Saunders

The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL. How does the nurse interpret this setting?

1. It is the amount of air delivered with each set breath. 2. It is a breath that has a greater volume than the preset tidal volume. 3. It is the number of breaths that the client will receive per minute by the ventilator. 4. It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.

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

1. "I need to hold my skin flat before I put the needle into my skin." 2. "I need to massage the skin with the alcohol wipe after I give the injection." 3. "A syringe that has a small %-inch (1.5 cm) needle is used to administer the injection." 4. "I need to pull back on the syringe and aspirate before pushing the medication into my skin."

A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value?

1. Below therapeutic range 2. In excess of the therapeutic range 3. Near the top of the therapeutic range 4. In the middle of the therapeutic range

Atenolol has been prescribed for a client, and the client asks the nurse about the side effects of the medication. What should the nurse tell the client is an occasional side effect of this medication?

1. Dry skin 2. Flushing 3. Decreased libido 4.Increased blood pressure

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

1. Effectiveness of medication therapy 2. The deep breaths that the client is taking 3. Decreased inflammatory reaction at the site 4. Accumulation of pleural fluid in the inflamed area

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply.

1. Fatigue 2. Malaise 3. Anorexia 4. Weight gain 5. Dyspnea at rest

A client who has begun taking betaxolol demonstrates an effective response to the medication as indicated by which nursing assessment finding?

1. Increase in edema to 3+ 2. Weight gain of 5 pounds 3. Decrease in pulse rate from 74 beats/min to 58 beats/min 4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg

A client with pulmonary edema has a prescription to receive morphine sulfate intravenously. The nurse should determine that the client is experiencing an intended effect of the medication as indicated by which assessment finding?

1. Increased pulse rate 2. Relief of apprehension 3. Decreased urine output 4. Increased blood pressure

The nurse is providing medication information to a client who is beginning medication therapy with enalapril. The nurse should tell the client that which is an anticipated, although unpleasant, side effect of this medication?

1. Rapid pulse 2. Persistent dry cough 3. Increased blood pressure 4. Metallic taste in the mouth

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem?

1. Silence the alarm to avoid disturbing the client. 2. Check the ventilator circuit for any disconnections. 3. Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4. Empty excess accumulated water from the ventilatory circuit tubing.

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately?

1. Stridor 2. Lung congestion 3. Occasional pink-tinged sputum 4. Respiratory rate of 26 breaths/min

Which are possible causes of upper airway obstruction? Select all that apply.

1. Thin secretions 2. Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement

The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective?

1."Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." 2."Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." 3."Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." 4."Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle."

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

1.Anterior chest pain 2.Pericardial friction rub 3.Weakness and irritability 4.Chest pain that worsens on inspiration

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function?

1.Breath sounds 2.Peripheral edema 3.Hepatojugular reflux 4.Jugular vein distention

A client has begun using a methylxanthine bronchodilator. What beverage should the nurse plan to teach the client to avoid while taking this medication?

1.Coffee 2.Orange juice 3.Mineral water 4.Cranberry juice

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

1.Glipizide 2.Metformin 3.Repaglinide 4.Regular insulin

A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA) by infusion. Which parameter should the nurse determine requires the least frequent assessment to detect complications of therapy with tPA?

1.Neurological signs 2.Blood pressure and pulse 3.Presence of bowel sounds 4.Complaints of abdominal and back pain

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning?

1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Sitting up with elbows resting on knees 4.Lying on the back in a low Fowler's position

Which is the nurse's priority assessment for monitoring for adverse effects for the client taking isoniazid?

1.Skin color 2.Urine color 3.Hydration status 4.Respiratory effort

What should the nurse teach a client about an expected outcome of nesiritide administration?

1.The client will have an increase in urine output. 2.The client will have an absence of dysrhythmias. 3.The client will have an increase in blood pressure. 4.The client will have an increase in pulmonary capillary wedge pressure.

The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?

1.The development of complaints of insomnia 2.The development of audible expiratory wheezes 3.A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication 4.A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after 2 doses of the medication

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?

1.The skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. 4.Heart rate decreases from 78 to 54 beats/minute.

The nurse is auscultating a 56-year-old adult client's apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action should the nurse take?

1.Withhold the digoxin, and re-evaluate the heart rate in 4 hours. 2.Administer half of the prescribed dose to avoid a further decrease in heart rate. 3.Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. 4.Administer the digoxin; the heart rate would be considered normal because of the client's age.

Atenolol has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?

1."I need to rise slowly from a lying to a sitting position." 2."If I feel that my heart rate is too low, I should stop the medication." 3."It will take 1 to 2 weeks before my blood pressure becomes controlled." 4."I should avoid tasks that require alertness until I know how the medication will affect my body."

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement?

1."I will discard used tissues in a plastic bag." 2."I need to wash my hands at least 4 times a day." 3."I will brush my teeth and rinse my mouth once a day." 4."I will turn my head to the side if I need to cough or sneeze."

Atorvastatin has been prescribed for a client, and the client asks the nurse about the action of the medication. How should the nurse respond?

1."It increases plasma cholesterol." 2."It increases plasma triglycerides." 3."It decreases low-density lipoproteins (LDLs)." 4."It decreases high-density lipoproteins (HDLs)."

The nurse has given a client information about the use of nitroglycerin sublingual tablets. The client has a prescription for PRN (as needed) use if chest pain occurs. Which client statement indicates an understanding of this medication?

1."It's best to keep this medication in a shirt pocket close to the body." 2."I need to discard unused tablets 6 to 9 months after the bottle is opened." 3."I will avoid using the medication until the chest pain actually begins and gets worse." 4."I can take aspirin for any headache that occurs when I first start taking the nitroglycerin."

A client scheduled to take a subcutaneous anticoagulant at home says to the nurse, "I'm not sure I will be able to take this medication at home." Which statement by the nurse is appropriate?

1."Maybe your spouse can give you your shots." 2."You'll be fine once you get used to giving your own shots." 3."What are your concerns about taking this medication at home?" 4."Don't worry. Your health care provider knows what's best for you."

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?

1.A disconnection of the ventilator tubing 2.An exaggerated client inspiratory effort 3.Accumulation of respiratory secretions 4.Generation of extreme negative pressure by the client

A hospitalized client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin, gr 1/4 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure remains stable, the nurse should take which action next?

1.Administer another nitroglycerin tablet. 2.Administer 10 L of oxygen via nasal cannula. 3.Call for a 12-lead electrocardiogram (ECG) to be performed. 4.Wait an additional 5 minutes, and then give a second nitroglycerin tablet.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?

1.Ask a family member to stay with the client at all times. 2.Ask the health care provider for a prescription for succinylcholine. 3.Encourage the client to sleep until arterial blood gas results improve. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect?

1.Atelectasis and viral infection 2.Bronchoconstriction and stridor 3.Collapse of alveoli and decreased compliance 4.Decreased ciliary action and retained secretions

A client receiving oral theophylline is due to have a theophylline level drawn. The nurse should question the client to ensure that the client has not ingested which substance before the blood sample is drawn?

1.Coffee 2.Oatmeal 3.Ginger ale 4.Bagel with cream cheese

A client is seen in the clinic complaining of anorexia and nausea. The health care provider (HCP) suspects that the client may be experiencing digoxin toxicity. While waiting for test results to become available, the nurse should assess the client for which sign or symptom that would support a diagnosis of digoxin toxicity?

1.Edema 2.Chest pain 3.Constipation 4.Photophobi

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply.

1.Get plenty of rest. 2.Increase intake of liquids. 3.Take antipyretics for fever. 4.Get a flu shot immediately. 5.Eat fruits and vegetables high in vitamin C.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding?

1.Hypotension 2.Flat neck veins 3.Complaints of nausea 4.Complaints of headache

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

1.Inform the HCP. 2.Continue to monitor the client. 3.Reinforce the occlusive dressing. 4.Encourage the client to deep breathe.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?

1.It is painless and safe. 2.It causes only mild discomfort at the site. 3.It requires insertion of only a very small catheter. 4.It has an alarm to signal dangerous drops in oxygen saturation levels.

A client who has been receiving theophylline by the intravenous (IV) route has the medication prescription changed to an immediate-release oral form of the medication. After discontinuing the IV medication, when should the nurse schedule the first dose of the oral medication?

1.Just after the next meal 2.Just before the next meal 3.4 hours after discontinuing the IV form 4.Immediately on discontinuing the IV form

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option?

1.Maintain activity level as prescribed. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

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

1.Monitor for kidney failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4.Have heparin sodium available.

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg?

1.Monitor oxygen saturation with pulse oximetry. 2.Assess activity tolerance before and after exercise. 3.Observe the client's cardiac rhythm with telemetry. 4.Assess peripheral pulses with an ultrasonic Doppler device.

A client is taking a prescribed course of therapy with ethambutol. The home health nurse assesses the client at each home visit for which adverse effect of this medication?

1.Orange urine 2.Visual disturbances 3.Hearing disturbances 4.Gastrointestinal (GI) upset

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

1.Osteoarthritis 2.Hypothyroidism 3.Diabetes mellitus 4.Polycystic disease

Atenolol has been prescribed for a hospitalized client. The nurse should check which item before administering this medication?

1.Pedal pulses 2.Apical heart rate 3.Most recent potassium level 4.Most recent electrolyte levels

The nurse has been given a medication prescription to administer intravenous (IV) hydralazine. The nurse obtains which prioritypiece of equipment needed for use during administration of this medication?

1.Pulse oximetry 2.Cardiac monitor 3.Noninvasive blood pressure cuff 4.Nonrebreather oxygen face mask

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?

1.Rhonchi are auscultated. 2.Pleural friction rub is heard. 3.Fine crackles are auscultated. 4.Pulse oximetry reading is 96%.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect?

1.Sudden increase in appetite 2.Weight gain of 2 to 3 lb in a few days 3.Increased urine output during the day 4.Cough accompanied by other signs of respiratory infection

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction?

1.Take acetaminophen if the chest pain worsens. 2.Take antibiotics until the chest pain is fully resolved. 3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4.Notify all health care providers (HCPs) of the history of infective endocarditis before any invasive procedures.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?

1.The neurovascular status is normal because of increased blood flow through the leg. 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented?

1.The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2.The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3.The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4.The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.