nursing exam 5

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

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

Which question about fluid balance would be appropriate when conducting a health history for a client?

"Describe your usual urination habits."

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe."

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

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

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?

"You will be asked to forcefully exhale into a mouthpiece."

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream

HCO3 range:

22-26 mEq/L

PCO2 range:

35-45 mmHg

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl

pH balance:

7.35 - 7.45

The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

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

An infant with a respiratory rate of 20 bpm

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence.

What food would the nurse provide for a client who has hypokalemia?

Bananas

Which category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?

Bronchodilators

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

Corticosteroids

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Electrolyte management Nutrition management Intravenous therapy

Which disease may result in decreased lung compliance?

Emphysema

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

Explain to the client why this is needed.

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client?

Fowler's position

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance?

Infant

In what age group would a nurse expect to assess the most rapid respiratory rate?

Infants

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?

Initiate interventions to help relieve the symptoms.

A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?

Isotonic

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

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

Nebulizer

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst.

The nurse should assess for respiratory depression before and after the administration of which drugs?

Opioid analgesics

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

Perform a respiratory assessment.

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?

Perform respiratory assessment.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

A client 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of the thorax. Based on age and the injury, the client is at risk for what complication?

Pneumonia

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which nursing intervention is appropriate to include in the client's care plan?

Provide six small meals daily.

The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication?

Regulate flow to allow 25 gtts every 15 seconds

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?

SpO2 92%

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply.

Stop the infusion immediately. Restart the IV at another site. Apply warm compresses as ordered by the primary care provider.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

The client donates his or her own blood.

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

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

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?

The nurse recognizes these symptoms of hypokalemia.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?

Verify the orders for type of solution and amount of infusion.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition?

Wheezes

a body with diarrhea is acidotic or alkadotic?

acidotic

when sleeping, is body acidotic or alkadotic?

acidotic

a body vomiting is acidotic or alkadotic?

alkadotic

when hyperventilating, is body acidotic or alkadotic?

alkadotic

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

Potassium is needed for neural, muscle, and:

cardiac function.

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?

cheese

A client's PaCO2 is abnormal on an ABG report. What is the most likely medical diagnosis?

chronic obstructive pulmonary disease (COPD)

A client has been admitted with fluid volume excess related to left-sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? Select all that apply.

crackles in the lungs distended neck veins

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

croup

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

While reading a physician's progress notes, a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find?

dyspnea, tachycardia, cyanosis

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

educating the client on the use of incentive spirometry

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:

fluid volume excess.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia.

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to:

increase her fluid intake to thin secretions.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

The home care nurse visits a client with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of:

infection.

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

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

nasal cannula

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

nasal cannula

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

The nursing instructor is teaching a nursing student about IV solutions. Which action by the nursing student requires the nursing instructor's intervention?

planning to use the solution one month after the expiration date

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

prolongs expiration to reduce airway resistance

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

pursed-lip breathing diaphragmatic breathing

Which nursing skill requires the nurse to use sterile technique?

suctioning a tracheostomy

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire