead ECG C. Obtain the blood work D. Prescribe the chest radiograph

A. Administer the morphine Rationale: Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

A nurse is monitoring the intracranial pressure (ICP) of a patient with a traumatic brain injury (TBI) from an MVA. Which of the following would the nurse associate with increased ICP? (Select all that apply) A.Altered respirations B.Change in level of consciousness C.Decorticate or decerebrate posturing D.Decreased blood pressure E.Increased blood pressure F. Increased pulse

A. Altered Respirations B. Change in LOC C. Decorticate or Decerebrate Posturing E. Increased Blood Pressure

The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? A. Talk with the client about how the client is feeling. B. Instruct the nursing assistant to sit with the client while the client eats. C. Contacts the physician to obtain an order for an antacid. D. Evaluate the most recent vital signs recorded in the chart.

A. Talk with the client about how he/she is feeling

You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? A. The patient was in a recent motor vehicle accident B. The patient participated in aerobics for 6 months C. The patient gave birth 1 month ago D. The patient sleeps 8 hours a night

A. The patient was in a recent motor vehicle accident Rationale: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? A.) Perform a complete neurological assessment. B.) Awaken the client every 30 minutes. C) Turn the client to the side and allow the client to sleep. D.) Interview the client to find out what caused the seizure.

Answer: C: Turn the client to the side and allow the client to sleep. Rationale: During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.

A nurse has given a client with a leg cast instructions on cast care at home. The nurse would evaluate that the client needs further instruction if the client makes which of the following statements? A. "I should avoid walking on wet, slippery floors." B. "I'm not supposed to scratch the skin underneath the cast." C. "It's okay to wipe dirt off the top of the cast with a damp cloth." D. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

ANSWER: D: "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." RATIONALE: Client instructions should include avoiding walking in wet slippery floors to prevent falls. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation.

A client's wound has eviscerated. Which of the following will you implement first? A. Stay with the client and notify the physician. B. Apply a clean, dry dressing to the wound. C. Cleanse the wound with Betadine and apply bacteriostatic ointment. D. Place sterile towels soaked in saline over the wound.

Answer D: Place sterile towels soaked in saline over the wound. Rationale: The nurse will place sterile towels soaked in sterile dressing over the eviscerated wound. An evisceration is the protusion of visceral organs through a wound opening. The condition is a medical emergency that requires surgical repair. If organs protude through the wound, the blood supply to the tissues is compromised. When evisceration occurs, the nurse places sterile saline over the extruding tissues to reduce the possibility of bacterial invasion and drying.

With a diagnosis of a brain attack (stroke), What nursing intervention is priority? a) monitor INR daily b) assess neurological status every shift c) evaluate platelet levels daily d) keep head of bed elevated

Answer D: keep the head of bed elevated Rationale: maintaining a patent airway is essential to supporting oxygenation and tissue perfusion. Elevating the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway. INR is monitored during Warfarin therapy. Neurological status should be monitored more often than 8-12hours as indicated by shift change and anticoagulants inhibit thrombin formation and do not usually affect platelets levels.

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. a. Keep the cast clean and dry b. Allow the cast 24-72 hours to dry c. Keep the cast and extremity elevated d. Use a hairdryer set on warm to hot setting to dry the cast e. Use a soft padded object that will fit under the cast to scratch the skin under the cast

Answer: A: Keep the cast clean and dry. B: Allow cast 24-72 hours to dry C: Keep the cast and extremity elevated Rationale: A plaster cast takes 24-72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat can not be used on a plaster cast because the cast heats us and burns skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.

A client is diagnosed with pyelonephritis.Which of the following is a priority for care now? A. Monitor hemoglobin levels. B. Insert a urinary catheter. C. Stress importance of use of long term antibiotics. D. Ensure sufficient hydration.

Answer: D- Ensure sufficient hydration Rationale: The nurse should ensure the client has adequate hydration. A urinary catheter is discouraged because of the risk of urinary tract infection. Monitoring of the hemoglobin level is not necessary for clients with pyelonephritis. Although antibiotics may be prescribed for long-term management and chronic pyelonephritis, at this the nurse should focus on helping the client maintain hydration.

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all the apply. A) Insert an oral airway B) Monitor the seizure activity C) Turn the client on the left side D) Begin oxygen by mask as 8 L/min E) Restrain the clients movements

Answer: B) Monitor the seizure activity C) Turn the client on the left side Rationale: Monitoring of the seizure activity, the body parts involved, the area of its progression, and the length of the episode, as well as the activity of the head and eyes, characteristics of the respiration, and alteration in consciousness provide information that assists in the identification of the type of seizure and, thus, its treatment. Turning the client on the side should be done in order to keep the airway clear. Insertion of an oral airway is contraindicated. Attempting to insert an oral airway may injure the client or the nurse. Do not restrain or try to stop the patient's movement; guide movements if necessary. Beginning oxygen by mask at 8 L/min is unnecessary because breathing does not occur during a seizure; this may be done after the seizure.

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? A.) Assist the client into a sitting position at 90 degrees B.) Administer oxygen at 6LPM via nasal cannula C.) Monitor vital signs with the client sitting upright D.) Notify the health care provider about the client's status

Answer: A: Assist the client into a sitting position at 90 degrees. Rationale: The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety.

The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels b. Low hemoglobin c. Hypocalcemia d. Hypokalemia

Answer: A: High serum creatinine levels Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients.

Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3. What action is most important for the nurse to take? A) Notify the health care provider of the platelet count. B) Administer the prescribed LMWH on schedule. C) Assess the activated partial thromboplastin time (aPTT). D) Assess the international normalized ratio (INR).

Answer: A: Notify HCP of the platelet count Rationale: If the platelet count falls below 20,000/mm3, spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. LMWH can cause thrombocytopenia, so it should not be administered when the client's platelet count is low. The aPTT is not affected by LMWH, so its assessment is not necessary. Usually, LMWH is given in a low prophylactic dose and does not affect the INR.

A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client's arterial blood gas values indicated respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare to begin gastric lavage. D. Obtain urine for drug screening

Answer: A: Prepare to assist with ventilation. Rationale: Respiratory acidosis is associated with hypoventilation, which in this client suggests intake of a drug that suppresses the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? a. The client diagnosed with MI who has an audible S3 heart sound. b. the client diagnosed with CHF who has +4 sacral pitting edema. c. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. d. The client with chronic renal failure who has an elevated creatinine level.

Answer: A: The client diagnosed with MI who has an audible S3 heart sound Rationale: An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.

The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? A) the client with a total knee replacement who is complaining of a cold foot B) the client diagnosed with osteoarthritis who is complaining of stiff joints C) the client who needs to receive a scheduled intravenous antibiotic D) the client diagnosed with back pain who is scheduled for a lumbar myelogram

Answer: A: the client with a total knee replacement who is complaining of a cold foot. Rationale: A cold foot in a client who has had a surgery may indicate a neurovascular compromise and must be assessed first

A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient: A. to a private room so she will not infect other patients and health care workers. B. to a private room so she will not be infected by other patients and health care workers. C. to a semiprivate room so she will have stimulation during her hospitalization. D. to a semiprivate room so she will have the opportunity to express her feelings about her illness.

Answer: B What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia? Needed Info: Lymphocytic leukemia, disease characterized by proliferation of immature WBCs. Immature cells unable to fight infection as competently as mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care. B. to a private room so she will not be infected by other patients and health care workers - CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection

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) A.Tremors B.Diarrhea C.Irritability D.Blurred Vision E.Nausea and vomiting

Answer: B, D, E Rationale: Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2ng/ml/

The Nurse is preparing a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? A. Urinary Incontinence B. Signs of skin breakdown C. The presence of bowel sounds D. Signs of infection around the pin sites

Answer: B. Signs of skin breakdown. Rationale: Skin traction is achieved by Ace wraps, boots, and slings that happy a direct force on the client's skin. Traction is maintained with 5-8 lb. of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? A. Unstable angina B. Variant angina C. Unstable angina D. Nonanginal pain

Answer: B. Variant Angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation

Answer: C The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor: A.Urine output. B.Blood pressure. C.Bowel movements. D.ECG for tall, peaked T waves.

Answer: C: Bowel Movements Rationale: Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation

Answer: C: Careful assessment of vital signs. Rationale: The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

A client with auto immune thrombocytopenic purpura undergoes a splenectomy. upon receiving the patient to the PACU (post anesthesia care unit), the nurse immediately assesses the clients airway and vital signs. What should the nurses next priority action be? A) Check the patient's Foley catheter for urinary output. B) Administering pain medication as prescribed. C) Checking the patient's dressing for excessive bleeding and drainage. D) Administer platelets as ordered.

Answer: C: Checking the patient's dressing for excessive bleeding and drainage. Rationale: A client undergoing a splenectomy with a history of ITP is at a high risk for hemorrhage, and therefore the priority assessment is to check the dressing for signs of bleeding. Although the nurse should check the urine and pain level, these aren't immediately life threatening.

Methylphenidate (Ritalin) is prescribed to treat a 7 year old child's attention-deficit/hyperactivity disorder (ADHD). Ritalin is used in the treatment of this disorder in children for its: A. Diuretic effect B. Synergistic Effect C. Paradoxical Effect D. Hypotensive Effect

Answer: C: Paradoxical Effect Rationale: Methylphenidate (Ritalin) is a stimulant, has an opposite effect on hyperactive children; this action is as yet totally unexplained.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? A. Heart rate of 58 beats/min B. Pale, cool extremities C. Respiratory rate of 6 breaths/min D. Suppressed gag reflex

Answer: C: Resp. Rate of 6 breaths/min Rationale: The most important postoperative assessment is respiratory assessment, and a rate of 6 breaths/min is too low. A heart rate of 58 beats/min, pale and cool extremeties, and a suppressed gag reflex are all normal postoperative findings

The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse's best first action? A. Call the blood bank B. Take and record the client's vital signs C. Stop the transfusion and keep the IV open D. Document the observation as the only action

B. Take the record the client's vital signs Rationale: Type O blood can be infused with A, B, C, or AB.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. A client complaining of muscle aches, a headache, and malaise B. A client who twisted her ankle when she fell while rollerblading C. A client with a minor laceration on the index finger while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Answer: D. A client with chest paint who states that he just ate pizza that was made with a very spicy sauce. Rationale: in an ED, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as laceration, sprain, or cold symptoms are classified as nonurgent are a number 3 priority.

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

Answer: D: A 50-year old with asthma who complains of shortness of breath after using a bronchodilator Rationale: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

After receiving a change-of-shift report at 7:00 AM, the nurse should assess which of these clients first? A. A 23-year-old with a migraine headache who has severe nausea associated with retching. B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast. D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.8^\circF and flank pain.

Answer: D: A 63-year-old with MS who has an oral temperature of 101.8 and flank pain. Rationale: Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client. (Billings & Hensel, 2014, p. 599)

The nurse observes precaution in caring for Mr. X as HIV is most easily transmitted in: a. Vaginal secretions and urine b. Breast milk and tears c. Feces and saliva d. Blood and semen

Answer: D: Blood and Semen Rationale: Keyword: MOST EASILY. Rationale: HIV is MOST EASILY transmitted in blood, semen and vaginal secretions. However, it has been noted to be found in fecal materials, urine, saliva, tears and breast milk.

The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which early symptom? A. Nocturia B. Urinary retention C. Urge incontinence D. Decreased force in the stream of urine

Answer: D: Decreased force in the stream of urine Rationale: Decreased force in the stream of urine is an early sign of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

The assessment findings for the nasogastric tube drainage of a client recently transferred from the PACU include the presence of 140 mL of greenish-yellow drainage. What is the nurse's best action? A. Instruct the client to drink water until the drainage is clear. B. Reposition the tube to increase the drainage. C. Call and report this finding to the surgeon. D. Document the finding as the only action.

Answer: D: Document the findings as the only action. Rationale: Both the amount and color of the fluid draining from the NG tube are normal and expected for this point in the postoperative period.

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? A. Apply ice to the site. B. Call the health care provider (HCP) C. Apply a dry sterile dressing and elevate it on one pillow. D. Rewrap the residual limb with an elastic compression bandage.

Answer: D: Rewrap the residual limb with an elastic compression bandage Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will for rapidly, which could cause significant delay in rehabilitation.

A client had surgery two (2) days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 1 to 10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan? A. Encouraging diversional activities B. Incorporating ADLs as soon as possible C. Teaching key points of the relaxation response D. Using preemptive analgesia

Answer: D: Using preemptive analgesia Rationale: Use of preemptive analgesia is a technique designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the hospital stay.

The Nurse interviews Mr. Jones regarding his elimination patterns. What client information indicates to the nurse for a need for additional assessment? a.) Increased Flatulence b.) Bowel movement every other day c.) Blood on paper when constipated d.) Stool has narrowed in diameter

Answer: d.) Stool has narrowed in diameter Rationale: Stool that is narrow in diameter, particularly "ribbon-like" stool, can be an indication of left sided colon cancer.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. A. Encourage a low-fat, low-cholesterol diet B. Instruct client to walk 30 minutes a day C. Decrease the salt intake to two (2) grams a day D. Refer to counselor for stress reduction techniques. E. Teach the client to increase fiber in the diet.

Answers: A, B, D, E Rationales: A. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. B. Walking will help increase collateral circulation. D. Stress reduction in encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. E. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.

A client comes into the emergency room with complaints of sudden onset of severe right flank pain. While tests are being performed, it is MOST important for the nurse to take which of the following actions? a) Make sure the the patient does not eat or drink anything b) Strain all the patient's urine through several layers of gauze c) Check the patient's grip strength and pupil reactivity d) Send blood and urine specimens to the lab for analysis

B) Strain all the patient's urine through several layers of gauze Rationale: "b" is the correct answer. "MOST" indicates a priority question. Symptoms suggest urinary caculi and should strain urine for stone. Needed information: Symptoms of renal calculi include- pain, diaphoresis, nausea and vomiting, fever and chills, hematuria. Nursing care: monitor I&O and temp, suggest increase in fluids, strain urine and check pH of urine, and administer analgesics. Diet for prevention of stones: consume foods low in calcium, sodium, and oxalates, avoid vitamin D enriched foods, decrease purine sources, restrict citrus fruits, milk, and potatoes.

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Risk for Injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction

B. Risk for Injury related to sensory and motor deficits

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. the nurse should conduct a focused assessment for : A. limited motion of joints B. deformed joints of the hands C. early morning stiffness D. rheumatoid nodules

C. Early morning stiffness RATIONALE: initially most clients with early symptoms of rheumatoid arthritis reports early morning stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion, deformed joints, especially of the hand: and rheumatoid nodules .

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake

CORRECT ANSWER: B: Straining all urine RATIONALE: Straining all urine (B) is the most important nursing action to take in this case. Encouraging fluid intake (D) is important for any client who may have a kidney stone, but is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. (C) is not the highest priority action. (A) is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

A client with gastroesophageal reflux diseas (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A) Losing weight. B) Decreasing caffeine intake. C) Avoiding large meals. D) Raising the head of the bed on blocks.

Correct Answer D) Raising the head of the bed on blocks Rationale: Raising the head of the bed on blocks(reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesaphageal reflux during sleep.

A nurse is caring for a client who has been administered digoxin (Lanoxin) 0.125 mg by mouth daily. The client develops sinus bradycardia with a heart rate of 50 bpm. His vital signs are stable. Which of the following actions should the nurse take first? A. Notify the physician B. Retake the vital signs in two hours C. Stop the medication D. Have the client turn on his left side

Correct Answer: A. Notify the physician

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? A. Providing emotional support to decrease fear B. Protecting the client from infection C. Encouraging discussion about lifestyle changes D. Identifying factors that decreased the immune function

Correct Answer: B. Protecting the client from infection Rationale: Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is a nurse's primary responsibility to protect the patient from infection.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for fluide volume deficit? A. A client with an ileostomy B. A client with heart failure C. A client on long-term corticosteroid therapy D. A client receiving frequent wound irrigations

Correct Answer: A: A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, are most at risk for fluid volume excess.

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. A client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. A client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. A client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. A client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

Correct Answer: A: A client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Rationale: Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune suppressed people; the nurse should see this client first.

The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? A. Blood pressure 170/96 mm Hg B. Respiratory rate 22 breaths/min C. Urine output of 70 mL/hr D. Heart rate 98 beats/min

Correct Answer: A: BP of 170/90 Rationale: Signs of excess vasoconstricting drugs include headache, hypertension.

Three days after abdominal aortic aneurysm repair, a client develops a pulmonary embolus. Which nursing diagnosis takes priority? A)Ineffecrive peripheral tissue perfusion B)Impaired physical mobility C)Ineffective airway clearance D)Risk for aspiration

Correct Answer: A: Ineffective peripheral tissue perfusion Rationale: Pulmonary embolus occurs when a thrombus lodges in a branch of the pulmonary artery, partially or totally occluding it. The lung is adequeately ventilated but can not be perfused, resulting in eneffective peripheral tissue perfussion. Although Impaired physical mobility is an appropriate nursing diagnosis, it does not take priority over Ineffective peripheral tissue perfussion. A pulmonary embolus does not increase secretions, so Ineffective airway clearance isn't an appropriate diagnosis. It also doesn't place the client at Risk for aspiration.

A patient with COPD is feeling short of breath and has an oxygen saturation of 86% on room air. The nurse auscultates inspiratory and expiratory wheezes. The nurse applies a nasal cannula at a rate of 2L per minute. What should the nurse do next? A. Notify the physician immediately B. Call respiratory therapy to administer the prescribed levalbuterol nebulizer treatment C. Stay with the patient until respiratory status improves D. Prepare the patient for an emergent intubation

Correct Answer: B. Call respiratory therapy to administer prescribed levalbuterol nebulizer treatment. Rationale: Since the nurse has already administered oxygen, the next action would be to administer prescribed bronchodilator such as levalbuterol to open the airway. The physician does not need to be informed of the situation immediately. If a bronchodilator has not been prescribed, the nurse should obtain an order form the physician. Although the nurse should stay with the patient to provide support, more action is needed to improve the patient's status. Intubation with an endotracheal tube is not necessary in this situation.

When suctioning mucus from a client's lungs, which nursing action would be least appropriate? A.Use sterile technique with a two-gloved approach B. Suction until the client indicates to stop or no longer than 20 second C. Hyperoxygenate the client before and after suctioning D. Lubricate the catheter tip with sterile saline before insertion.

Correct Answer: B. Suction until the client indicates to stop or no longer than 20 second Rationale: One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain

Correct Answer: B: Edema of the arms and hands Rationale: Edema of the arms and hands indicates worsening compression of the superior vena cava syndrome. The compression must be relieves immediately, often with radiation therapy, because death can result without timely intervention.

A patient has been taking antibiotics for 3 days to treat pyelonephritis. Which of the following findings requires the nurse's immediate attention? A. Cloudy urine B. Elevated temperature C. Flank pain D. Nausea

Correct Answer: B: Elevated Temperature Rationale: An elevated temperature 72 hours after antibiotic treatment indicates that the medication is ineffective. The physician should be notified so the antibiotic can be changed.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.

Correct Answer: B: Turn off the continuous feeding pump. Rationale: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially? A. Calls the care provider for a change in the medication order B. Changes the order to every six (6) hours rather than every four (4) hours C. Gives the client a dose of naloxone (Narcan) 0.4 mg IV D. Performs a cognitive assessment on the client

Correct Answer: C. Gives the client a dose of naloxone (Narcan) 0.4 mg IV Correct Rationale: In an unresponsive client, the nurse should administer Narcan 0.4 mg (diluted in 10 mL) over a 2-minute time period to reverse the action of the opioid analgesic.

A patient is admitted to the hospital with a diagnosis of a sickle cell crisis. What consultation is a priority for this patient? A. Nutritionist B. Occupational Therapist C. Pain Specialist D. Physical Therapist

Correct Answer: C. Pain specialist Rationale: A sickle cell crisis can cause horrific pain. Therefore, a pain specialist should be consulted immediately to help manage the patient's pain.

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A. Hypo-active bowel sounds with abdominal distention B. Client reports continued pain of 8 on a 10-point scale C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% D. Client reports nausea after receiving the medication

Correct Answer: C. RR of 12 bpm, with O2 Sat of 85% Rationale: Administration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse but are of less priority than (C).

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while flushing the line.

Correct Answer: C. Stop flushing and try to aspirate blood from the line. Rationale: If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A. Fluid overload (overhydration) B. Hemorrhage C. Hypoxia D. Infection

Correct Answer: D: Infection Rationale: Fluid overload is not a priority problem for the client with leukemia. Hemorrhage is not a priority problem for the client with leukemia. Hypoxia is not a priority problem for the client with leukemia. The main objective in caring for a newly diagnosed client with leukemia is protection from infection.

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) A. Assess for fever. B. Observe for bleeding. C. Administer pegfilgrastim (Neulasta) D. Do not permit fresh flowers or plants in the room. E. Do not allow the client's 16-year-old son to visit. F. Teach the client to omit raw fruits and vegetables from the diet.

Correct Answers: A, C, D, F Rationale: Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.

A client had a right total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Stand on your right leg to pivot to the chair" B. "Do not bend your leg more than 90 degrees" C. "Cross your legs to be more comfortable" D. "Avoid twisting your body when moving" E. "Use a long-handled shoe horn to put on your shoes"

Correct Answers: B, D, and E Rationale: B, D, and E are proper ways to care for clients with THA. A and C can lead to dislocation of the affected hip. Chart 18-3 on page 298 contains information on precautions, pain management, and care for patients with THA

Which priority problems may be considered for the client with heart failure? Select all that apply. A. Decreased fluid volume related to compromised regulatory mechanism B. Impaired Physical Mobility related to limited cardiovascular endurance C. Impaired Gas Exchange related to ventilation-perfusion imbalance D. Potential for pulmonary edema E. Risk for Ineffective renal Perfusion related to hypervolemia

Correct: B, C, D, E B. Rationale-Owing to intra-alveolar edema and poor cardiac output, the client is fatigues and has limited endurance. C. Rationale-Owing to intra-alveolar edema and poor cardiac output, the client may develop hypoxemia. D. Rationale-Owing to limited cardiac reserve, the client is at risk for pulmonary edema E. Rationale-The client with heart failure has poor cardiac output, reduced blood flow to the kidney and accumulation of pulmonary and peripheral fluid.

A patient diagnosed with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? A. Call the HCP and report the change in the patient's condition. B. Turn the patient's O2 up to 4 liters on nasal cannula. C. Encourage the patient to sit down and take a few deep breaths. D. Encourage the patient to use the pursed lip breathing technique and rest.

D. Encourage the patient to use the pursed lip breathing technique and rest. Rationale: Clients with COPD are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates breathing. Deep breathing does not help and there is no need to call the physician in this instance.

The nurse is providing care to a patient with chronic obstructive pulmonary disease. The nurse should be aware that: A. Airway obstruction in COPD is typically more pronounced on inspirations. B.The barrel chest deformity often seen in emphysema is caused by copious secretions that are difficult to clear from the airways. C. With adequate treatment and patient compliance, COPD is fully reversible. D. Pulmonary function testing that measures expiration airflow limitations is the key to diagnosing the disease.

D. Pulmonary function testing that measures expiration airflow limitations is the key to diagnosing the disease.

The nurse is caring for a patient with a diagnosis of COPD, bronchitis-type, in the long-term care facility. The patient is wheezing, and his oxygen saturation is 85%. Four hours ago, the oxygen saturation was 88 percent. It is MOST important for the nurse to take which of the following actions? A. administer beclomethasone (Vanceril), two puffs per metered dose inhaler B. listen to breath sounds C. increase oxygen to 4 L per mask D. administer albuterol (Proventil), two puffs per metered dose inhaler

D. administer albuterol (Proventil), two puffs per metered dose inhaler

With a diagnosis of a brain attack (stroke), what priority intervention should the nurse include in the patient's plan of care (is on Heparin)? A.) Monitor INR daily B.) Assess neurological status every shift C.) Evaluate platelet levels daily D.) Keep the head of the bed elevated

D.) Keep the head of the bed elevated Rationale: Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway.