PN2 exam 1

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain?

Occupation and hobbies

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.)

Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders c. Checks for correct placement by checking the pH of the fluid aspirated from the tube e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)

Phlebitis Thrombophlebitis

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority?

Place the client in a high-Fowlers position.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?

Place warm compresses on the site

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?

Prepare to administer dextrose 20% and 10 units of regular insulin IV push

.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Report of headache and stiff neck

After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching?

Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)

Serum potassium of 2.8 mEq/L c. Abdominal pain in upper quadrants e. Serum sodium of 121 mEq/L

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?

Severe, steady right lower quadrant pain

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?

Share any thoughts and feelings that cause you to limit social activities. Friends can be a good support system for clients with chronic disorders.

A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

Sodium bicarbonate 100 mEq diluted in 1 L of D5W

A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

Stop the infusion of intravenous fluids

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

Stridor d. Ecchymosis behind the ear

After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.

Strong productive cough d. Active bowel sounds

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

Teach the client fall prevention measures.

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

infection

nurse reviewing prescription for client with bowel obstruction. which actions should nurse expect to take?

insert nasogastric tube, pt NPO, administer IV fluids

nurse is caring for elderly client with UTI. which findings are specific to this clients condition?

loss of appetite, incontinence, confusion

post operative following abdominal surgery. what indicates peristalsis returning?

passage of flatus

urine is cloudy and has an unpleasant odor

pt has urinary tract infection

client diagnosed with hyponatremia. findings that nurse should be concerned with

shallow respirations, lethargy, coma

A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care?

skin protection

teaching client who is preoperative for a colectomy. client asks nurse why he needs an NG tube

tube is used to decompress gas and fluid from your stomach and allow bowels to rest

client admitted with respirations 6/min, ABGs drawn and reveal following: PH7.22

uncompensated respiratory acidosis

A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority?

Assess the clients oxygenation

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

Assess the clients respiratory rate, rhythm, and depth

A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to

16 drops/min

a nurse is preparing to administer IV ciprofloxacin 500 mg

200

change of shift report for clients, who should you assess?

29 year old with colon resection yesterday. foley catheter removed 12 hours ago

A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? ( Record your answer using a whole number. ) ____ mL/hr

41.6 mL/hr. (42 is the answer)

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 pounds overweight

.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin?

ANS: D (10-mL syringe picture)

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Absent breath sounds

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client?

Add vegetables such as broccoli and cauliflower to your new diet

A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first?

Administer intravenous fluids.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

Administer pain medication and encourage the client to take deep breaths.

A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety?

Agree on a postoperative communication method.

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.

Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?

Assess the clients bowel sounds.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?

Assess the clients gag reflex before giving any food or water.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?

Assess the clients gag reflex.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the clients oxygen saturation

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

Anxiety-induced hyperventilation

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

Apply oxygen by mask or nasal cannula

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?

Ask all providers to vigorously clean the connections prior to accessing the device.

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take?

Ask the health care provider to prescribe the medication as an enema instead

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

Ask the spouse to explain the fear of visiting in further detail.

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

Assess clients rate, rhythm, and depth of respiration

A nurse assesses a clients oral cavity and observes the condition depicted in the photo below: What action by the nurse is best?

Assess the client for dysphagia

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?

Avoid carrying your grandchild with the arm that has the central catheter.

A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond?

Berries, cherries, apples, and peaches are low in potassium

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?

Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

Cardiac rate and rhythm

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.)

Chocolate Citrus fruits Peppermint Tomato sauce

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds. Nurse calls physician immediately.

A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist?

Client who smokes and drinks daily

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?

Client with pancreatitis who has continuous nasogastric suctioning

A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.

Coal miner Metal worker Plumber Textile worker

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Contact the provider and prepare for intubation

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?

Cover the insertion site with sterile gauze

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

Depth of respirations

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?

Do you experience shortness of breath with basic activities?

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching?

Eat a well-balanced, nutritious diet

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)

Electrocardiogram changes d. Paralytic ileus e. Skeletal muscle weakness

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Ensure an x-ray is completed to confirm placement.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find?

High-pitched, rushing bowel sounds in the right lower quadrant

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.

Hypertension c. Leukemia d. Cocaine use

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching?

I will take this medication every morning to help prevent an acute attack.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

I will take this medication on an empty stomach.

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

I will take this medication with my breakfast each morning

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)

Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?

Increased rate and depth of respirations

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Initiate Standard Precautions.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?

Intact skin behind the ears

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond?

It is important to use this type of inhaler every day. Lets identify potential community services to help you.

A nurse cares for a client with ulcerative colitis. The client states," I feel like I am tied to the toilet." This disease is controlling my life. How should the nurse respond?

Lets discuss potential factors that increase your symptoms.

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)

Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cance

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

Metabolic alkalosis

pt admitted for gastrointestinal bleed due to diverticulitis and is complaining of severe nausea and vomiting. what orders should the nurse expect

NPO, low fiber diet, 0.9% NS continuous infusion, NG tube to suction, clear liquid diet

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?

Notify the provider immediately.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is deviated toward the opposite side of the neck.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?

This medication will promote daytime wakefulness.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)

Tracheal deviation c. Sudden onset of shortness of breath

.A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

Upper extremity swelling is noted.

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)

Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Validate that informed consent has been given by the client

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?

heart rate and rhythm

nurse is caring for a child with suspected appendicitis. which prescription should the nurse question?

administer a sodium biphosphate/sodium phosphate laxative.

acute episode of gastritis. what teaching is needed

avoid alcohol

nurse is assessing pt who complains of muscle cramps and paresthesia in his hands and feet. a positive chvostek is associated with what electrolyte disorder?

hypocalcemia

After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?

c. I take sodium bicarbonate after every meal to prevent heartburn

potential cause of the acid base imbalance of metabolic alkalosis

client with diarrhea, NG tube low intermittent suction

male diagnosis of urolithiasis. nurse expect: SATA

flank pain, nausea vomiting, testicular/scrotal pain

UTI with urinary retention

frequent voiding of smaller amounts

nurse is caring for a client whose ABGs show PH 7.36, HCO3 of 30

fully compensated respiratory acidosis

nurse is caring for a client with diverticular disease. what is indication of gastrointestinal perforation

general abdominal pain, fever, bradycardia, chiles,