Custom: Spring 23 Week 11
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Movement of the ET tube into the right main bronchus
A nurse is caring for a client on the medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Request a 12-lead ECG Prepare for cardioversion Ventricular Tachycardia Cardiac Rhythm Serum potassium
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Respiratory acidosis
A nurse is teaching a client who will undergo a bronchoscopy procedure. The provider will use a rigid scope and general anesthesia. The nurse should explain that the client's neck will be in which of the following positions?
A hyperextended position
A nurse is caring for a client on the medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Anticipate administering IV antibiotics Request a prescription for bronchodilator Respiratory acidosis PaCO2 papilledema
A nurse is caring for a client on the medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Anticipate administering IV heparin Prepare client for ultrasound doppler of the lower extremity Arterial Thrombosis aPTT Platelet count
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?
Assess the client's airway.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?
Assist the client to the correct room.
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?
Auscultate lung fields.
A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
Breathing ranging from very deep to very shallow with periods of apnea
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Continuous bubbling in the water-seal chamber
A nurse is caring for a client in the emergency department. Complete the diagram by dragging from the choices below to specify what condition the client is most experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Ensure oxygen and suctioning equipment are readily available. Place the client on droplet precautions Bacterial Meningitis Level of consciousness WBC count
A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take?
Keep the collection device below the level of the client's chest.
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Place in a prone position.
A nurse is caring for a 36-hr-old newborn in the neonatal intensive care unit (NICU) born at 34 weeks of gestation. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Administer oxygen as prescribed Restrict fluids Patent ductus arteriosus Arterial blood gases Intake and output
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
No fluctuations in the water seal chamber
A nurse is caring for a client who has a pneumothorax. A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Obtain ABGs - Anticipated Prepare the insertion of a chest tube - Anticipated Obtain intravenous access - Anticipated Computed tomography (CT) of the chest - Nonessential Pulmonary Function Tests (PFTs) - Nonessential Thoracentesis - Contraindicated
A nurse is caring for a client in the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Obtain a 12-lead electrocardiogram (ECG) Administer an anticoagulant Arterial fibrillation Manifestations of stroke PTT/INR
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
Reposition the client.
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Yellow sclera Increasing AST level Increasing ALT level Weight loss Mantoux test result