Exam #1

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. respiratory Acidosis

A nurse is caring for a client who has a postoperative ileus and an NG tubethat has drained 2,500 mL in the past 6 hr. Which of the following electrolyteimbalances should the nurse monitor the client for? 1. elevate Na levels 2. Decrease K levels 3. elevate Mg levels 4. Decreased calcium level

4. Decreased K Level

a nurse is planning care for a client who has Hep B which of the following interventions should the nurse include in the plan? 1. administer ABX 2. Provide high fat diet 3. restrict fluids 4. encourage short periods of ambulation

4. encourage short periods of ambulation

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? 1. bradycardia 2. bradypnea 3. lethargy 4. intercostal retractions

4. intercostal retractions

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. What is the nurses highest priority Administering a nebulizer beta- adrenergic

Administering a nebulizer beta- adrenergic

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

Before the examination your provider will give you a sedative that will make you sleepy

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client hasA. Kussmaul breathing.B. apneustic breathing.C. Cheyne-Stokes respirations (CSR).D. stridor.

C

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?A. Avoiding covering sores and bandages B. Avoiding handwashing after eating C. Avoids foods prepared w/ tapwater D. Avoid eating meat

C

a nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. which of the following statements by the client indicates the need for further teaching?

I will be able to eat sold food when i wake up from anesthesia

A nurse is caring for a patient who is 6 hour postoperative and has a chest tube in place attached to a closed-chest water-seal drainage system. The nurse should observe for which of the following indications of a problem in the drainage system? A. constant bubbling in suction-control chamber B. fluctuations in fluid level in water-seal chamber C. occasional bubbling in water-seal chamber D. continuous bubbling in water-seal chamber

D

A nurse is preparing to hang a new bag of TPN and notices it has not arrived from he pharmacy. Which of the available solutions should the nurse infuse until he client's TPN arrives?a. Lactated Ringersb. Dextrose 5% in .225% salinec. 0.9% salined. Dextrose 10% in water

Dextrose

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

Oral Mucosa

a nurse is reviewing the laboratory results of a client who has respiratory acidosis

PaCO2 50

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Purplish-colored stoma

a nurse in a clinic sees a client who has an acute asthma exacerbation. which of the following medications should reduct the symptoms

albuterol via jet nebulizer

a nurse is caring for a client who has a three-chamber closed chest tube system. which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration

continue to monitor the patient

While assessing a client who is receiving intravenous (IV) therapy via his left forearm, the nurse notes that the site is red, swollen, and painful, and that the surrounding tissues are hard. The nurse's first action should be which of the following?

dc the IV

the nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. the nurse recognizes which of the following laboratory findings as indicating the clients

elevated BUN

A nurse in the ER is caring for a client who was injured in a MVA, the client reports dyspnea and severe pain. the nurse notes that the clients chest moves inward during inspiration and bulges out during expiration. the nurse should identify this finding as which of the following

flail chest

the nurse is caring for a post op client who has a chest tube connected to suction and a water seal drainage system. which of the following indicates to the nurse that the chest tube is functioning properly

fluctuation of the fluid level within the water seal chamber

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?A. History of bulimia.B. History of NSAID use.C. Drinks green tea.D. Has a glass of wine with dinner each day.

hx of NSAID use

A nurse is caring for a client with recurrent kidney stones. The provider order several diagnostic studies, including intravenous pyelogram (IVP), urine culture and sensitivity, and strain all urine. The nurse needs to inquire further if the client states which of the following?

i dont eat shellfish because it gives me hives

a nurse is assessing a client who has a pneumothorax with a chest tube in place. for which of the following findings should the nurse notify the provider

movement of the trachea toward the unaffected side

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

semi-fowlers

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18-28 b. Increased oral temp from 36.6C (97.8F) to 37C (98.6F) c. Increased blood pressure from 112/68 to 120/72 d. Increased heart rate from 68 to 72/min

A

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? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

A

a nurse is assessing a client who has peptic ulcer disease. which of the following findings

hematemesis

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

heparin

a nurse is caring for a client who is Post op and whose respirations are shallow and 9/min which of the following ABG should the nurse identify the client as being at risk for

resp acidosis

A nurse is caring for a patient who's ABG results show a pH of 7.3 and a PaCO2 of 50. The nurse should identify that the patient is experiencing what? metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis

respiratory acidosis

a nurse is caring for a client who has a tracheostomy. which of the following interventions should the nurse implement when performing tracheostomy

secure new tracheostomy ties before removing old ones