fundamentals examm 2

Oliguria is defined as less than ______ mL of total output in 24 hr or less than 30 mL per hr

400

A __venturi______ _mask______ delivers a specific concentration of oxygen at a constant rate of flow.

A _nasal____ __cannula_____ delivers a relatively low concentration of oxygen (24% to 44%).

A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery dose which of the following?

A nasal cannula delivers a relatively low concentration of oxygen (24%-44%)

A nurse has a client with a lab potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Administering sodium polystyrene sulfonate.

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching?

Check the cannula position on a regular basis, Check the tops of the ear for skin breakdown, Post "no smoking" signs in a prominent location in the home, Check the cannula position on a regular basis

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?

Decreased potassium level

Where should the nurse put the pulse oximeter on a patient with edema in the hands and thickened toenails?

Earlobe

The nurse is reviewing the results of a client's arterial blood gas (ABG). Which ABG interpretation would indicate that this client is experiencing metabolic alkalosis? -

Elevated pH, elevated HCO3

A nurse is caring for a client who is postoperative. Which of the following nonpharmacological interventions should the nurse use to promote bowel elimination for this client?

Increase ambulation

A nurse is caring for a client who has pneumonia. Which action will promote thinning of respiratory secretions?

Increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose.

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

Instruct the client about the use of a sequential compression device

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room.

What is the correct procedure for obtaining an O2 saturation?

Measured using a two sided sensor probe with infrared red light. Placed at the toe, finger, or ear. clean the site, ensure no nail polish and good capillary refill

ABGs are prescribed for a client with CRF who has hypotension, cold and clammy skin, and dysrhythmias (see table). The nurse should notify the HCP to report that the client is experiencing which imbalance? pH: 7.20 PaCO2: 32 HCO3: 14

Metabolic acidosis

A nurse is reinforcing teaching with a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? Select all that apply. ·

Post a "No Smoking" sign inside the home. ·Attach oxygen containers to a fixed object. ·Store spare oxygen containers in a closet. ·Notify the fire department that oxygen is used in the home. ·Ensure oxygen tubing is no longer than 60 feet in length.

A nurse is caring for a client with renal failure. Blood gas results indicate a pH of 7.30; a PCO2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. The nurse has determined that the client is experiencing metabolic acidosis. Which of the following laboratory values would the nurse expect to note?

Potassium level of 5.2 mEq/L

A nurse is caring for a client who is 4 hour postoperative following a hip replacement. The nurse should instruct the client to avoid which of the following activities?

Putting on shoes and socks

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's O2 sat is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed.

pt just came back from PACU with IV and PEG tube following abd surgery. What is your first priority assessment?

Surgical dressing

A nurse is planning care for a client who is preoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (select all that apply)

There is minimal risk of an overdose of pain medication while using the PCA pump, using the PCA regularly will provide a consistent level of pain relief, Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable

Why is it important for the pulse oximetry probe to be on a finger with capillary refill < 2 seconds? Should the O2 sensor be placed on the same side as the blood pressure cuff? Why or why not?

This will cause pulse oximeter alarm to sound every time the blood pressure cuff inflates.

A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs?

To establish a baseline for postoperative assessment

A nurse is caring for a client who has a JP drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound

What happens during the Evaluation phase of the Nursing Process?

a nurse determines if the client's outcomes have been met by the interventions that have been utilized.

Post op atelectasis is an incomplete ________ expansion or collapse. Breath sounds are dull or ______ over areas of alveolar collapse.

alveolar, absent

DUring the _________ stage of the nursing process, a nurse uses clinical judgement regarding the health conditions or needs of a client.

analysis

The nurse should check the client's gag reflex after anesthesia before administering ordered ice chips or fluids to reduce the risk of

aspiration

When transferring a client- using a powered standing-assist lift is the ____option to ensure the safety of the client and the nurse.

best

smoking increases risk of what after surgery

blood clots, myocardial infarction, pneumonia, tissue necrosis, and delayed wound healing

The tops of the ears, the nares and the nasal mucous membranes should be assessed regularly for skin __________. The family is instructed to post no ________" signs in a prominent location in the home because oxygen increases the risk of ____injuries.

breakdown, smoking, fire

A nurse is assisting with preoperative teaching for a client. Which of the following outcomes should the nurse expect?

decrease length of stay in the health care facility

A client experiencing respiratory acidosis would have a ________pH, a ______ (or slightly elevated if acute) HCO3 and an _________ PaCO2. Several conditions can lead to respiratory acidosis, including _____ and pneumonia.

decreased, normal, increased COPD

Elevating the head of the bed uses gravity to reduce pressure on the __________________ from the abdominal organs and allows for increased expansion of the lungs

diaphragm

The use of a _____ _____ for oxygen delivery restricts the client's ability to eat, speak or drink.

face mask

Area rugs increase risks for tripping and falling, fluorescent lights can create glare, a night light is sufficient. A bath chair in the shower helps to reduce ____ in the shower. Walkers and canes should be kept within _____ during the night.

falls, reach

To prevent dryness of sinuses from oxygen, the nurse should attach _________ for a client receiving oxygen greater than 4 L/min via nasal cannula. Clients may eat with a _____ cannula on.

humidification, nasal

If client experiencing fluid volume deficit would manifest in

increased BUN, increased hematocrit, and urine specific gravity greater than 1.030

A client experiencing respiratory alkalosis would an _________ pH, a _____ (or slightly decreased if compensated) HCO3 and a _________ PaCO2.

increased, normal, decreased

because nurses cannot measure pain objectively, it is standard practice to accept that pain

is what the client says it is and to intervene accordingly

Auscultation of crackles in the ______often indicate fluid in the alveoli, but they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a ____.

lungs, cough

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?

metabolic alkalosis

A nurse is reviewing the arterial blood gas (ABG) results of client. The client's ABG's are pH: 7.6, PaCO2: 40 mmHg, and HCO3: 32 mEq/L. Which of the following acid base conditions should the nurse identify the client is experiencing?

metabolic alkalosis

When preparing for a CXR, the client must remove all _ objects since the _metal___blocks visualization of body structures and tissues.

metal

A nurse is assessing a postoperative patient 3 days after an abdominal surgery. Absence of bowel sounds, abdominal distention, and the client passing no flatus are indications of

paralytic ileus

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

planning

covert manifestations of bleeding

rapid, thready pulse, tachycardia, and decreased urine output

When caring for clients on O2 via nasal cannula: verify the ____of flow daily. The position of the ____ _______ should be verified every 8 hours or more often if needed.

rate, nasal cannula

The O2 sensor should be relocated every 4 hrs. to decrease the risk of impaired ____ integrity.

skin

Which is an example of a nurse-initiated intervention?

teach the client how to splint an abdominal incision when coughing n deep breathing

A nurse is reviewing the lab results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

urine specific gravity 1.035

Protecting the nares from dryness is important, but the client should use a _____-based lubricant or saline nasal spray to reduce dryness and irritation. ______ has a high combustion potential, and petroleum products are combustible.

water, oxygen

A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication?

~Obstructive sleep apnea places the client at risk for postoperative airway obstruction.