Foundations Final Prep you

The nurse is cleaning the inner cannula of a tracheostomy tube with equal parts of normal saline and:

hydrogen peroxide.

A nurse is preparing to insert an oral airway. The nurse would position the client supine with the neck in which position?

hyperextension

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

The family of a client with short-term memory deficits cannot provide needed care at home. The client does not require 24-hour nursing care but will need some assistance with administering medications. What would be the best facility for this client?

intermediate care facility

A client is having difficulty breathing. During assessment of the client, which findings would the nurse expect to see? Select all that apply.

lack of energy rapid, shallow breathing nasal flaring

A nurse is caring for a client with diabetes. What is the recommended blood sugar level 1 to 2 hours after the client has completed a meal?

less than 180 mg/dL

A nurse is preparing to position a client who will be undergoing a gynecologic procedure. Which position would the nurse most likely help the client take?

lithotomy

Which test does the nurse anticipate will be ordered for a client presenting to the emergency department that is suspected of having meningitis?

lumbar puncture

A nurse has just completed tracheal suctioning on a client. Which finding would the nurse interpret as indicating that the treatment was effective?

lungs clear on auscultation

An older adult is having a diagnostic test at 10:00 am and is to have nothing to eat or drink after midnight the night before. How can the nurse determine that the patient is tolerating the fasting state? Select all that apply.

mental status urinary output blood pressure

Which of the following persons is responsible for handling and filing a death certificate with proper authorities?

mortician

A client is ordered to receive nasopharyngeal suctioning every 2 hours. Which of the following would the nurse anticipate using as a protective measure for the client?

nasopharyngeal trumpet

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

nonrebreather mask

A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?

nonrebreather mask

A nurse is caring for a client involved in an accident. The client informs the nurse that he wants to leave the facility immediately after first aid, although the physician has ordered tests and not given permission for discharge. Which nursing action is the priority at this time?

obtaining the client's signature on a dated release form

A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?

options for smoking cessation

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

Pulse oximetry gives what type of information about the client?

percentage of hemoglobin carrying oxygen

The sedated client has an oxygen saturation that has dropped to 88%, a respiratory rate of 10 breaths per minute, and gurgling sounds when taking breaths. The best action of the nurse is to:

perform nasopharyngeal suctioning.

Which is a major organ of the upper respiratory tract?

pharynx

A client who has completed all the admission formalities is escorted to the nursing unit. Meanwhile, the admission department also informs the nursing unit about the arrival of the client. Which nursing action is the priority at this time?

placing oxygen administration equipment

Public health nursing is the branch of nursing that

provides health care for the community.

Which nursing action should the nurse implement for an adult client who may be anxious during the admission process?

providing explanations and instructions to the client

The nurse needs to assess arterial oxygen saturation (SaO2) in a client. What is the best procedure to accomplish this?

pulse oximetry

A physician orders the nurse to administer 131I to alter the molecular structures of the client's body. The physician needs to find the hot spot and the cold spot using this element. What does 131I mean?

radioactive iodine

A nurse is caring for a client who needs to get a chest x-ray done. The nurse assesses the client's vital signs before the procedure in order to assess the client's condition. What other nursing action must be completed before the client is taken to the x-ray department?

removing all metal items from the client's body

The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?

removing secretions from the throat through an orally inserted catheter

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

shock

A middle-aged client is agitated and wants to go home. The nurse attempts to engage the client in conversation and to listen. It soon becomes clear that the nurse needs to contact the nurse manager. The client cannot be held in the hospital against the client's will. However, if the client leaves the hospital against medical advice (AMA), the client must:

sign the form releasing the facility and doctor from legal responsibility.

A client is to undergo a sigmoidoscopy with a flexible scope. The nurse should assist the client into which position?

sims

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather?

tent

An 84-year-old man has presented to the primary care provider accompanied by his daughter. The daughter tells the care provider that her father has recently stopped sleeping in his bedroom and bathing in his bathroom. The man denies this, stating that he has simply decided to change his routines around the house. A nurse should consider the possibility that:

the man may be downplaying his lack of mobility out of fear of having to move out of his home.

Which older adult clients are at increased risk for aspiration? Select all that apply.

those who report, "I have trouble swallowing" those with late-stage dementia those who are hospitalized following a stroke those recovering from general anesthesia

A physician instructs the nurse to administer iodine orally to a client before an x-ray. What is the primary reason for the administration of iodine before an x-ray?

to make hollow body parts appear distinct

A nurse is caring for a client who underwent a tracheostomy (trach) following throat surgery. What is the rationale for swabbing the area around the outside of the trach tube with hydrogen peroxide?

to remove encrusted secretions

The nurse is observing a student nurse perform nasopharyngeal suctioning on a client. The nurse corrects the student when the student nurse:

touches the connecting tubing with the dominant hand.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

true

The husband of a client who died of breast cancer is still grieving for his wife 2 years later. What type of grief is he experiencing?

unresolved

After performing a Gram stain, a nurse knows that the culture is positive when the cells turn what color?

violet

Which statement by the nurse best explains the need of clients who are cared for at a progressive care unit?

"A progressive care unit provides care for clients who were critical and have recovered sufficiently to require less intensive nursing care."

The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning? You Selected:

"All efforts will be taken to make sure your loved one is comfortable and out of pain."

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

The nurse is preparing a client for a bedside thoracentesis. Which question by the nurse would best assess the client's comprehension of the procedure?

"Can you tell me the risks for this procedure?"

Which client statement does the nurse assess as reflective of understanding about Pap test results?

"Class II means that my result is unusual, but not cancerous."

The client is prescribed postural drainage two times per day at home. When reinforcing client instructions, the nurse states:

"Cough sputum into paper tissues."

The nurse is preparing a client for an angiography, when the client states, "I am not sure if I really need this procedure." What would be the most appropriate response by the nurse?

"Do you have any specific questions about the procedure?"

Which statement could assist the nurse in identifying the role of the admitting department?

"Have you gathered the client's information for billing?"

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?

"Make each breath deep enough to move the bottom ribs."

A client diagnosed with a terminal illness is displaying periods of depression and anger alternating with acceptance. The client's spouse is concerned about the client's labile mood. When talking with the client's spouse, which statement made by the nurse best addresses principles of loss and grieving?

"Not everyone experiences grief in the same way and your loved one needs our support."

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone."

An older adult is admitted to the hospital. When the certified nursing assistant (CNA) brings in an admission kit, the nurse overhears the CNA say to the client, "Hi, Sally. I'm the CNA who will be with you this evening." What should the nurse discuss with the CNA?

"Thank you for bringing the kit. To prevent a loss of identity, please use the client's last name unless the client requests otherwise."

Which statement made by an older adult would suggest to the nurse that the client is facing barriers when trying to access community-based services?

"The business hours for the health facility are the same as that of my part-time job."

A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation?

"The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes."

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

"The inability to talk about your dad without crying, even after a year, is still considered normal."

The clinic nurse is reviewing a client's Papanicolaou (Pap) class I test results. How would the nurse explain the results to the client?

"The results show no abnormal cell changes."

The nurse informed the relatives of an older client as to why the client will be referred to a life care housing option. Which statement by the relative indicates that the teaching was effective?

"This means that my relative will be living in a residential complex that provides services and accommodations as each resident's needs change."

The nurse is preparing the client for a Papanicolaou (Pap) test. The client asks the nurse, "What will this test tell me?" What responses by the nurse are correct? Select all that apply.

"This test will screen for abnormal cervical cells." "This test will help determine the status of reproductive hormone activity." "This test will detect normal or infectious microorganisms in the vagina or uterus."

An HIV-positive 34-year-old client asks the nurse how often she should have a Pap test. What is the best response by the nurse?

"You should have a Pap test more frequently than every 3 years."

A 59-year-old woman is scheduled to undergo a screening colonoscopy and has presented to the hospital's outpatient department for the procedure. What should the nurse teach the client about the conscious sedation that will be used during the procedure?

"You'll talk to us during the procedure, but you won't likely remember it after the fact."

Which activities should the nurse consider during the initial nursing plan for care for a client who was just admitted? Select all that apply.

-revising the care plan if the client's condition changes -identifying the client's projected need for teaching -identifying the client's priority needs

A nurse is collecting a sputum specimen from a client. How much sputum should the nurse collect?

1 to 3 mL

A client meets the criteria for Medicare benefits in a nursing home. The client's son asks the nurse how many days the client will be eligible for assistance with the costs. What response from the nurse would be accurate? Record your answer using a whole number.

100

A nurse is reviewing home care measures with a client who must perform postural drainage. The nurse advises the client to perform the exercise how often?

2 to 4 times/day

A nurse is reviewing a client's reproductive and sexual history with her. The nurse advises the client that she should have a Pap test no later than what age? Record your answer using a whole number.

21

The nurse is arranging the timing for a client to undergo glucometer testing. How many minutes before a meal should the nurse schedule the test? Record your answer using a whole number.

30

A nurse is teaching a client about postural drainage. What is the maximum duration, in minutes, that a client should hold each of the prescribed positions?

45 minutes

A client has responded to a recent diagnosis of lung cancer by making extensive plans for overseas travel with family, despite the extremely poor prognosis. The client is adamant about not discussing cancer and is identified by the nurse as experiencing the denial stage of grief. How can the nurse best facilitate the client's healthy grieving?

Address the client's diagnosis and prognosis at a later time or date.

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

Administer sedation and analgesia.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?

Anger

The nurse is reviewing a client's Pap test results and observes that for identifiable microorganisms, the client has a score of 4. What does this indicate?

Candida, which is a yeast-like fungus

The hospice nurse is caring for several clients on the unit. Which client is exhibiting signs or symptoms of impending death?

Client with circumoral cyanosis and abdominal mottling

The nurse is preparing a pregnant client who will soon undergo ultrasonography. What is the appropriate nursing teaching regarding intake/output prior to this procedure?

Consume five to six full glasses of fluid, 1 to 2 hours before testing.

A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?

Contact the organ procurement team to discuss organ donation with the spouse.

A client injured in an accident at her place of work has to be admitted in the health care facility. The client was taken directly to the nursing unit, and the client's colleague is asked to continue with the admission formalities. What of the following information must be entered on the form?

Correct response: Medicare details

Which of the following is a sign of impending death related to the central nervous system?

Diminished pain perception

For an older adult to return home after discharge from the hospital, what intervention should be implemented?

Early discharge planning must occur.

The client is actively dying and has a prescription for Do Not Resuscitate. The nonresponsive client is mouth breathing and has noisy respirations. The client is incontinent of urine and feces. The family is at the bedside. What interventions would be appropriate for the nurse to perform to meet the needs of the client and the family? Select all that apply.

Elevate the head of the bed to a semi-Fowler's position. Encourage the family to reminisce about positive, enjoyable events that the client and family shared together. Cleanse the client's mouth every shift and p.r.n.

A sputum specimen is to be collected from a client. What would the nurse do?

Encourage a forceful cough to expectorate sputum.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently?

Encourage the client to take deep breaths

A nurse is preparing to suction a client. Place the suction procedure in the correct order.

Gather equipment. Adjust the suction to 120 to 150 mm Hg with tubing occluded. Provide preoxygenation. Set up a sterile field and apply gloves. Insert the catheter without suction approximately 5 to 6 inches. Withdraw the catheter, applying intermittent suction, and oxygenate the client

A client is advised by her physician to receive a Pap test approximately 3 years after the onset of sexual intercourse. What are the recommended guidelines for the client to follow after the first Pap test has been completed?

Have annual Pap tests thereafter until 30 years of age.

The nurse is preparing to assist the physician with a paracentesis. What intervention can the nurse provide to avoid a complication with this procedure?

Have the client empty the bladder prior to the procedure.

A nurse is taking care of a client who is experiencing the shock phase of grieving. Which nursing intervention is best for this client?

Help the client mobilize support systems

A client says, "You guys are not doing anything for me. I am leaving." Which interventions are indicated by the nurse? Select all that apply.

Inform the client of the risks of leaving. Witness the client's signature on the against medical advice form. Don't insist that the client sign the form!

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence

A client visits the health agency with severe headaches and nausea. The physician advises the client that an MRI needs to be obtained to determine the exact cause of the client's problem. Which of the following is a feature of the MRI test?

It produces images by using atoms through a strong electromagnetic field.

Why is keeping clients with respiratory disorders well hydrated an important nursing intervention?

It thins mucus, promoting its expectoration.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Label the sputum specimen and take it to the lab.

A nurse is collecting a sputum specimen from the client. Place the steps in the correct sequence

Obtain a sterile sputum specimen cup and help the client to a sitting position. Encourage the client to rinse the mouth with tap water. Explain that the desired specimen should be from deep within the respiratory passages, not saliva from within the mouth. Instruct the client to take several deep breaths, attempt a forceful cough, and expectorate into the specimen container. Collect at least a 1- to 3-mL (nearly a half teaspoon) specimen. Wear gloves and cover and enclose the specimen container in a clear plastic bag.

The nurse is evaluating the effectiveness of therapy for a client who has received inhalation therapy treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

Oxygen saturation is > 94%.

A nurse is providing tracheostomy care for a client. After removing the plastic inner cannula, which would the nurse do next?

Place the cannula in the diluted hydrogen peroxide.

The nurse is to obtain a sputum specimen from the client. Which actions should the nurse perform? Select all that apply.

Plan to collect the sputum in the morning. Assist the client to a sitting position.

The nurse is caring for an older adult client who worked in a coal mine for 40 years. Which finding(s) does the nurse anticipate upon assessment of the client's respiratory system? Select all that apply.

Shortness of breath Chest tightness and discomfort Winded at rest and with activity Cough, with or without black sputum

A nurse is to collect a sputum specimen for a client admitted with acute bronchitis. Which instruction(s) does the nurse give the client about collecting the specimen? Select all that apply.

Spit the sputum into the tube carefully and try not to touch the rim of the container Do not smoke before coughing up sputum from the lungs Rinse (do not swallow) the mouth with water before collecting sputum Take several deep breaths and cough hard from deep inside the chest three times to bring sputum up from the lungs

A nurse is preparing to obtain a throat culture from a client. Place the steps in the order that the nurse would complete them, from first to last.

Tell the client to open the mouth and stick out the tongue. Depress the middle of the tongue with a tongue blade. Rub and twist the tips of the swab around the tonsil areas. Remove the swab and spread the secretions on a glass slide. Replace the swab securely in the tube, crushing the packet in the tube.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation.

The nurse is preparing to begin the discharge planning process with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process?

The client's identified needs and goal

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first

What is the result of increasing health care costs on hospital admissions?

The length of hospital stay has decreased.

A hospice nurse finds that a terminally ill client has let go of many of the people around him and is losing interest in routine activities. The nurse interprets this as indicating which stage of grief?

acceptance

A nurse is admitting a client to the hospital for surgery. Which pieces of information must be obtained from the client? Select all that apply.

address date of birth admitting physician

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:

apnea.

What is the responsibility of the nurse to a client who has decided to leave the facility against medical advice? Select all that apply.

asking the client to sign the leave against medical advice form informing the physician of the client's wish to leave persuading the client to delay such action

The client has a chest incision under the left arm from cardiac surgery 1 week ago. The client now has pneumonia and has percussion during postural drainage prescribed. The nur

avoids striking the area under the left arm.

A client comes to the clinic reporting that it "feels like when I swallow my food, it gets stuck in my esophagus." What diagnostic test does the nurse anticipate arranging for the client?

barium swallow

On what substances do nurses commonly assist with performing cultures? Select all that apply

blood urine stool wound drainage

According to the Harvard University Medical School committee, what function must be irreversibly lost to define death?

brain function

The nurse is developing the plan of care for a client who is recovering from a bronchoscopy. Which action by the nurse would be a priority to prevent aspiration during administration of medication?

checking for a gag reflex

The nurse is caring for an older adult client with pathologic pulmonary changes. The nurse should be aware that which conditions cause pathologic pulmonary change? Select all that apply.

clients with a history of smoking occupations where clients have inhaled pollutants clients residing in an area with toxic emission

A nurse is preparing a client for an endoscopic procedure in which a light, short-acting form of anesthesia will be used. What is the term for this type of anesthesia?

conscious sedation

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies

For which persons are death certificates necessary? Select all that apply.

death from an infectious disease death in an institutional setting unexpected death murder victims death before age 65 years

A nurse is caring for a client who has a long history of smoking, and states, "I cough for a long time every morning." The client has thick mucus secretions and is dyspneic with a respiratory rate of 28/min. The nurse uses which phase of the nursing process to apply the NANDA of Ineffective Airway Clearance?

diagnosis

What are important roles of the nurse in providing continuity of care to clients? Select all that apply.

educator collaborator advocate

The findings of an audit revealed that 40% of medical errors are attributed to inadequate medication reconciliation. Which finding would indicate to the nurse that there is evidence of inadequate medication reconciliation?

failure of the nurse to verify the client's current medication

A nurse is to perform capillary blood glucose testing with a client. Which materials would the nurse gather to perform this procedure? Select all that apply.

glucometer control solution lancet holder

The physician at the health care facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of performing vibration on the client?

helps shake underlying tissue and loosen the retained secretion