Funds exam 6 final Review

a nurse is caring for a client who has a new diagnosis of chronic kidney disease. which of the following statements should the nurse identify as an indication of anticipatory grieving.

" I just cant believe that this dialysis is going to ruin my whole life. "

a nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. which of the following solutions should the nurse prepare to infuse for this client?

0.45 sodium chloride

a hospice nurse is reviewing the prescription for a client who is receiving palliative care. which of the following prescriptions should the nurse expect. select all that apply.

A. provide skin care with a moisture barrier cream B. administer artificial tears PRN D. perform mouth care every hour E. administer oxygen 2 L/min via nasal cannula.

nurse is reviewing the EKG strip of a client who has prolonged vomiting. which of the abnormalities on the clients EKG should the nurse interpret as a sign of hypokalemia?

Abnormal prominent U wave

a nurse is caring for a client and identifies an infiltration at the IV catheter site. identify the order the nurse should perform the following actions.

B. Stop the infusion D. remove the IV catheter. E. Apply a sterile dressing A. Elevate the extremity. C. Apply warm or cold compresses.

a nurse is providing postmortem care for an adult client. which of the following actions should the nurse take. select all that apply.

B. determine whether the client will have an autopsy C. cover the body with a clean sheet & place arms outside of the sheet. E. give the clients personal belongings to the family.

a nurse is assessing a client who has narcolepsy. which of the following findings should the nurse expect. Select all that apply

B. sudden attacks of sleep C. hallucination at the onset of sleep

a nurse in a dialysis center is caring for a client who has a new diagnosis of end stage kidney disease. when he arrives for his first dialysis treatment, he tells the nurse, " I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again. the nurse should identify that this client is demonstrating which of the following kubler-ross stages of grieving?

Denial

a nurse is caring for a client who has cancer and is receiving palliative care. which of the following statements by the client indicates they understand this type of treatment.

I am hoping this will limit my discomfort

a nurse is instructing a young client about healthful sleep habits. which of the following statements should the nurse identify as an indication that the client needs further teaching?

I watch television until I fall asleep

a nurse is teaching a client who reports insomnia about promoting rest and sleep. which of the following statements should the nurse identify as an indication that the client understands the instructions.

I will no longer have a glass of wine before bedtime.

a client is admitted to the ER with a respiratory rate of 7/min. arterial blood gases (ABG) reveal the following values. which of the following is an appropriate analysis of the ABGS? ph 7.22 PaCO2 68mm Hg base excess -2 PaO2 78 mm Hg saturation 80% bicarbonate 26 mEq/L.

Respiratory acidosis

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

Urine specific gravity

a nurse is prioritizing the client care after receiving change of shift report. which of the following clients should the nurse plan to see first?

a client who told an assistive personnel he is short of breathe.

The nurse is performing nasotracheal suctioning. what should the nurse do when suctioning this client

apply intermittent suction during withdrawal of the tube

a client is demonstrating signs of hypoxia. what laboratory value will help the nurse determine the clients degree of effective gas exchange.

arterial blood has

a nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 l/min via nasal cannula. which of the following actions should the nurse take

attach a humidifier bottle to the base of the flow meter

a client tells the nurse that he suspects that he grinds his teeth at night. the nurse should explain that the client should see a dentist for this problem, which should see document as which o the following disorders.

bruxism

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq/L PO daily. the nurse reviews the clients most recent laboratory results and finds the clients potassium level is 5.2 mEq/L/ wwhich of the following actions should the nurse take?

call the prescribing physician and inform her of the clients serum potassium level results.

a nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. which of the following findings should the nurse recognize as a potential causative factor

client has a NG tube to gastric suction

A nurse is assessing a client who has chronic respiratory insufficiency. which of the following findings should the nurse expect as result of the long term inadequate oxygenation.

clubbing of the fingers

a nurse is assessing an IV infusion site on an infants left hand. which of the following findings should the nurse identify as an indication of an infiltration?

edema in the palm of the hand

a nurse is caring for a client who reports difficulty sleeping while in the hospital. which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene.

flushes the clients toilet after emptying the urinary catheters drainage bag.

a nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. which of the following actions should the nurse take?

obtain a 12 lead ecg

a nurse is caring for a client who has a peripheral vascular disease and reports difficulty sleeping because of cold feet. which of the following nursing actions should the nurse take to promote the clients comfort?

obtain a pair of slipper socks for the client.

a nurse is reviewing the laboratory values of a client who has respiratory acidosis. which of the following findings should the nurse expect.

paCO2 50mm Hg

a nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. which of the following actions should prompt the nurse to intervene.

prepares to cleanse the body

a nurse is teaching about risk factors of developing a stroke with a group of older adult clients. which of the following nonmodifiable risk factors should the nurse include in the teaching?

race

a nurse is caring for a client who has returned to the unit following a surgical procedure. the clients oxygen saturation is 85%. which of the following actions should the nurse take first?

raise the head of the bed

a nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. which of the following actions should the nurse take?

suction intermittently, only while withdrawing tube

a nurse is assessing a client who has hypoxia. which of the following findings should the nurse expect?

tachycardia

a nurse is working with a licenses practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

the area surrounding the insertion site feels warm to the touch

a nurse is caring for a client who sustained blood loss. which of the following is a manifestation of hypovolemic?

weak, rapid pulse

a nurse is preparing to administer ranitidine 300 mg PO daily to a client. the amount available is ranitidine 150 mg/tablets. how many tablets should the nurse administer?

2 tablets

a nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. the nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28%

a nurse is preparing to administer clonidine 0.3 mg at bedtime to a client. the amount available is clonidine 0.1 mg/ tablets. how many tablets should the nurse administer per dose?

3 tablets

A nurse is caring for a client who has mastic bone cancer. The client states " I want to go home to die." the family is concerned about meeting the clients care needs at home. which of the following actions should the nurse take.

A discuss initiating hospice care with the client and family.

a nurse in a providers office is reviewing the laboratory results of a client who takes furosemide for hypertension. the nurse notes that the clients potassium level is 3.3 mEq/L. the nurse should monitor the client for which of the following complications?

Cardiac Dysrhythmias

a nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternation periods of hyperventilation and apnea. the nurse should document that the client has which of the following respiratory alternations.

Cheyne-strokes respiration.

a client has a medical condition that often results in the development of metabolic acidosis. the nurse should observe this client for the development of which breathing pattern as a result of this condition?

Kussmauls

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

a low concentration of oxygen delivers

a client diagnoses with chronic obstructive lung disease (emphysema) who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. what action should the nurse take?

have the client breathe through pursed lips

a nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. which of the following client statements indicates an understanding of the teaching?

if I could lose about 50 pounds, I might stop having so many apneic episodes.

a nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. which finding indicates to the nurse that the client may be developing hypovolemic shock?

increase in the heart rate from 88 to 110/min

a nurse is planning care for a client who has hypernatremia. which of the following actions should the nurse anticipate including in the plan of care

infuse hypotonic IV fluids.

a nurse receives a laboratory report for a client indicating a potassium level of 5.5 mEq/L. when notifying the provider, the nurse should anticipate which of the following actions.

initiating continuous cardiac monitoring

a nurse is caring for a client who has the following arterial blood gas results. HCO3 18mEq. PaCO2 28mm Hg and PH 7.30. the nurse recognizes the client is experiencing which of the following acid base imbalances?

metabolic acidosis.

a nurse is assessing a client who has a sodium level of 116 mEq/L. which of the following findings should the nurse expect.

nausea and vomiting

a nurse is caring for four clients who have drainage tubes. which of the following clients should the nurse recognize as being at risk for hypokalemia

the client who has a nasogastric (NG) tube to suction

A nurse is assessing a client who had left femoral cardiac angiography. identify where the nurse will palpate to assess the most distal pulse on the affected side.

the most distal pulse refers to the pulse that is at the farthest point on the affected extremity. the dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. because the clients had left sided angiography, the correct answer will be the left pedal pulse.