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CardiUh Oh 3

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The clinic nurse is giving discharge instructions to the mother of a 12-year-old boy who has been diagnosed with a mild cold. Which statements by the mother demonstrate knowledge of care? (Select all that apply.) a. "He will be receiving an antibiotic, correct?" b. "I will be sure he drinks plenty of apple and orange juice." c. "If he runs a fever, I will give him 2 aspirin every 4 hours until his fever comes down." d. "I will be sure he washes his hands well so he doesn't pass this on to his younger sister." "Since his cold just started, zinc lozenges are a good idea for him to take."

" ANS: B, D, E Citrus juices and zinc lozenges are helpful in limiting the duration and severity of a cold. Hand hygiene helps prevent the spread of the virus. Antibiotics are not used for colds (because colds are viral in etiology) unless a secondary infection is present or there is an increased risk for a secondary infection. Aspirin should not be given to children under age 12 due an increased risk for Reye's syndrome.

Stage 3 lung cancer

-lung cancer stage 3b: to lymph node and opposite side

. The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask, which: 1. delivers constant positive pressure to keep the airway open. 2. requires the patient to be intubated. 3. delivers oxygen only when a patient becomes apneic. 4. delivers negative pressure to stimulate respiration.

The prime causative organisms for the infection causing sinusitis are: (Select all that pneumococci. Pseudomonas. staphylococci. Haemophilus influenzae. streptococci.

1, 4, 5 ANS: The common organisms causing sinusitis are pneumococci, Haemophilus influenzae, and streptococci.

The signs the nurse would expect to see in a patient with advanced emphysema are: (Select all that apply.) Productive cough 2. dyspnea. 3. barrel chest. 4. wheezing 5. cyanotic skin tone

1235 The emphysemic has a barrel chest and dyspnea. There is minimal coughing and mucus production until late in the disease. Wheezing usually does not occur in the emphysemic patient. Cyanosis is usually absent until late in the disease when the patient becomes hypoxic.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? 1. The platelet count is 52,000/μL. 2. The patient is difficult to arouse. 3. There is purpura on the oral mucosa. 4. There are large bruises on the patient's back. patient with thrombocytopenia.

2. patient difficult to arouse

To enhance gas exchange, the nurse would position a patient who had a left pneumonectomy this morning: 1. on the right side. 2. on the left side. 3. in a semi-Fowler's position. 4. flat, with a small pillow.

3Semi fowlers position

A teenage client has been diagnosed with infectious mononucleosis and asks the health care provider what caused the condition. Which response is most accurate for the nurse to share with this client? a) Epstein-Barr virus (EBV) b) Human immunodeficiency virus (HIV) c) Abnormal cell nucleus development d) Non-Hodgkin lymphoma

The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Ensure that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console will shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed, based on the patient assessment and the decision of the health care provider.

The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. The nasogastric (NG) tube is disconnected from suction and clamped off. b. The patient is in a side-lying position with the head of the bed flat. c. The Hemovac in the neck incision contains 200 mL of bloody drainage. d. The patient is coughing blood-tinged secretions from the tracheostomy.

ANS: B, D, C, A The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 mL of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.) a. transcutaneous pacemaker. b. atropine IV. c. temporary transvenous pacemaker. d. permanent pacemaker. e. amiodarone IV.

ANS: Transcutaneous pacemaker. Temporary tranvenous pacemaker. Permanent pacemaker. Atropine Other meds: IV dopamine,epinephrine "AED" - IV - atropine,epinephrine,dopamine

The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each answer choice (a, b, c, d, etc.) a. The nasogastric (NG) tube is disconnected from suction and clamped off. b. The patient is in a side-lying position with the head of the bed flat. c. The Hemovac in the neck incision contains 200 mL of bloody drainage. d. The patient is coughing blood-tinged secretions from the tracheostomy.

In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress? Put a comma and space between each answer choice (a, b, c, d, etc.) a. Obtain a portable chest-x-ray. b. Place the patient in the supine position. c. Inflate the cuff of the endotracheal tube. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask system for several minutes.

ANS: E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, then with a chest x-ray.

Control mode, which means that the machine will: (Select all that apply.) The nurse explains to the patient on a mechanical ventilator that it is set on assist- deliver a set tidal volume. deliver a set number of breaths if the patient's rate falls. automatically cuts off if the patient is breathing independently. deliver more oxygen at the end of an inspiration. help to correct respiratory acidosis.

ANS: 1, 2 The assist-control mode delivers a set tidal volume on every respiration and will deliver a set number of breaths per minute should the patient's rate drop. It does not cut off automatically, or deliver more oxygen at the end of the inspiration, nor does it correct respiratory acidosis

When epistaxis has been controlled, the nurse instructs the patient to: (Select all that apply.) 1. avoid sneezing. 2. rest for several hours until all threat of epistaxis is gone. 3. avoid rubbing nose. 4. gently remove clotted blood from occluded nostril. 5. blow nose gently in small breaths.

ANS: 1, 2, 3 The patient should not blow the nose or attempt to remove clotted blood.

The radical neck resection removes a large amount of tissue on the same side as the lesion. The tissues removed include: (Select all that apply.) 1. all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle. 2. all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline. 3. all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the maxilla, including the zygomatic arch. 4. part of the tongue and parotid salivary glands. 5. lower lip to midline.

ANS: 1, 2, 3 The radical neck resection does not ordinarily include the tongue, parotid salivary glands, or lip.

Following a thoracentesis that drained off 700 mL of fluid that was inhibiting the inflation of the left lung, the nurse will: (Select all that apply.) 1. place patient on the right side for 1 hour. 2. record procedure and amount and character of the fluid. 3. monitor for respiratory change. 4. count fluid withdrawn as output. 5. coach patient in deep-breathing exercises.

ANS: 1, 2, 3, 4, 5 All options are appropriate following a thoracentesis.

The nurse would recommend that a full-year preventative protocol of isoniazid (INH) be given to people who: (Select all that apply.) 1. are living with a person newly diagnosed as having tuberculosis. 2. have a positive skin test but negative chest films. 3. have a positive skin test and are on steroids. 4. have a positive skin test and have diabetes. 5. have a positive skin test and have had a gastrectomy.

ANS: 1, 2, 3, 4, 5 All options are people for whom a protocol of isoniazid should be recommended.

The nurse assesses the older adult with a family tendency to laryngeal cancer for: (Select all that apply.) 1. history of smoking. 2. alcohol abuse. 3. exposure to asbestos. 4. eating spicy foods. 5. infection with human papillomavirus.

ANS: 1, 2, 3, 4, 5 All options are risk factors for laryngeal cancer.

The nurse setting up the environment for tracheal suction on a newly postoperative tracheostomy patient will: (Select all that apply.) 1. auscultate lungs for retained secretions. 2. wash hands and open out sterile suction kit. 3. don sterile glove and lift out catheter and connect to suction. 4. don sterile glove and prepare solutions from kit. 5. perform suction with sterile supplies.

ANS: 1, 2, 3, 4, 5 All options are significant to perform suctioning safely and aseptically.

Anorexic to enhance her nutrition by the practices of: (Select all that apply.) resting before eating. avoiding gas-producing food. eating four to six small meals rather than three large ones. lying down after eating. taking small bites and chewing slowly.

ANS: 1, 2, 3, 5 Lying down after meals increases shortness of breath.

The nurse working with a client who has acute sinusitis plans to teach the client about 1. cover mouth and nose when sneezing. 2. wash hands frequently. 3. take saline nose sprays. 4. turning head to crook of arm when coughing. 5. drinking juices with vitamin C.

ANS: 1, 2, 4 Covering mouth and nose when sneezing and coughing as well as frequent washing of hands will reduce the risk of passing a cold to another. Using saline sprays and drinking juices with vitamin C are not helpful in containing a cold.

The nurse remarks that influenza is peculiar in that it is spread by: (Select all that apply.) 1. direct contact. 2. indirect contact. 3. vector. 4. blood-borne method. 5. droplets.

ANS: 1, 2, 4, 5 Influenza is not spread by the blood-borne method.

The nurse instructs the adult post-tonsillectomy patient to avoid: (Select all that apply.) 1. citrus fluid. 2. hot fluids. 3. milk products. 4. coughing and sneezing. 5. using a straw.

ANS: 1, 2, 4, 5 Milk products are acceptable for post-tonsillectomy patients.

The home health nurse making an initial call on a newly diagnosed Hispanic tuberculosis patient who lives at home with his wife and child would give special instruction for infection control to: (Select all that apply.) 1. place contaminated tissues in sealable plastic bag. 2. take prescribed drug as directed without fail. 3. take airborne precautions. 4. wash hands frequently. 5. wear mask when in crowds.

ANS: 1, 2, 4, 5 As the family is already exposed, taking airborne precautions is unnecessary.

The signs the nurse would expect to see in a patient with advanced emphysema are: (Select all that apply.) 1. coughing up copious mucus. 2. dyspnea. 3. barrel chest. 4. elevated PaCO2. 5. cyanotic skin tone.

ANS: 2, 3 The emphysemic has a barrel chest and dyspnea, but there is minimal coughing and no mucus. There is no retained CO2, so the PaCO2 will be normal. The emphysemic has a pink complexion as there is no retained CO2.

19. The nurse includes in the discharge instruction to a patient who has had a microlaryngoscopy with laser removal of polyps to: (Select all that apply.) 1. be alert for massive swelling. 2. return to work in 3 days. 3. cough to expectorate blood. 4. observe 2 days of voice rest. 5. take opioids for pain.

ANS: 2, 4

ANS: 3 Elevation of the head helps gas exchange in a new pneumonectomy. Complete side-lying on the unaffected side may cause mediastinal shift.

hen assessing the patient with thrombocytopenia, the nurse observes for: 1 . distended neck veins and skin discoloration. 2 . discoloration of the nails and sclera. 3 . petechiae on the skin and bleeding gums. 4 . enlarged thyroid gland and excitability.

ANS: 3 Symptoms of thrombocytopenia include petechiae, purpura, bleeding gums, and epistaxis.

The client has been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse is attempting to determine if the client's self-image has suffered as a result of his diagnosis. What is the nurse's priority line of questioning? a. Whether the earning power of the client's household has decreased b. Whether the client has experienced difficulty quitting smoking c. Whether the client has a fulfilling relationship with his wife d. Whether the client has changed his hobbies to accommodate his disease

ANS: A Economic status may be affected by COPD through changes in income and health insurance coverage. If the client is the head of the household, severe COPD may require role changes that have a negative impact on self-image. If the client is experiencing difficulty in quitting smoking, his self-image will probably not be altered as much as it would be related to income. The client may be experiencing difficulty with his marital relationship, but it probably will not be causing changes in his self-image. Although the client may have had to change his hobbies to accommodate the disease, it probably will not have affected his self-image adversely.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position.

ANS: A Increasing oxygen flow rate usually will improve oxygen saturation in patients with a ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

ANS: A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first? a. Listen to the patient's lungs. b. Offer reassurance to the patient. c. Bag the patient at an FIO2 of 100%. d. Notify the patient's health care provider.

ANS: A The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern

After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a.Increase in the patient's heart rate b.Decrease in premature contractions c.Increase in peripheral pulse volume d.Decrease in ventricular ectopic beats

ANS: A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have ventricular ectopy or premature contractions.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? 1. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg 2. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg 3. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg 4. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg .

ANS: A The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis

The nurse explains to the patient on a mechanical ventilator that it is set on assist-control mode, which means that the machine will: (Select all that apply.) a. deliver a set tidal volume. b. deliver a set number of breaths if the patient's rate falls. c. automatically cuts off if the patient is breathing independently. d. deliver more oxygen at the end of an inspiration. e. help to correct respiratory acidosis.

ANS: A, B

ANS: A, B The assist-control mode delivers a set tidal volume on every respiration and will deliver a set number of breaths per minute should the patient's rate drop. It does not cut off automatically or deliver more oxygen at the end of the inspiration, nor does it correct respiratory acidosis.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 - 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output Positive Trousseau's sign

ANS: A, B, C

A busy nurse in the ICU wishes to delegate aspects of respiratory care to an unlicensed assistive personnel (UAP). Which of the following actions can the nurse delegate? (Select all that apply.) a. Measuring and recording oxygen saturations b. Setting up oxygen delivery and suction equipment c. Suctioning secretions of a client with a long-standing tracheostomy d. Teaching the client how to cough with a tracheostomy e. Verifying that the correct amount of oxygen is being delivered

ANS: A, B, C A UAP can do the items in options a, b, and c. Teaching is always the responsibility of the nurse; however, the UAP can reinforce the teaching once the nurse has assessed that the client and family understand what has been presented. Verifying that the oxygen is set to deliver the correct

Which of the following actions can the nurse delegate? (Select all that apply personnel (UAP). Which of the following actions can the nurse delegate? (Select all that apply.) a. Measuring and recording oxygen saturations b. Setting up oxygen delivery and suction equipment c. Suctioning secretions of a client with a long-standing tracheostomy d. Teaching the client how to cough with a tracheostomy e. Verifying that the correct amount of oxygen is being delivered

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips

ANS: A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

ANS: A, B, C Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

A client enters the clinic with an acute sore throat and a temperature of 101.5° F (38.5° C). What diagnostic testing does the nurse educate the client about? (Select all that apply.) a. Complete blood count (CBC) b. Throat culture c. Monospot test d. Arterial blood gas e. Biopsy f. HIV testing

ANS: A, B, C CBC, throat culture, and monospot testing can help to determine the causes of sore throat and fever. A biopsy is not needed. Human immune deficiency virus (HIV) testing would not be indicated unless the symptoms were a recurrent problem. Arterial blood gases would not be performed unless the client had dyspnea and a low oxygen saturation reading.

Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.) a. Clubbed fingers b. Increased residual volume c. Decreased peak flow d. Increased anterior-posterior diameter Elevated platelets f. Expiratory wheezing g. Stridor h. Change in sputum color and amount

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client's risk of for acidosis.

1. A client is being evaluated for a lung transplant. The nurse assists the client to understand that the psychological assessment includes which of the following? (Select all that apply.) a. Ability to cope with stress and coping mechanisms b. History of compliance with medical regimen c. History of substance abuse d. Occupational and financial resources

ANS: A, B, C Options a, b, and c all relate to the extensive psychosocial assessment done before listing a client for transplantation.

A client is being evaluated for a lung transplant. The nurse assists the client to understand that the psychological assessment includes which of the following? (Select all that apply.) a. Ability to cope with stress and coping mechanisms b. History of compliance with medical regimen c. History of substance abuse d. Occupational and financial resources

ANS: A, B, C Options a, b, and c all relate to the extensive psychosocial assessment done before listing a client for transplantation.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

ANS: A, B, C Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

When epistaxis has been controlled, the nurse instructs the patient to: (Select all that apply.) a. avoid sneezing. b. rest for several hours until all threat of epistaxis is gone. c. avoid rubbing the nose. d. gently remove clotted blood from the occluded nostril. e. blow the nose gently in small breaths.

ANS: A, B, C The patient should not blow the nose or attempt to remove clotted blood. DIF: Cognitive Level: Application REF: 280 OBJ: 2 (clinical)

The radical neck resection removes a large amount of tissue on the same side as the lesion. The tissues removed include: (Select all that apply.) a. all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle. b. all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline. c. all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the maxilla, including the zygomatic arch. d. part of the tongue and parotid salivary glands. lower lip to midline.

ANS: A, B, C The radical neck resection does not ordinarily include the tongue, parotid salivary glands, or lip. DIF: Cognitive Level: Application REF: 283-284 OBJ: 2 (theory)

The nurse notes physical signs of labored breathing, which include: (Select all that apply.) a. grunting on expiration. b. elevating shoulders and ribs on inspiration. c. tensing neck and shoulder muscles. d. substernal retraction. e. productive cough.

ANS: A, B, C, D Productive cough is not a sign of labored breathing. All other options are often seen with laboring respirations.

The nurse assesses the older adult with a family tendency of developing laryngeal cancer for: (Select all that apply.) a. history of smoking. b. alcohol abuse. c. exposure to asbestos. d. eating spicy foods. e. infection with Streptococcus bacteria.

ANS: A, B, C, D Streptococcus bacteria are not considered a risk factor for laryngeal cancer; rather, infection with human papillomavirus is considered a risk factor. All other options are risk factors for laryngeal

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol Suctioning the client on a regular schedule

ANS: A, B, C, D The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Irrigate your mouth every 2 hours to prevent infection." d. "Sleep in a semi-Fowler's position after the surgery." e. "Gargle with mouthwash that contains Benadryl once a day."

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler's position to assist in avoiding aspiration. Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

. A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. Change the nasal packing.

ANS: A, B, C, D The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. Administer a nasal steroid to decrease edema. Change the nasal packing.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury

A nonsmoking client has been diagnosed with mild asthma. The nurse instructs the client to try to identify and reduce or eliminate exposure to triggers, which may include (Select all that apply) a. being overly excited. b. household pets. c. physical exercise. d. perfumes. e. second-hand smoke.

ANS: A, B, C, D, E All of the options can induce an asthma attack. When people with asthma are exposed to extrinsic allergens and irritants, their airways become inflamed, producing shortness of breath, chest tightness, and wheezing. Identification of irritants is essential, and irritants should be eliminated in a reasonable fashion, one at a time, to assess the effect of their removal on manifestations.

The nurse is working with a pulmonary specialist and is aware that the physician will most likely recommend that a full-year preventative protocol of isoniazid (INH) be given to people who: (Select all that apply.) a. are living with a person newly diagnosed as having tuberculosis. b. have had a positive tuberculin skin test but negative chest films. c. have had a positive tuberculin skin test and are on steroids. d. have had a positive tuberculin skin test and have diabetes. e. have had a positive tuberculin skin test and have had a gastrectomy.

ANS: A, B, C, D, E All options are people for whom a protocol of isoniazid should be recommended.

The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate at this time? (Select all that apply.) a. Observe for clear drainage. b. Observe for bleeding. c. Observe the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. g. Administer pain medication. h. Place the client in Trendelenburg position.

ANS: A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth andStandard Precautions are not enough. The client does not have to wear a mask while others are in the room because they should be protecting themselves by using Airborne Precautions.

ANS: A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth andshould observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

The home health nurse recommends to the 60-year-old patient with emphysema who is anorexic to enhance her nutrition by the practices of: (Select all that apply.) a. resting before eating. b. avoiding gas-producing food. c. eating four to six small meals rather than three large ones. d. lying down after eating. e. taking small bites and chewing slowly.

ANS: A, B, C, E Lying down after meals will likely increase shortness of breath. All other options will enhance her ability to increase her nutritional state.

The signs the nurse would expect to see in a patient with advanced emphysema are: (Select all that apply.) a. productive cough. b. dyspnea. c. barrel chest. d. wheezing. cyanotic skin tone

ANS: A, B, C, E The emphysemic has a barrel chest and dyspnea. There is minimal coughing and mucus production until late in the disease. Wheezing usually does not occur in the emphysemic patient. Cyanosis is usually absent until late in the disease when the patient becomes hypoxic.

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)? a. Taking a hot shower will increase sinus drainage and decrease pain. b. Over-the-counter (OTC) antihistamines can be used to relieve congestion and inflammation. c. Saline nasal spray can be made at home and used to wash out secretions. d. Blowing the nose forcefully should be avoided to decrease nosebleed risk. e. You will be more comfortable if you keep your head in an upright position.

ANS: A, B, C, E The steam and heat from a shower will help thin secretions and improve drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

ANS: A, B, C, E The steam and heat from a shower will help thin secretions and improve drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or home- prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Presence of confusion Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

The nurse advises that, to reduce the risk of giving a cold to another, one should: (Select all that apply.) a. cover the mouth and nose when sneezing. b. wash the hands frequently. c. use saline nose sprays. d. turn the head to the crook of the arm when coughing. e. drink juices with vitamin C.

ANS: A, B, D Covering the mouth and nose when sneezing and coughing as well as frequent washing of hands will reduce the risk of passing a cold to another. Using saline sprays and drinking juices with vitamin C are not helpful in containing a cold.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and cephalosporins

ANS: A, B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30year-old increases the risk for infection.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

ANS: A, B, D Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

ANS: A, B, D, C The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. Document the change in status. d. Notify the health care provider.

The nurse reminds a group of retirees that age may alter the respiratory systems by: (Select all that apply.) a. weakened cough. b. kyphosis. c. increased ciliary movement. d. decrease in body fluid. muscle weakness.

ANS: A, B, D, E Age often decreases ciliary movement. All other options are age-related changes that affect the respiratory system.

1. A client presents to the emergency department having a severe sickle cell crisis. The nurse should be prepared to do which of the following interventions? (Select all that apply.) a. Administer oxygen. b. Offer heat therapy. c. Order hydroxyurea from the pharmacy. d. Prepare to give IV morphine. e. Start an IV with normal saline.

ANS: A, B, D, E Care of the client in sickle cell crisis includes administering oxygen, providing heat for painful joints, giving IV opioids (morphine is preferred), and providing hydration with IV fluids. Hydroxyurea has been approved by the FDA for SSD, but is given long-term to clients for whom other treatments are not effective and who have frequent, painful crises.

The nurse instructs the adult post-tonsillectomy patient to avoid: (Select all that apply.) a. citrus fluids. b. hot fluids. c. milk products. d. coughing and sneezing. e. using a straw.

ANS: A, B, D, E Milk products are acceptable for post-tonsillectomy patients. Citrus fluids should be avoided until the throat has healed. Hot fluids, coughing and sneezing, and using a straw may cause bleeding.

The nurse setting up the environment for tracheal suction on a newly postoperative tracheostomy patient will: (Select all that apply.) a. auscultate lungs for retained secretions. b. wash hands and open sterile suction kit. c. don clean gloves and lift out catheter and connect to suction. d. don sterile gloves and prepare solutions from kit. e. perform suction with sterile supplies.

ANS: A, B, D, E Sterile rather than clean gloves should be worn during the suctioning procedure. All other options are significant to perform suctioning safely and aseptically.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

ANS: A, B, D, E The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse is planning interventions that regulate acid-base balance to ensure the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs

ANS: A, B, E Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing the effectiveness of many drugs.

The nurse providing patient education states that influenza is spread by: (Select all that apply.) a. direct contact. b. indirect contact. c. vector. d. blood-borne method. e. droplets.

ANS: A, B, E Influenza is not spread by vectors or the blood-borne method.

A client who previously had a bacillus Calmette-Guérin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply.) a. Nausea b. Weight loss c. Insomnia d. Ankle edema e. Night sweats Increased urination

ANS: A, B, E TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle edema are not typical symptoms. Increased urination also is not a typical symptom.

The client with which conditions requires immediate nursing intervention? (Select all that apply.) a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min Arterial blood gas showing a pH of 7.35 g. Stridor

ANS: A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately

When administering a blood transfusion to a client, which tasks can the nurse delegate to the experienced unlicensed personnel? (Select all that apply.) a.Assisting the client to a comfortable position c. Reporting any complaints to the physician d. Taking the client's vital signs e. Verifying the client's identity with the nurse

ANS: A, C Two professional nurses are required to verify the client's identity and verify the blood

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

The U.S. Public Health Service recommends influenza immunization for: (Select all that apply.) a. physicians. b. compromised infants. c. older adults. d. chronically ill people. e. nurses.

ANS: A, C, D, E Compromised infants should not be immunized. Health care workers, older adults, and chronically ill individuals are at risk for contracting influenza and should be immunized.

Age-related physiologic changes the nurse would consider when planning care for an elderly client admitted with an acid-base abnormality include (Select all that apply) decreased pulmonary and renal function limit the ability to compensate. hypermetabolism predisposes the elderly to metabolic acidosis. hypoventilation can easily cause respiratory acidosis in the elderly. renal perfusion is diminished because of decreased cardiac output there is decreased alveolar surface area for gas exchange.

ANS: A, C, D, E Many age-related physiologic changes limit the client's ability to compensate for acid-base disturbances, including options a, c, d, and e above, plus the fact that the elderly take more medications that can contribute to hypokalemia and metabolic alkalosis. Aldosterone is also less effective in older persons, as is ammonia buffering. The elderly are not hypermetabolic

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) 24-year-old with a traumatic brain injury A 36-year-old who fractured his left femur A 58-year-old at risk for aspiration following radiation therapy A 66-year-old who is a quadriplegic and has a sacral ulcer An 80-year-old who is aphasic after a cerebral vascular accident

ANS: A, C, D, E Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

The nurse clarifies that when interstitial edema occurs in the lung tissue, ventilation is inhibited by (Select all that apply.) a. thickened alveolar membranes. b. pus formation. c. alveoli filling with fluid. d. surfactant evaporation. e. failure of gas to diffuse across membrane.

ANS: A, C, E Interstitial edema will cause problems that affect the alveoli: thickened walls and filling with fluid that obstructs gas exchange across the thickened walls. Pus formation is associated with infection. Surfactant decreases surface tension on the alveolar wall, allowing it to expand more easily with inspiration and preventing alveolar collapse on expiration.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. Use strict aseptic technique when using the drug delivery system.

ANS: A, C, E Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

What teaching is appropriate for a client with acute rhinitis and sinusitis? (Select all that apply.) a. Using hot packs over the sinuses b. Fluid restriction c. Saline irrigations d. Staying in a dry climate e. Taking echinacea Antifungal medications

ANS: A, C, E Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. As complementary therapy, echinacea is recommended for the symptom of rhinitis. Antifungal medications, fluid restrictions, and staying in a dry climate are not recommended.

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

ANS: A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider

A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.) a. Eat a diet rich in protein, iron, and vitamins. b. Do not drink fluids with medications. c. Take medications at bedtime. d. Space medications 12 hours apart. e. Take medications with milk. f. Take an antiemetic daily.

ANS: A, C, F Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics are often prescribed. Drinking fluids with medications should not influence the nausea; neither should taking medications with milk. Spacing medications 12 hours apart is not recommended therapy.

The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called "battle sign" and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

ANS: A, D The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. Wear fashionable scarves.

ANS: A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

Common causative organisms for the infection causing sinusitis are: (Select all that apply.) a. pneumococci. b. Pseudomonas. c. staphylococci. d. Haemophilus influenzae. e. streptococci.

ANS: A, D, E The common organisms causing sinusitis are pneumococci, Haemophilus influenzae, and streptococci.

Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) Provide close supervision for the client during eating and drinking. Add liquids to foods to make them thinner and easier to swallow. Inflate the tracheostomy cuff tube to maximum pressure before starting. Let the client indicate readiness for another bite when being fed. Have the client tuck the chin down and forward while swallowing. Instruct the client to dry swallow to clear food particles from the throat. Place the client in a semi-Fowler's position for an hour after eating.

ANS: A, D, E, F The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration.

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvostek's sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability

ANS: A, E;client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.

A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 40 mg IV

ANS: B Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.

ANS: B Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.

The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the United States?" d. "Do you take any over-the-counter (OTC) medications?"

ANS: B Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

Which is the highest priority teaching need for a client with sinusitis? a. Use cold packs over the sinus area. b. Increase his fluid intake to more than 10 glasses of fluid daily. c. Avoid using nasal saline irrigations because of the risk of spreading the infection. d. Keep the room air dehumidified to dry out the nasal sinuses.

ANS: B Teach the client to increase fluid intake to more than 10 glasses of water or juice daily unless another medical problem requires fluid restriction. Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. If this treatment plan is not successful, the client may need to be evaluated with sinus films and computed tomography (CT). Surgical intervention may be needed.

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

ANS: B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery? a. Older age and anemia b. Albumin level and weight loss c. Recent arthroscopic procedure d. Confusion and disorientation to time

ANS: B The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure

Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.

The client with respiratory difficulty has a V/Q ratio of 0.5. What is the significance of this value? a. The ratio is low. Ventilation is exceeding perfusion. b. The ratio is low. Perfusion is exceeding ventilation. c. The ratio is high. Ventilation is exceeding perfusion. d. The ratio is high. Perfusion is exceeding ventilation.

ANS: B When ventilation and perfusion match, the ratio is or close to 1. When this ratio is less than 1, ventilation is decreased and is not matched with perfusion. Ventilation and perfusion are not the same throughout, even in healthy lungs. Perfusion is greater at the bases of the lungs and ventilation is greater at the apices of the lungs. Therefore, the normal V/Q ratio for the entire lung is about 0.8. When the V/Q ratio is 0.5, essentially blood flow through some area is occurring, but the blood is not becoming oxygenated because ventilation is less than adequate.

A nurse caring for a patient with crushing injuries from an automobile accident notes that the patient is bleeding profusely from the nose, mouth, and rectum, as well as from the injuries. What should the nurse suspect as the cause of this patient's bleeding? a. Hemophilia b. Disseminated intravascular coagulation (DIC) c. Leukemia d. Thrombocytopenia

ANS: B DIC occurs in massive crushing injuries, burns, and allergic responses. The body's clotting ability is exhausted because of its attempt to repair so many areas with coagulation. When the platelet supply is gone, the clotting ability is lost, and massive hemorrhaging occurs.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a. "PEEP will push more air into the lungs during inhalation." b. "PEEP prevents the lung air sacs from collapsing during exhalation." c. "PEEP will prevent lung damage while the patient is on the ventilator." d. "PEEP allows the breathing machine to deliver 100% O2 to the lungs."

ANS: B By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L White blood cell (WBC) count: 72,000/mm3

ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

A client with HIV infection has a history of close exposure to someone with active pulmonary tuberculosis and has developed a cough and low-grade fever. The client's Mantoux is negative but the client has been admitted to the hospital for further testing. The most appropriate action by the nurse is to (Select all that apply) a. admit the client to a private room. b. anticipate orders for AFB testing. c. place the client in respiratory isolation. d. screen potential roommates carefully. e. select a room close to the nurses' station.

ANS: B, C The client should understand that a negative test result does not always mean that TB is absent, particularly in HIV-positive clients, who are immunosuppressed. Until TB has been ruled out, the client needs to be in respiratory isolation in a negative airflow room. These rooms should send room air directly to the outside and have at least six air exchanges per hour. Putting the client in a private room is not enough. The client should not have a roommate. The location of the room is less important than having negative airflow capability. Definitive testing for tuberculosis includes chest x-ray, AFB smears from sputum, and culture.

A nurse is planning care for a client who is anxious and irritable. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3- 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been experiencing any vomiting?" e. "Are you experiencing any shortness of breath?"

ANS: B, C This client's symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a client's personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis.

The nurse advises that, to reduce the risk of giving a cold to another, one should: (Select all that apply.) the routinely-used treatments for this condition, which include (Select all that apply) a. antibiotics. b. antihistamines. c. mucolytic agents. d. oral alpha-adrenergic vasoconstrictors.

ANS: B, C, D Antibiotics, once the mainstay of treatment for sinusitis, are no longer used routinely because many sinus infections are viral. Routine treatments include antihistamines for clients who acute sinusitis in the setting of allergies, mucolytic agents such as guaifenesin, and oral alpha-adrenergic vasoconstrictors such as pseudoephedrine

The nurse working with a depressed client who has COPD realizes that many factors negatively affect the client's quality of life, including (Select all that apply) familial support systems. loss of control over their bodies. reduced activity tolerance. social isolation.

ANS: B, C, D Familial support systems should help with quality of life

A client develops epistaxis. Which conditions in the client's history could have contributed to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets g. High cholesterol

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis.

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b.Hypertension c.Leukemia d.Cocaine use e.Migraine f. Elevated platelets

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (VAP) in a ventilator-dependent client? (Select all that apply.) a. Provide prophylactic antibiotics. b. Provide frequent oral care. c. Keep the head of the bed elevated. d. Maintain good hand hygiene. e. Perform chest percussion frequently.

ANS: B, C, D Providing frequent oral care, keeping the head of the bed elevated, and maintaining good hand hygiene are currently stated as the best ways to help prevent VAP. Prophylactic antibiotics are not recommended; neither is taking the client off the ventilator. Likewise, frequent chest percussion is not stated as an intervention to decrease VAP.

The nurse working with a client who has acute sinusitis plans to teach the client about the routinely-used treatments for this condition, which include (Select all that apply) a. antibiotics. b. antihistamines. c. mucolytic agents. d. oral alpha-adrenergic vasoconstrictors.

ANS: B, C, D Antibiotics, once the mainstay of treatment for sinusitis, are no longer used routinely because many sinus infections are viral. Routine treatments include antihistamines for clients who have acute sinusitis in the setting of allergies, mucolytic agents such as guaifenesin, and oral alpha- adrenergic vasoconstrictors such as pseudoephedrine.

Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). e. Provide oral care with chlorhexidine (0.12%) solution daily.

ANS: B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.

ANS: B, C, D, E All these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

2. A nurse caring for an elderly client with COPD alters care knowing that in the older population (Select all that apply) a. COPD is not a common problem in the elderly. b. impaired nutrition is a common problem in the elderly. c. multiple co-morbidities may be present that complicate care. d. sensory disturbances may hinder their ability to provide self-care. e. there may be more problems with drug-drug interactions.

ANS: B, C, D, E COPD is a common problem in the elderly; it is a leading cause of hospitalizations in older persons. Options b through e are all correct statements about COPD and age-related considerations.

A nurse caring for an elderly client with COPD alters care knowing that in the older population (Select all that apply) a. COPD is not a common problem in the elderly. b. impaired nutrition is a common problem in the elderly. c. multiple co-morbidities may be present that complicate care. d. sensory disturbances may hinder their ability to provide self-care. e. there may be more problems with drug-drug interactions.

The nurse is preparing a presentation highlighting the benefits of annual influenza vaccination. The nurse correctly targets which groups? (Select all that apply.) a. The parents of children 3 to 6 months of age b. Diabetics who are over 50 years old c. Pregnant women d. Home health aides e. CNAs who work in long-term care facilities

ANS: B, C, D, E Children ages 6 to 59 months should receive the influenza vaccine, not children 3 to 6 months of age. The Advisory Committee on Immunization Practices also suggests that pregnant women, people over age 50, and people with certain chronic illnesses receive the vaccine. In addition, health care workers and those caring for persons in homes that are at high risk for contracting influenza should receive the vaccine.

The nurse explains that anorexia in the patient with a respiratory disorder may be attributed to: (Select all that apply.) a. increased sense of taste. b. bad taste in mouth. c. fear that eating will exacerbate coughing. d. fatigue. e. altered sense of smell.

ANS: B, C, D, E The sense of taste is usually altered in the patient with a respiratory disorder. All of the other factors contribute to lack of appetite in the patient with a respiratory disorder.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

ANS: B, C, E Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine activity tolerance. Which questions elicit the most important information? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis - Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis - Postoperative client who received 6 units of packed red blood cells Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease

ANS: B, C, E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

Yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)? The nurse is reviewing the charts for five patients who are scheduled for their A 56-year-old patient who is allergic to eggs A 36-year-old female patient who is pregnant A 42-year-old patient who has a 15 pack-year smoking history A 30-year-old patient who takes corticosteroids for rheumatoid arthritis A 24-year-old patient who has allergies to penicillin and the cephalosporins

ANS: B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, have chronic medical conditions, or are immunocompromised should receive inactivated vaccine. The corticosteroid use by the 30-year-old increases the risk for infection. Individuals with egg allergies should not receive inactivated flu vaccine because it is made using eggs.

The nurse includes in the discharge instruction to a patient who has had a microlaryngoscopy with laser removal of polyps to: (Select all that apply.) a. be alert for massive swelling. return to work in 3 days. c. cough to expectorate blood. d. observe 2 days of voice rest. e. take opioids for pain.

ANS: B, D Observation of voice rest for 2 days and return to work in 3 days are the basic instructions. There is minimal swelling or bleeding, and NSAIDs (not opioids) are used for pain control.

2. Nurses caring for clients being treated for active pulmonary tuberculosis in the hospital are required to have (Select all that apply) an annual chest x-ray. an annual skin test for TB. no allergies to anti-TB medications. properly-fitting particulate respirators.

ANS: B, D Personal protective equipment called a particulate respirator is required for all health care providers who enter the room of a client with active TB. Skin testing should be performed annually for all health care workers.

Nurses caring for clients being treated for active pulmonary tuberculosis in the hospital are required to have (Select all that apply) a. an annual chest x-ray. b. an annual skin test for TB. c. no allergies to anti-TB medications. d. properly-fitting particulate respirators.

To increase the safety of a blood transfusion, which of the following actions should the nurse take? The nurse should prepare to administer the blood with (Select all that apply) a. a second nurse to take the vital signs. b. a tubing set designed for blood products. c. an IV of D5W. d. an IV of normal saline.

ANS: B, D To prevent hemolysis, add no solution other than normal saline to blood components. Following institutional policy, use a tubing set designed for blood products. Most will contain a filter that will trap small fibrin clots and other cellular debris. A second nurse is used during the identity-verification step.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr Disconnection at Y site

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

The nurse is caring for a client who is suspected of having severe acute respiratory syndrome (SARS). What actions by the nurse are most appropriate? (Select all that apply.) a. Wash hands when entering the client's room and use Standard Precautions. b. Wear a gown and goggles when entering the client's room. c. Teach the client to wear a mask at all times when someone is in the room. d. Use a disposable particulate mask respirator when the client is coughing. e. Keep the door to the client's room open to allow close monitoring. f. Place the client in a negative airflow room, if available in the facility.

ANS: B, D, F The nurse should follow Airborne Precautions when caring for clients suspected of SARS. Wear a gown and goggles when in the room and caring for the client. Use a disposable particulate mask respirator if the client is coughing, or if particles are being aerosolized. Handwashing andStandard Precautions are not enough. The client does not have to wear a mask while others are in the room because they should be protecting themselves by using Airborne Precautions.

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

ANS: B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast (select all that apply)? Ask the patient about any claustrophobia. Question the patient about allergies to iodine. Avoid administration of bronchodilator drugs. Have the patient remove wedding bands or any other jewelry. Review the recent blood urea nitrogen (BUN) and creatinine levels.

ANS: B, E Since the contrast dye is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies and monitoring renal function before the CT scan is necessary. The other actions are not needed for CT of the chest, although they may be needed for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

ANS: B, E The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer An 88-year-old with esophageal cancer who is awaiting gastric tube placement

For an elderly client who has a posterior nasal plug and anterior nasal packing in place to control an episode of severe epistaxis, the priority assessment for the nurse would be assessing for a. continuing nasal pain. b. dislodged packing. c. presence of hypoxia. d. swallowing blood.

ANS: C Clients with posterior plugs and anterior nasal packing are admitted to the hospital and monitored closely for hypoxia. Posterior packing can affect both level of consciousness and respiratory status, especially in the elderly client.

When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action? a. The chest appears barrel shaped. b. The patient has a weak cough effort. c. Crackles are heard from the lung bases to the midline. d. Hyperresonance is present across both sides of the chest.

ANS: C Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

Which assessment finding alerts the nurse to the possibility of pneumonia in a client with chronic bronchitis? a. Pulse oximetry reading of 92% b. Shallow respirations of 32/min c. Percussion is dull in left lower lobe d. Wheezes are audible over right and left bronchi

ANS: C Dull percussion indicates consolidation, a hallmark of pneumonia. A decreased pulse oximetry reading, shallow, increased respirations, and audible wheezing would be expected findings in the client with chronic bronchitis, but would not be indicative of the development of pneumonia.

A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)

ANS: C Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.

ANS: C Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.

When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis

The client is undergoing radiation therapy as a treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client? a. Spaghetti with meat sauce, ice cream b. Scrambled eggs, bacon, toast c. Omelet, untoasted whole wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too hard to swallow with this condition, and orange juice and other foods with citric acid are too caustic in this condition.

When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 500 mL.

ANS: C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 500 mL is within the acceptable range.no more than 25 rpm

The 30 year old american indian female is taking Rifater, a drug containing rifampin,isoniazid,pyrazinamide, complains that she is tired of taking medicine and having to spit in a bottle all the time. She asks " when can i stop all this and get on with my life?" the nurse's best response is that she will no longer be considered contagious when The sputum culture comes back negative The medication has been taken for 9 months Three consecutive sputum cultures are negative The tb skin test (TST) is no longer positive

ANS: C Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

Which nursing concern takes priority in the care of a patient after a laryngectomy? a. Encouraging nutrition b. Avoiding infection c. Establishing a communication system d. Ensuring adequate fluid intake

ANS: C Establishing a communication system with the patient who has undergone a laryngectomy is a primary concern

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. The Administrator prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

ANS: C The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he orshe would like to use after surgery. Assessing the client's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this client's gait should not be impacted by a total laryngectomy and therefore is not a priority.

The nurse preparing a client for a bronchoscopy would include information about its (Select all that apply) A bronchoscopy can be used for both therapeutic and diagnostic purposes. By directly visualizing the larynx, trachea, and bronchi, it can be used to diagnose tumors, inflammation, and strictures; obtain tissue biopsies; remove retained secretions and foreign bodies; and control bleeding within the bronchus. It cannot be used to visualize gas exchange ability to visualize gas exchange at the alveolar level. limitation of not being able to take tissue biopsies. therapeutic use to remove retained secretions. usefulness in diagnosing tumors, inflammation, and strictures.

ANS: C, D A bronchoscopy can be used for both therapeutic and diagnostic purposes. By directly visualizing the larynx, trachea, and bronchi, it can be used to diagnose tumors, inflammation, and strictures; obtain tissue biopsies; remove retained secretions and foreign bodies; and control bleeding within the bronchus. It cannot be used to visualize gas exchange.

A client has rapidly progressing ARDS. Which actions by the nurse can help the family during this crisis? (Select all that apply.) a. Avoid disturbing them in the waiting room. b. Limit visiting time so the family does not fatigue. c. Provide frequent condition updates. d. Use clear communication.

ANS: C, D ARDS can progress rapidly and still has a high death rate, leaving the family unprepared and in crisis. Nursing actions that can assist the family in this situation include providing frequent updates on their loved one's condition and using clear communication.

A client has rapidly progressing ARDS. Which actions by the nurse can help the family during this crisis? (Select all that apply.) Avoid disturbing them in the waiting room. Limit visiting time so the family does not fatigue. Provide frequent condition updates. Use clear communication.

The nurse is teaching a client who is scheduled to undergo allogeneic bone marrow transplantation. Which statements indicate that the client correctly understands the teaching? (Select all that apply.) a. "The surgeon will insert the marrow into my femur bone." b. "Until the marrow transplant takes, I can have visitors." c. "The transplant does not start working immediately." d. "I will need chemotherapy before my transplant." e. "Radiation treatments will begin 2 days after transplantation."

ANS: C, D Engraftment, or the successful take of transplanted cells, takes anywhere from 8 to 28 days, depending on the type of cell transplantation. For donated marrow or stem cells to work, the client will require large doses of chemotherapy before transplantation. The client will not require radiation after the transplant. Transplanted marrow is delivered intravenously. It is not placed into any bone. The client is at risk for infection until the bone marrow begins to produce white blood cells. Therefore visitors should be limited to prevent infection to the client.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the highest priority? (Select all that apply.) a. Placing the client in an isolation room b. Teaching the client how to use a mask c. Teaching the client about long-term antibiotic therapy d. Using handwashing and other Standard Precautions e. Reporting suspected cases to the proper authorities

ANS: C, D, E The client should not stop the drug merely because he or she has no manifestations. The client will need to be on the drug for longer than 1 month. The nurse should teach the client about long- term antibiotic therapy to help with compliance. Inhalation anthrax is not spread by person-to- person contact, so isolation would not be necessary. The client would not need a mask. Health care providers need only use handwashing and Standard Precautions. Always report inhalation anthrax to authorities because it is considered an intentional act of terrorism

The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.

ANS: C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing.

The nurse planning care for an intubated client includes which interventions to prevent accidental extubation? (Select all that apply.) a. Avoid opioid analgesics to prevent confusion and sedation. b. Do not reposition the client unless absolutely necessary. c. Keep tubing out of the client's reach. d. Provide adequate sedation and pain control. e. Use wrist restraints according to hospital policy.

ANS: C, D, E There are several suggested actions to prevent accidental extubation. See Box 63-2 for a comprehensive list. Option a is wrong because the client may need pain control and withholding analgesia is unethical. Option b is wrong because all clients need to be repositioned at least every 2 hours.

The nurse planning care for an intubated client includes which interventions to prevent accidental extubation? (Select all that apply.) a. Avoid opioid analgesics to prevent confusion and sedation. The nurse planning care for an intubated client includes which interventions to prevent b. Do not reposition the client unless absolutely necessary. c. Keep tubing out of the client's reach. d. Provide adequate sedation and pain control. e. Use wrist restraints according to hospital policy.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: C, E Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

The nurse preparing a client for a bronchoscopy would include information about its (Select all that apply) a. ability to visualize gas exchange at the alveolar level. b. limitation of not being able to take tissue biopsies. c. therapeutic use to remove retained secretions. d. usefulness in diagnosing tumors, inflammation, and strictures.

ANS: C,D A bronchoscopy can be used for both therapeutic and diagnostic purposes. By directly visualizing the larynx, trachea, and bronchi, it can be used to diagnose tumors, inflammation, and strictures; obtain tissue biopsies; remove retained secretions and foreign bodies; and control bleeding within the bronchus. It cannot be used to visualize gas exchange.

A client who is immune compromised develops muscle aches and fever. The client is admitted to the hospital for several days and is diagnosed with influenza. At discharge, the client asks when he can go back to work. What is the nurse's best response? A. "You should be able to return to work in 5 days." b. "You can return to work as soon as you feel ready." c. "You cannot return to work for several weeks." d. "You will need to have cultures performed before returning to work."

ANS: C. Immune compromised clients are contagious for several weeks. The client should remain at home until he is not contagious.

A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.

ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

ANS: D Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that a. over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered. b. corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. c. use of oral antihistamines for a few weeks before the allergy season may prevent reactions. d. identification and avoidance of environmental triggers are the best way to avoid symptoms.

ANS: D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.

A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position slightly since insertion, the nurse would assess the a. results of the chest x-ray film taken 2 hours earlier. b. current oxygen saturation readings. c. status of the client's breath sounds. d. position of the numbers on the ET tube at the lip line.

ANS: D The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tube's side. If the tube slips, its correct position can be quickly established. Then the nurse should listen to lung sounds.

In preparing discharge plans for a patient recently diagnosed with pernicious anemia, the nurse must include information regarding: Adding daily high-fat, low-fiber supplements. B Adding a rigorous daily workout. C Avoiding prolonged exposure to direct sunlight. D Providing sufficient rest periods throughout the day.

ANS: D Fatigue and weakness are seen in all anemias.

When a nurse is preparing to give ferrous sulfate (Feosol) to a home health care patient, what is the most appropriate nursing action to implement? a. Mix the drug with a high-protein milkshake. b. Give it undiluted with a small snack. c. Mix it with coffee or cola to disguise the bitter taste. d. Dilute it and offer it through a straw and a few crackers.

ANS: D Patients should avoid taking iron with milk or caffeine because both inhibit drug absorption. The liquid form of the drug is offered with food in a diluted form through a straw to prevent staining the teeth.

10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a Metabolic acidosis bRespiratory acidosis cMetabolic alkalosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. Oxygenate the patient with a bag-valve-mask device for several minutes.

Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur. Take as deep a breath as possible. Stand up (unless you have a physical disability). Place the meter in your mouth, and close your lips around the mouthpiece. Make sure the device reads zero or is at base level. Blow out as hard and as fast as possible for 1 to 2 seconds.

ANS: d, b, a, c, e, f, g The proper order for obtaining a peak expiratory flow rate is as follows: Make sure the device reads zero or is at base level. Stand up (unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two more times, and record the highest of the three numbers in your chart.

A client has been diagnosed with lung cancer and requires a wedge resection. How much of the lung is removed? a. One entire lung b. A lobe of the lung c. A small, localized area near the surface of the lung. d. A segment of the lung, including a bronchiole and its alveoli.

ANSWER C. A small area of tissue close to the surface of the lung is removed in a wedge resection. An entire lung is removed in a pneumonectomy. A segment of the lung is removed in a segmental resection and a lobe is removed in a lobectomy

The client is ordered to be treated with Singulair. The nurse anticipates the client will experience what type of change in her laboratory values? a.Abnormal liver function tests b. Hyperglycemia c.Increased potassium level d. Change in cardiac enzymes

Answer: A (abnormal liver fxn test)

A neighbor tells a nurse that s/he has been experiencing hoarseness for over 3 weeks. The nurse should advise the client to see a doctor for a. a prescription for antacids b. possible laryngeal cancer. c. throat cultures and antibiotics d. vocal cord paralysis.

Answer: B GERD and throat infections can certainly cause hoarseness, but hoarseness that lasts for more than 2 weeks is suspicious for laryngeal cancer. Vocal cord paralysis could cause a hoarseness with a breathy quality to the voic

Answer: C semi fowlers Elevation of the head helps gas exchange in the patient with a new pneumonectomy. A complete side-lying position on the unaffected side may cause mediastinal shift.

47. The nurse determines that the patient understands patient teaching regarding esophageal speech when witnessing the patient perform which activity? A. Inhaling air through the nose and forcing it down the esophagus B. relaxing the diaphragm to allow air into the trachea and esophagus C. coughing to express air D. swallowing air and forcing it back up through the esophagus

Answer: D Esophageal speech involves swallowing air, trapping it in the esophagus, and releasing it to create sound.

Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion? a.Prothrombin time b.Erythrocyte count c.Fibrinogen degradation products d.Activated partial thromboplastin time

Answer: D. ApTT

The home health nurse making an initial call on a newly diagnosed tuberculosis patient who lives at home with his wife and child would give special instruction for infection control to: (Select all that apply.) a. place contaminated tissues in sealable plastic bag. b. take prescribed drug exactly as directed. c. take airborne precautions. d. wash hands frequently. e. wear mask when in crowds. ANS: A, B, D, E

As the family is already exposed, taking airborne precautions is unnecessary.

A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client's health history, which priority question does the nurse ask this client? A "Are you having any pain?" B "Are you having blood in your stools?" C "Do you notice any changes in your memory?" D "Do you bruise easily?"

A community health nurse is cautious when recommending the use of OTC cold remedies to patients. The use of pseudoephedrine would most likely be contraindicated in which of the following patients? A) woman who is breast-feeding b)A man with a history of angina and hypertension C) A man who has diagnoses of chronic obstructive pulmonary disease and diabetes D) A woman who has myasthenia gravis

B angina and hypertensio

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr ANS:

B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

The client with respiratory difficulty has a ratio of 0.7. What is the significance of this value? A. The ratio is low; ventilation is exceeding perfusion. B. The ratio is low; perfusion is exceeding ventilation. C. The ratio is high; ventilation is exceeding perfusion. D. The ratio is high; perfusion is exceeding ventilation

B. perfusion exceeds ventilation

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow . c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.

C the pao2 of 45

A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse, "I feel so sick that I don't know if the treatment is worth completing." The nurse's best response to the patient is A "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again." B "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill." C "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you." D "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life."

Correct Answer: D Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse should not tell the patient that he or she will feel normal or not so ill. The survival with AML is not 80%.

28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should a. position the patient so that the right chest is dependent. b. administer high-flow oxygen using a non-rebreathing mask. c. cover the sucking chest wound with an occlusive dressing. d. tape a nonporous dressing on three sides over the chest wound.

Correct Answer: D Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of tension pneumothorax.

A 64-year-old with acute myelogenous leukemia (AML) who has induction therapy prescribed asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a.If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation. b.The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do. c.You don't need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly. d.The side effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.

A client has folic acid deficiency. which information in the nursing history would be of concern to the nurse? the client A. cooks in cast iron skillets b. does not like to eat fish has one alcoholic drink a week d. takes metformin

D metformin impairs folate uptake in the ileum

the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. the ventilator tubing is clear. what is the best immediate action by the nurse? a. humidy the 02 source b increase provided oxygenation c. remove the inner cannula of the tracheostomy d. suction the tracheostomy tube

D suction the trach tube

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon

D taking set of vital signs

The fluctuation of the level in the water seal indicates patency of the tubes with the re inflating lung. Constant bubbling in the wet suction control is normal. Constant bubbling in the water seal indicates an air leak. Decreasing drainage is normal. Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Developing a discharge teaching plan for the patient and family d. Administering the ordered subcutaneous filgrastim (Neupogen) injection

DAdministration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

The nurse is developing the care plan for a laryngectomy patient. Which patient need will be the highest priority for the nurse to address? A. A method of pain control B. Family support C. A method of communication D. The need for long term care

My answer would be C; rationale: because not being able to communicate increases anxiety which in turn increases pain also because how are you going to assess pain if there is no communication? Family support and long term care are not immediately of concern.

Pt went for a polyectomy he has to come back in 6 months why?

Polyps have a recurrence of coming back

You come on shift who would you asses first?

Pt that came back from bronchoscopy

ANS: D The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. If the client does not already have an IV , other members of the team can insert one after defibrillation. Likewise, intubation can occur later if necessary. Atropine is not given for ventricular fibrillation.

The nurse is alerted to a client's telemetry monitor. After assessing the following ECG,what is the nurse's priority intervention? a. Start a large-bore IV. b. Administer atropine. c. Prepare for intubation. d. Perform defibrillation.

When patient is using Spiriva what is important?

Use a spacer

smoking does what?

Weakens airways 2. Decreases area of gas exchange

A flutter Stable but symptomatic: Beta blockers and CCB to control rate ( Cardizem) Unstable: synchronized cardioversion Meds to convert to sinus rhythm → amiodarone/procainamide Catheter ablation Consult with cardiology

What ecg strips is this and the treatment?

A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best? a."It inhibits thrombin." b. "It inhibits fibrinogen." c. "It thins your blood." d."It works against vitamin K."

Which newly admitted patient should the nurse assign as a roommate for a patient who has aplastic anemia? a.A patient with severe heart failure b.A patient who has viral pneumonia c.A patient who has right leg cellulitis d.A patient with multiple abdominal drain

he client is ordered to be treated with Singulair. The nurse anticipates the client will experience what type of change in her laboratory values? a.Abnormal liver function tests b. Hyperglycemia c.Increased potassium level d. Change in cardiac enzymes

The nursing intervention that will enhance the nutritional status of a patient with COPD is to: a. Offer small, frequent meals. b. Encourage extra liquids with meals. c. Assist the patient to exercise before meals. d. Supply information about nutrition.

a offer small frequent meals

A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility. d. provide hope and encouragement to the family because the patient's disease process has started to resolve

a)support the family and help them understand the realistic expectations that the patient chance for survival is poor.

a patient who has had a left pneumonectomy to remove lung cancer is returned to the unit from surgery. the nurse should position the patient in a _____ position 1. high fowler 2. semi fowler 3. right side lying 4. left side lying

answer 4- post op positioning after a pneumonectomy is on the operated side to prevent the threat of tension pneumothorax with mediastinal shift and leakage from amputated bronchial stump

For which client with leukemia should you be prepared to teach about maintenance therapy? A. The client with acute lymphocytic leukemia who has relapsed B. The client with acute lymphocytic leukemia who is in remission C. The client with acute myeloblastic leukemia who has relapsed D. The client with acute myeloblastic leukemia who is in remission

answer: B Rationale: The purpose of maintenance therapy is to maintain an achieved remission. Clinical trials indicate that clients with acute myelogenous leukemia are not helped by maintenance therapy.

answer: Macrolides, (zithromax) Know these Pneumonia meds: "Various meds frequently Treat pneumonia cases" Vancomycin, Macrolides Tetracycline Fluoroquinolone Penicillin G Cephalosporin *(rocephin/Keflex

What is important about Spiriva?

aswer: do not use it as a rescuer inhaler.

The nurse would know that the client most likely to exhibit a false-negative Mantoux reaction is the client who is a. being treated for sickle cell disease. b. HIV-positive. c. malnourished. d.previously diagnosed with TB.

b hiv pt

the nurse closely monitors bilateral breath sounds and chest movement after a thoracentesis because: a.Fluid may quickly accumulate as result of inflammation b.Lung may have been punctured during the procedure c.Severe bronchospasm may cause atelectasis d.Asthma may result after the procedure

b.the lung may have been punctured during the procedure

1) Which assessment finding alerts the nurse to the possibility of pneumonia in a client with chronic bronchitis? a. Pulse oximetry reading of 92% b. Shallow respirations of 32/min c. Percussion is dull in left lower lobe d. Wheezes are audible over right and left bronchi

c)dull percussion

c. hypoxia

Is barrel chest the patient with emphysema

has in increase AP diameter

Hemolytic anemia includes _____ iron and reticulocytes

increase

bag was deflated

increase 02 to inflate bag

Pt with COPD you would be concerned with

increase somnolence

Sinus arrhythmia treament?

monitor BP & 02

lung cancer 3b lymph nodes

opposite side

The symptoms of hypoxemia for which the nurse should be alert are: a. Restlessness, tachycardia, and tachypnea b. Bradycardia, cyanosis, and restlessness c. Dyspnea, flushed face, and tachycardia d. Cyanosis, nausea, and bradycardia

restlessness, tachycardia, and tachypnea

Pre-op teaching for lobectomy

spirometry

purse lip breathing

through nose and longer exhale through mouth

give b6 vit when taking ING

to avoid neuropathies

Ensure patient is HEMODYNAMICALLY STABLE Observe & monitor If caused by meds → Discontinue meds ( amiodarone,BB,digoxin,CCB)

CardiUh Oh 3

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