Adults final exam questions
A client hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? A. "Oxygen use can improve your quality of life if used more than 15 hours per day" B. "Apply vaseline or petroleum jelly on lips and nose to prevent dryness and irritation" C. "Avoid use of a microwave oven when using your supplemental oxygen" D. "As long as you do not smoke, it is safe to go into areas where others are smoking cigarettes or cigars."
A. "Oxygen use can improve your quality of life if used more than 15 hours per day"
the nurse teaches a client information about transient ischemic attacks (TIAs). which statements made by the nurse is accurate? A. "it is important that you seek treatment for any stroke symptoms" B." if you experience a TIA you are at 50% risk of developing stroke" C. "symptoms from a transient ischmic attack last 24 hours or more" D. "there is no risk that you experience a TIA that you will have a stroke"
A. "it is important that you seek treatment for any stroke symptoms"
An hour after a left pleural chest tube is inserted for a hemopneumothorax, a client reports incisional pain at a "7" (based on 0 to 10 scale). Breath sounds are decreased on the left side, and the pleural drainage system has 100 mL of bloody drainage with a positive air leak. Which action should the nurse take? A. Administer prescribed pain medication B. milk the client tube to remove any clots C. Check tube patency by clamping tubing D. Drain the blood from the collection chamber
A. Administer prescribed pain medication
a client with left sided weakness that stared 60 minutes earlier is admitted into the ED and diagnostic tests are ordered. which test should be done first? A. computed tomography (CT) scan B. CBC C. 12 lead ECG D. chest x-ray
A. CT scan
A client diagnosed with a right-sided pneumothorax has continuous bubbling in the suction-control of a water suction collection device. Which action by the nurse is most important?? A. Continue to monitor the collection device B. Notify the surgeon of a possible hemopneumothorax C. Document the presence of an intermittent air leak D. Adjust the dial on the wall regulator
A. Continue to monitor the collection device
The nurse assess a client diagnosed with PAD. Which clinical manifestation swill the nurse expect to find? (select all that apply) A. decrease hair growth on toes B. brownish "brawny" colored skin C. pallor with extremity elevation D. edema around ankles and feet E. scaling eczema of lower legs
A. Decreased hair growth on toes C. Pallor with extremity elevation
A client diagnosed with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the clients ventilation? A. Encourage the client to sit up at the bedside in a chair and lean forward B. Have the client rest in bed with the head elevated 15 to 20 degrees C. Place the client in Trendelenburg position with pillows behind the head D. Ask the client to rest in bed in a high-Fowler's position with the knees flexed
A. Encourage the client to sit up at the bedside in a chair and lean forward
A registered nurse (RN) is performing a nasopharyngeal swab for influenza. Which action would indicate POOR technique? A. Insert, gently rotate, and immediately remove swab B. support client's head to reduce tendency to pull away during procedure C. Place swab into transport container after collection D. Insert swab straight back along floor of nasal passage
A. Insert, gently rotate, and immediately remove swab
The clinic nurse makes a follow-up telephone call to a client diagnosed with asthma. The client reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first? A. Instruct the client to use prescribed albuterol (Ventolin HFA) B. Ask about recent exposure to any new allergens or asthma triggers C. Tell the client to go to the hospital emergency department D. Question the client about use of the prescribed inhaled corticosteroids
A. Instruct the client to use prescribed albuterol (Ventolin HFA)
The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the healthcare provider? A. Oxygen saturation of 88% on room air B. Respiratory rate of 24 breaths/minute when lying flat C. Blood pressure of 135/90 mmHg D. Pain level of "5" (on 0 to 10 scale) with deep breaths in
A. Oxygen saturation of 88% on room air
Which factors will the nurse consider when calculating the CURB-65 score for a client with pneumonia? SELECT ALL THAT APPLY A. Respiratory Rate B. Blood pressure C. Blood urea nitrogen (BUN) D. Oxygen Saturation E. Presence of confusion
A. Respiratory Rate B. Blood pressure C. Blood urea nitrogen (BUN) E. Presence of confusion
A client develops a left tension pneumothorax after insertion of a central venous catheter. Which will the nurse expect to find? A. Right tracheal deviation B. Bradycardia C. Hypertension D. Client reports pain with exhalation
A. Right tracheal deviation
A client newly diagnosed with persistent asthma with recurring attacks is being discharged. Which topic should the nurse anticipate in the discharge teaching? A. Self-administration of inhaled corticosteroids B. Side effects of sustained-release theophylline C. Use of long-acting B-adrenergic medications D. Complications associated with oxygen therapy
A. Self-administration of inhaled corticosteroids
A client having an acute asthma attack is in a state of panic. Which intervention should the nurse implement? A. Utilize the "talk-down" approach B. Use music or television as a distraction C. Lay the client down in a suing position D. Use intravenous (IV) sedation
A. Utilize the "talk-down" approach
A client diagnosed with asthma is scheduled for spirometry testing. Which action should the nurse take to prepare the client for this procedure? A. Withhold bronchodilators for 6 to 12 hours before the examination B. Give the rescue medication immediately before testing C. Ensure that the client has been NPO for several hours before the test D. Administer oral corticosteroids two hours before the procedure
A. Withhold bronchodilators for 6 to 12 hours before the examination
which clients are at risk for ischemic stroke (select all that apply) A. a client diagnosed with hypertension B. a client diagnosed with pneumothorax C. an 87 year old client D. a client diagnosed with type 2 diabetes E. an African American client
A. a client diagnosed with hypertension C. an 87 year old client D. a client diagnosed with type 2 diabetes E. an African American client
A client diagnosed with bacterial pneumonia has coarse and thick sputum. Which action should the nurse plan to promote airway clearance? A. assist client to splint their chest when coughing B. Teach pursed-lip breathing technique C. Encourage client to wear nasal O2 cannula D. Restrict oral fluids throughout the day
A. assist client to splint their chest when coughing
The nurse cares for a client after peripheral artery bypass surgery. Which is a priority action 24 hours postnop? A. assist client with ambulation four to six times throughout the day B. assist the client to sit in a chair with legs in a dependent position C. place client in side-lying position with both knees in a flexed position D. maintain bedrest with both legs elevated on pillows
A. assist client with ambulation four to six times throughout the day
a left handed client with left sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? A. assist the client to eat with the right hand B. provide a wide variety of food choices C. provide oral care before and after meals D. teach the client "chin-tuck" technique
A. assist the client to eat with the right hand
the 70 year old female client with left sided hemiparesis arrives by ambulance to the ED. which action should the nurse take first? A. check the respiratory rate and effort B. send the client for a CT scan C. take the clients BP D. assess the Glasgow coma scale
A. check RR and effort
a client is receiving IV heparin following a diagnosis of PE. the nurse notes that the client has purplish color to their fingertips, and the platelet count is 15,000mm3. which action should the nurse take? A. discontinue the heparin and notify provider B. request an order for idarucizumb (pracbind) C. administer oxygen and notify the provider D. request an order for vitamin K
A. discontinue the heparin and notify provider
a client is prescribed with an IV infustion of 5% dectrose in water. The nurse observes that the skin around the IV infusion side is red, warm to touch, and painful. Which priority action should the nurse take? A. discontinue the peripheral IV catheter B. Place a warm compress on the area C. change the D5W to 0.9% normal saline D. administer oral acetaminophen
A. discontinue the peripheral IV catheter
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds
A. hypertension
the nurse cares for a client diagnosed with acute arterial ischemia. which clinical manifestation will the nurse expect to observe? (select all that apply) A. pain B. pallor C. petechiae D. paresthesia E. Pruitus
A. pain B. pallor D. paresthesia
A client diagnosed with PAD has an ulcer on their right second toe. Which finding would the nurse expect to see with an arterial ulcer? A. pale, pink granulation B. serosangeous drainage C. dilated superficial veins D. dry scaly, skin around ankles
A. pale, pink granulation
The nurse reviews information collected by a client diagnosed with asthma. Which findings would indicate the client's asthma is being well controlled? Select all that apply A. Nighttime awakenings occurring two or less times per week B. Symptoms occurring two or less days per week C. Peak flow meter greater than 80% of personal best D. Use of short acting B2 agonist (SABA) two or less days per week E. No interference with normal activities of daily living (ADLs)
All are correct A. Nighttime awakenings occurring two or less times per week B. Symptoms occurring two or less days per week C. Peak flow meter greater than 80% of personal best D. Use of short acting B2 agonist (SABA) two or less days per week E. No interference with normal activities of daily living (ADLs)
Which instruction should the nurse include in an exercise teaching plan for a client diagnosed with chronic obstructive pulmonary disease (COPD)? A. "Avoid upper body strength training exercise, as this will make your breathing more difficult and increase shortness of breath" B. "Walking combined with strength training are the best ways to strengthen muscles and improve activity endurance" C. "It is not recommended that clients diagnosed with chronic obstructive pulmonary disease (COPD) perform physical exercise of any kind" D. "If it takes longer than two minutes to return to baseline, you need to proceed at a slower pace during the next exercise period."
B. "Walking combined with strength training are the best ways to strengthen muscles and improve activity endurance"
Which is a priority question for the nurse to ask during a PAD assessment? A. "do you get dizzy when getting out of bed?" B. " do you have leg pain when walking?" C. "do you have SOB at night?" D."do your feet swell at the end of the day?"
B. "do you have leg pain when walking?"
a client with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. which response by the nurse is accurate? A. "a catheter with a deflated balloon is positioned at the narrow area and the balloon is inflated to flattened the plaque" B. "the obstruction plaque is surgically removed from inside an artery in the neck" C. " the diseased portion of the artery in the brain is replaced with a synthetic graft" D. "a wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed"
B. "the obstruction plaque is surgically removed from inside an artery in the neck"
The nurse monitors a client in the emergency department with a chest tube for a hpmopnemothorax. Which assessment finding would most concern the nurse? A. A large air leak in the water-seal chamber B. 400 mL of blood noted one hour after insertion C. Subcutaneous emphysema at the insertion site D. Reports of pain with each deep
B. 400 mL of blood noted one hour after insertion
Which client(s) are at increased risk to develop influenza? Select all that apply A. 24-yr-old client with allergies to penicillin and cephalosporin B. 42-yr-old client who has been diagnosed with an autoimmune disorder C. 36-yr-old client who is seven months pregnant D. 76-yr-old client who resides at a nursing home E. 30-yr-old client who cross country skis
B. 42-yr-old client who has been diagnosed with an autoimmune disorder C. 36-yr-old client who is seven months pregnant D. 76-yr-old client who resides at a nursing home
The nurse prepares to administer pneumoccal conjugate vaccine (Preener 13) to a 72 year old client. Which criteria would prevent the client from receiving the vaccine? A. A client on warfarin (Coumadin) with an International Normalized Ratio (INR) or 2.1 seconds B. A temperature of 101.2°F (38.4°C) in the last 12 hours C. Currently hospitalized on the surgical unit recovering from an appendectomy D. Currently hospitalized with heart failure (HF), but prognosis is improving
B. A temperature of 101.2°F (38.4°C) in the last 12 hours
A client has just been admitted with bacterial pneumonia and sepsis. The client is unable to provide a sputum sample. Which action should the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg oral tablets B. Administer ciprofloxacin (cipro) 400mg IV C. Request respiratory therapy administer a nebulizer treatment D. Send the client to radiology for chest X-ray
B. Administer ciprofloxacin (cipro) 400mg IV
The nurse reviews the medication administration record (MAR) for a client having an acute asthma attack. Which medication should the nurse administer first? A. Salmeterol (Serevent) 50 mpg per dry-powder (DPI) B. Albuterol (Ventolin HFA) 2.5 mg per nebulizer C. methylprednisolone (Solu-Medrol) 60 mg IV D. ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
B. Albuterol (Ventolin HFA) 2.5 mg per nebulizer
The nurse is caring for a client diagnosed with cor pulmonale. The nurse should monitor the client for which expects finding? A. Finger clubbing B. Peripheral edema C. chest pain D. elevated temperature
B. Peripheral edema
The nurse teaches a client diagnosed with asthma about pursed-lip-breathing. Which action by the client would indicate to the nurse that further teaching is needed? A. Ratio of inhalation to exhalation is 1:3 B. Puffs up their cheeks- while exhaling C. Inhales slowly through the nose D. Practices by blowing through a straw
B. Puffs up their cheeks- while exhaling
A client diagnosed with chronic obstructive disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? A. Change the oxygen flow rate to the highest prescribed rate B. Teach the client to use the Flutter airway clearance device C. Reinforce the ongoing use of pursed lip breathing techniques D. Teach the client about consistent use of inhaled corticosteroids
B. Teach the client to use the Flutter airway clearance device
The client with right lower-lobe pneumonia has been treated with IV antibiotics for three days. Which assessment data obtained by the nurse indicates that the treatment is effective? A. The client coughs up small amounts of green mucus B. The client's white blood cell (WBC) count is 9000/uL C. Bronchial breath sounds are heard at the right base D. Increased tactile remits is palpable over the right chest
B. The client's white blood cell (WBC) count is 9000/uL
Which information will the nurse include in the asthma teaching plan for a client being discharged? A. "Use mometasone (Asmanex Twisthaler) when you first start experiencing asthma symptoms." B. Tremors are an expected side effect with albuterol (Ventolin HFA)." C. "Hold your breath for two to three seconds after using ciclesonide (Alvesco) meter-dosed inhaler (MDI)." D. "Inhale slowly and deeply when using fluticasone (Flovent Diskus) dry powder inhaler (DPI)
B. Tremors are an expected side effect with albuterol (Ventolin HFA)."
after receiving charge of shift report on the following four clients, which client should the nurse see first? A. a 40 year old client who experienced a transient ischemic attack yesterday who has a dose of aspirin due. B. a 60 year old client with right sided weakness who has an infusion of tPA C. a 30 year old client with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled D. a 50 year old client who has a. fib and new order for warfarin
B. a 60 year old client with right sided weakness who has an infusion of tPA
which client is most at risk to develop a PE? A. client diagnosed with infective endocarditis of the aortic valve? B. client diagnosed with an active deep vein thrombosis in the right leg C. client diagnosed with left ventricular myocardial infarction (MI) D. client diagnosed with pleural effusion requiring chest insertion
B. client diagnosed with an active deep vein thrombosis in the right leg
a male client who has right sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activites. the nurse observes that when the client's wife is visiting , she feeds and dresses him. which nursing diagnosis is most appropriate for the client? A. impaired nutrition less than body requirements related to hemiplegia and aphsia B. disabled family coping related to inadequate understanding by clients spouse C. interrupted family processes related to effects of illness of a family member D. situational low self esteem related to increasing dependence of spouse for care.
B. disabled family coping related to inadequate understanding by clients spouse
a client with a DVT suddenly develops dysonea, tachypnea, and chest discomfort. Which action should the nurse take first? A. Encourage the client to cough and deep breathe B. elevate HOB C. contact the healthcare provider D. administer IV morphine sulfate
B. elevate HOB
when caring for a client with a new right sided homonymous hemianopsia resulting from a stroke, which interventions should the nurse include in the plan of care? A. apply an eye patch to the right eye B. place needed objects on the client's left side C. approach the client from the right side D. teach the client that the left visual deficit will resolve
B. place needed objects on the clients left side
a client is diagnosed with a right hemisphere stroke. Which clinical manifestation would the nurse expect to find based on this diagnosis? A. ineffective coping related to depression and distress about disability B. risk for injury related to denial of deficits and impulsiveness C. impaired verbal communication related to speech language deficits D. impaired physical mobility related to right sided hemiplegia
B. risk for injury related to denial of deficits and impulsiveness
which is an appropriate food for a client with a stroke who has mild dysphagia? A. fruit juice B. scrambled eggs C. fortified milkshakes D. pureed meat
B. scrambled eggs
a client is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? A. the client reports that symptoms began with a severe headache B. the client has A. fib C. the client has dysphasia D. the client has a history of brief episodes of right sided hemiplegia
B. the client a fib
which information about the client who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? A. the client reports a severe and unrelenting headache B. the clients BP is 90/50 C. the CSF report shows RBC's D. the client reports having a stiff neck
B. the clients BP is 90/50
the home health nurse is caring for an 81 year old who had a stroke 2 months ago. Based on the information shown in the accompanying figure from the history, physical assessment and physical and occupational therapy, which problem is the highest priority? history: well controlled type 2 diabetes for 10 years. married 45 years, spouse has heart failure and chronic obstructive pulmonary disease. Physical assessment: oriented to time, place and person. speech clear. minimal left leg weakness. PT/OT: uses cane with walking. spouse does household cleaning and cooking and assists patient with bathing and dressing. A: impaired transfer ability B: risk for caregiver role strain C: ineffective health maintenance D:risk for hypoglycemia
B: risk for caregiver role strain
The nurse teaches a client diagnosed with pneumonia. Which statement by the client indicates a good understanding of the discharge instructions? A. "I will schedule separate appointments for the pneumonia and influenza vaccines" B. "I will cancel my follow up chest x-ray appointment if i feel better next week" C. "I will continue to do deep breathing and coughing exercises at home" D. I will call my healthcare-provider if I feel tired after one week
C. "I will continue to do deep breathing and coughing exercises at home"
A client is suspected of having influenza. Which assessment data obtained by the nurse would support this diagnosis? A. Temperature of 99.1°F B. Purulent nasal discharge C. Abrupt onset of symptoms D. Mild, localized, muscle aches
C. Abrupt onset of symptoms
The nurse completes an admission assessment on a client diagnosed with asthma. Which information from their home medication list indicates a need for a change in therapy? A. Client is prescribed albuterol (Ventolin HFA) and bubesonide (Pulmicort Flexhaler) B. Client is prescribed albuterol (Ventolin HFA) and theophylline (Theo-24) C. Client is prescribed albuterol (Ventolin HFA) and salmeterol (Serevent) D. Client is prescribed albuterol (Ventolin HFA) and montelukast (Singulair)
C. Client is prescribed albuterol (Ventolin HFA) and salmeterol (Serevent)
Which assessment finding in a client prescribed omalizumab (Xolair) subcutaneously (SQ) for asthma would need to be reported immediately to the healthcare provider? A. Pain at injection site B. Peak flow reading 75% of normal C. Flushing and hives D. Respiratory rate 24 breaths/minute
C. Flushing and hives
Postural drainage with percussion and vibration is ordered twice daily for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care? A. Schedule the procedure one hour after the client eats B. Maintain the client in the lateral position for 20 minutes C. Give the prescribed albuterol (Ventolin HFA) before the therapy. D. Perform percussion after assisting the client to the drainage position
C. Give the prescribed albuterol (Ventolin HFA) before the therapy.
A client diagnosed with pneumonia has a fever of 101.4°F (38.6°C), a non productive cough, and an oxygen saturation of 88% on room air. The client reports weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? A. Ineffective airway clearance related to thick secretions B. Impaired transfer ability related to weakness C. Impaired gas exchange related to respiratory congestion D. Hyperthermia related to infectious illness
C. Impaired gas exchange related to respiratory congestion
The nurse assesses the chest of a client diagnosed with consolidated pneumococcal pneumonia. Which finding would the nurse expect? A. pleural friction rub B. Hyperresonance to percussion C. Increased tactile remits D. Dry, nonproductive cough
C. Increased tactile remits
A client diagnosed with chronic obstructive pulmonary disease (COPD) is receiving 35% oxygen via a Venturi mask. Which action by the nurse is appropriate for the care of this equipment? A. Drain moisture condensation from the corrugated tubing every hour. B. Give a high enough flow rate to keep the bag from collapsing C. Keep air entrainment ports clean and unobstructed D. Wash and dry under the mask every eight hours
C. Keep air entrainment ports clean and unobstructed
A client is admitted to the emergency department for an acute asthma exacerbation. Emergency Medical Technicians (EMTs) report the client is tachycardic, tachypnic, and has both inspiratory and expiratory wheezing. On assessment the nurse notes that there is no wheezing but the client is still struggling to breathe. Which action should the nurse implement first? A. Administer IV methylprednisolone (Solu-Medrol) B. Document changes in respiratory status C. Notify the healthcare provider D. Encourage the client to cough and deep breath
C. Notify the healthcare provider
A client diagnosed with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the client for the procedure? A. Remind the client not to eat or drink anything for six hours B. Obtain a collection device to hold three liters of pleural fluid C. Position the client sitting up on the side of the bed D. Start a peripheral IV line to administer sedatives
C. Position the client sitting up on the side of the bed
A client is admitted to the emergency department (ED) with an open stab wound to the left chest. Which action should the nurse take? A. Keep the head of the client's bed positioned flat B. Position the client so that the left chest is dependent. C. Tape a nonporous dressing on three sides over the wound D. Cover the wound tightly with an occlusive dressing
C. Tape a nonporous dressing on three sides over the wound
The home health nurse is visiting a client diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implementation for a nursing diagnosis of impaired breathing pattern related to anxiety? A. suggest the use of over-the-counter sedative medications B. Titrate oxygen to keep saturation at least 90% C. Teach the client how to use pursed-lip breathing D. Discuss a high-protein, high-calorie diet with the client
C. Teach the client how to use pursed-lip breathing
A client diagnosed with influenza A is prescribed oseltamivir (Tamiflu) five days after developing symptoms. Which statement is the MOST appropriate for the nurse to make when teaching the client about this medication? A. The medication will alleviate symptoms within 24 hours of taking the first dose B. It's safe to take this medication and receive the influenza vaccine at the same time C. This medication may not be effective because of the delay in starting treatment D. Do not take this medication if you have a lactose food allergy
C. This medication may not be effective because of the delay in starting treatment
The nurse teaches a client diagnosed with asthma about peak flow meter use. Which action by the client indicates that teaching was successful? A. Takes montelukast (Singular) for peak flows in the red zone B. Calls the healthcare provider when the peak flow is in the green zone C. Uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. D. Inhales rapidly through the peak flow meter mouthpiece
C. Uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
a63 year old clients who began experiencing right arm and leg weakness is admitted into the ED in which order will the nurse implement these actions included in the stroke protocol? A. obtain CT scan without contrast B. infuse tPA C. administer O2 D. perform baseline neuro assessment
C. administer O2 D. perform baseline neuro assessement A. obtain CT B. infuse tPA
a female client who had a stroke 24 hours ago has expressive aphasia. Which is an appropriate nursing intervention to help the client communicate? A. develop a list of words that the client can read and practice reciting B. have the client practice her facial and tongue exercises with a mirror C. ask questions that the client can answer with "yes" or "no" D. prevent embarrassing the client by answering for her if she does not respond
C. ask questions that the client can answer with "yes" or "no"
the nurse assess the lower extremities of a client diagnosed with chronic venous insufficiency (CVI) which clinical manifestations will the nurse expect to observe? A. brittle toenails B. cap refill > 3 seconds C. brawny skin color D. absent pedial pulses
C. brawny skin color
The nurse receives change-of-shift report on the following clients diagnosed with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? A. Client with a productive cough of thick green mucous B. Client with bilateral lower peripheral edema C. client with a respiratory rate of 38 breaths/min D. Client with loud expiratory wheezes
C. client with a respiratory rate of 38 breaths/min
The nurse cares for a client abdominal surgery. The reports a feeling of "fullness" in their right leg. Which is the priority action for the nurse to take? A. review the medication administration record (MAR) B. measure the circumference of the right and left leg C. compare skin temperature of right and left foot D. assess for pain with deep palpation of right leg
C. compare skin temperature of right and left foot
The nurse cares for a client diagnosed with varicose veins. Which will the nurse expect the client to report? A. decreased hair growth of the leg B. shooting pains down the leg C. dull pain relieved by walking D. thickened toe nails
C. dull pain relieved by walking
The nurse cares for a client diagnosed with an embolic stroke. Which is the nurse most likely to observe? A. RR 28/min B. BP 96/48 C. irregular heart rhythm 152 BPM D. blood glucose 60 mg/dL
C. irregular heart rhythm 152 bpm
The nurse reviews ankle brachial index readings on a client at risk for right lower extremity PAD, right ankle systolic pressure equals 140 mmHG. Brachial systolic pressure equlas 120 mmHG. Which is the best interpretation of the results? A. severer RLE arterial disease B. non-compressible arteries in RLE C. normal RLE arterial blood flow D. mild RLE arterial disease
C. normal RLE arterial blood flow
the nurse cares for a client with superficial vein thrombosis of the left leg. which clinical manifestation will the nurse expect to find on assessment? A. generalized edema B. cool skin temperature C. palpable, cordlike vein D. brawny, leathery skin
C. palpable cordlike vein
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.
C. the patients usual BP is 170/94
What information should the nurse include in a teaching plan for a client newly diagnosed with chronic obstructive pulmonary disease (COPD)? A. "Pulmonary rehabilitation programs offer very little benefit" B. "If you quit smoking, your lungs will heal and you will no longer have COPD" C. "Pneumococcal vaccination is contraindicated for clients with lung disease" D. "A bronchodilator with metered-dose inhaler should be readily available"
D. "A bronchodilator with metered-dose inhaler should be readily available"
a client diagnosed with cerebral atherosclerosis is prescribe clopidogrel (Plavix). which statements will the nurse include when teaching the client about this medication? A. "this medication will dissolve clots in the cerebral arteries" B. "this medication will reduce cerebral artery plaque formation" C. "monitor and record you BP daily" D. "Call you health care provider if stools look tarry"
D. "Call you health care provider if stools look tarry"
The nurse provides dietary teaching for a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which client statement indicates that the teaching has been effective? A. "I will decrease my intake of meat and poultry" B. " I will drink lots of fluids with my meals" C. "I will exercise for 15 minutes before meals" D. "I can have ice cream as a snack every day"
D. "I can have ice cream as a snack every day"
a client will attempt oral feedings for the first time after having a stroke. which action should should the nurse take after assessing the gag reflex? A. order a varied pureed diet B. assess the client's appetite C. offer the client a sip of juice D. assist the client into a chair
D. Assist the client into a chair
A client with severe chronic obstructive pulmonary disease (COPD) tell the nurse. "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? A. Complicated grieving related to expectation of death B. Deficient knowledge related to lack of education about COPD C. Ineffective coping related to unknown outcome of illness D. Chronic low self-esteem related to physical dependence
D. Chronic low self-esteem related to physical dependence
The nurse obtains the following assessment data on an older client diagnosed with influenza. Which information will be MOST important for the nurse to communicate to the healthcare provider? A. Fever of 100.4°F (38°C) B. Myalgia and persistent headache C. sore throat and frequent cough D. Diffuse crackles in the lungs
D. Diffuse crackles in the lungs
The charge nurse observes a new nurse care for a client with a wet chest tube system. Suction is set at -20 cm of H2O. An air leak is present. Which action by the new nurse requires immediate intervention by the charge nurse? A. Instructs client to use incentive spirometry ever hour while awake B. Increases wall suction until gentle bubbling is present in suction control chamber C. Ambulates client to bathroom while maintaining continuous wall suction D. Elevates drainage system above insertion site to check drainage
D. Elevates drainage system above insertion site to check drainage
The nurse cares for a client diagnosed with a pleural effusion. Documentation states, "Chest tube to -20cm of pressure. Tidaling present. No air leak noted." Which is the best interpretation of this statement? A. The water seal chamber needs sterile water added B. The affected lung has fully expanded C. A leak is present around the chest tube insertion site D. Fluid is still present in the pleural space
D. Fluid is still present in the pleural space
When assessing a client who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. Which intervention is most appropriate for the nurse to take? A. Prepare for emergency thoracentesis B. Administer a short-acting bronchodilator (SABA) C. Instruct the client on the use of incentive spirometry D. Prepare for chest tube insertion
D. Prepare for chest tube insertion
a client has a ruptured cerebral aneurysm and subarachnoid hemorrhage. which intervention will the nurse include in the plan of care? A. assist to dangle on the edge of the bed and assess for dizziness B. insert orophayngeal airway to prevent airway obstruction C. encourage patient to couch and deep breathe every 4 hours D. apply intermittent pneumatic compression stockings
D. apply intermittent pneumatic compression stockings
A client diagnosed with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the client, which clinical manifestation will the nurse expect first? A. right sided neglect B. impulsive behavior C. hyperactive left sided tendon reflexes D. difficulty comprehending instructions
D. difficulty comprehending instructions
The nurse in the emergency department receives arterial blood gas results for four recently admitted clients diagnosed with obstructive pulmonary disease (COPD). Which result requires rapid action by the nurse? A. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg B. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg D. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
D. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
The nurse cares for a client diagnosed with PAD. Which intervention is most appropriate to implement for pain control? A. wrap a moist heat source around the right leg B. elevate legs so they are above heart level C. Apply TEDS D. place bed in the reverse trandleneburg position
D. place bed in reverse trandelenburg position
a client arrives in the ED with hemiparesis and dysarthia that started 2 hours previously and health records show a history of several transient ischemic attacks (TIAs). the nurse anticipates preparing the client for which procedure? A. transluminal angioplasty B. surgical endartercotomy C. IV heparin drip administration D. tPA infusion
D. tPA infusion
the nurse is caring for a client who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A. BP is 144/86 B. there are fine crackles at the lung bases C. the pulse is 102 D. the client has difficultly speaking
D. the client has difficulty speaking
A 55 year old male weighing 115 kg has a hisotyr of tobacco use, high BP and sedentary lifestyle. Which factor indicated risk for PAD? A. sedentary lifestyle B. high BP C. excess weight D. tobacco use
D. tobacco use
a client is being treated for DVT. the provider has prescribed 60mg of enoxaparin (lovanox) SQ. before administering the medication, the nurse checks the clients lab results. Which is most appropriate action for the nurse to take? PTT 12.5 seconds INR 2 seconds platelet count 15,000 A. contact the pharmacist for a lower dose of the medication B. administer medication as prescribed by the provider C. assess the client for signs of bruising on the extremities D. withhold the dose of medication and contact the provider
D. withhold the dose of medication and contact the provider
What is the best method for assessing circulation in a client after peripheral bypass surgery? (in picture form)
Doppler pedal pulse
a client in the ED with sudden-onset right sided weakness is diagnosed with an intracerebral hemorrhage. which information is most important to communicate to the health care provider? A. the clients BP is 144/90 B. the client takes a diuretics because of a history of hypertension C. the client has a. fib and takes warfarin D. the clients speech is difficult to understand
`C. the client has a.fib and takes warfarin
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.
b. Assist the patient onto the bedside commode every 2 hours.
