Lifespan evolve 2

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do?

Repeat the peak flow test.

A client with a new tracheostomy has a soiled dressing. What is the best nursing intervention?

Replace the dressing with a sterile, folded 4 × 4 gauze.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess?

Reproducible leg pain with exercise

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention?

Respiratory rate of 6 breaths/min

Which symptom reported by a client who has had a total hip replacement requires emergency action?

SOB and chest pain

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern?

Redness and swelling around the incision.

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done?

Reduce the number of intestinal bacteria

A client wishes to become pregnant, but has a family member with cystic fibrosis. She asks about the need for genetic testing. How does the nurse respond?

Refers the client to a genetic counselor

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success?

SpO2 level of 92% after ambulating 50 feet

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis?

Splinter hemorrhages

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction?

Troponin of 5.2 ng/mL

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding?

Urine output of 20 mL over 2 hours

A new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action?

Use a Doppler device to assess flow to the area.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet?

Use canola oil rather than palm oil

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential?

Validate that the client has remained NPO.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant?

Washing the skin with soap and water

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client?

Wearing a disposable particulate mask respirator and protective eyewear

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions?

Weight loss of 6 pounds since the last visit

The client says, "I hate this stupid COPD." What is the best response by the nurse?

What is bothering you?"

A child with asthma is having pulmonary function tests. The purpose of the peak expiratory flow rate (PEFR) is to:

assess the severity of asthma.

Nurses counseling parents regarding the home care of the child with a cardiac defect before corrective surgery should stress the:

desirability of promoting normalcy within the limits of the child's condition.

The nurse should explain to the parents that their child is receiving Lasix for severe congestive heart failure because it is a/an:

diuretic

The nurse is preparing to give digoxin to a 9-month-old infant. He or she checks the dose and draws up 4 ml of the drug. The MOST appropriate nursing action is to

not give the dose; suspect dosage error

An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to:

prevent respiratory syncytial virus (RSV) infection.

Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. The nurse should recognize that in clinical practice this system is:

problematic because children with acyanotic heart defects may develop cyanosis

After a patient returns from cardiac catheterization, the nurse assesses that the pulse distal to the catheter insertion site is weaker. The nurse should:

record the data on the nurse's notes.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit?

Client with pulmonary tuberculosis who is receiving multiple medications

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse?

Collaborate with the health care provider to administer a positive inotropic agent.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis?

Computed tomography (CT) scan

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response?

Considers further assessment for depression

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels?

Consume melons and baked potatoes.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response?

Contact the surgeon.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care?

Contacting the provider if the throat feels more swollen

The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for?

Continuous oozing of bright-red blood

A "do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?

Ensure that the tubing is patent and that oxygen flow is high.

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do?

Ensure written consultation of two noninvolved physicians.

What does the nurse do first when setting up a safe environment for the new client on oxygen?

Ensures that no combustion hazards are present in the room

Which activity related to genetic counseling best illustrates the role of the medical-surgical nurse?

Ensures that the client understands the consequences of having a genetic test performed.

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?

Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes?

Ethambutol

Which statement is true about the structure and forms of DNA?

Every time a cell divides, it must replicate its DNA.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?

Excessive swallowing

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?

Face tent

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history?

Fatigue

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action?

Honor the DNR order

Which condition might require genetic counseling for a client?

Huntington Disease

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?

Hyperoxygenate before and after suctioning.

A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication?

IV morphine sulfate (Morphine)

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF?

Ibuprofen (Motrin)

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action?

Immediately stop all inhalation anesthetic agents and succinylcholine.

A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first?

Immobilize the neck with a cervical collar.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first?

Implement nothing-by-mouth (NPO) status.

In the older adult client, which respiratory change requires no further assessment by the nurse?

Increased anteroposterior (AP) diameter

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action?

Place a respiratory mask on the client.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching?

"This test evaluates you for potentially fatal cardiac rhythms."

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)?

"Walk to the point of leg pain, then rest, resuming when pain stops."

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label?

"What is your name, and where were you born?"

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?

"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first?

Albuterol (Proventil) 2 inhalations

Which two factors in combination are the greatest risk factors for head and neck cancer?

Alcohol and tobacco use

What should the nurse recognize as an early clinical sign of compensated shock in a child?

Apprehension

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment?

Arrange for a health care worker to watch the client take the medication

A 23-year-old female client has a BRCA1 gene mutation, which increases her risk for developing breast cancer. She says, "I do not want to cut off my breasts!" What is the nurse's response?

"Let's discuss some other options."

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client?

"Avoid grapefruit juice."

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?

"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe."

A 36-year-old client with a suspicious mammogram tells the nurse that her mother died of bone cancer at age 40. In assessing the client for cancer risk, what question does the nurse ask next?

"Did your mother ever have any other type of cancer?"

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response?

"Do you have a scarf or a large loose collar that you could place over it?"

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective?

"Eating foods like green beans won't interfere with my Coumadin therapy."

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question?

"Give ibuprofen 800 mg every 8 hours as needed for pain."

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease?

"I am here to receive the yearly pneumonia shot again."

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care?

"I can only take baths, but no showers."

Which statement by a client with a laryngectomy indicates a need for further discharge teaching?

"I can't put anything over my stoma to cover it."

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (Select all that apply.)

-Combination drug therapy is effective in preventing transmission. -Combination drug therapy is the most effective method of treating TB. -Multiple drug regimens destroy organisms as quickly as possible. -The use of multiple drugs reduces the emergence of drug-resistant organisms.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial?

"I don't need to change. It hasn't killed me yet."

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction?

"I don't need to get a flu shot."

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks?

"I had a heart attack 4 months ago."

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement?

"I just started to feel a tearing pain in my belly."

The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective?

"I may need to restrict my activities for several months."

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions?

"I must have my emergency inhaler with me at all times."

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching?

"I should avoid eating hamburgers."

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching?

"I will call the provider if I have a cough lasting 3 or more days."

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure?

"I will have to take special care not to aspirate while eating."

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching?

"If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer?

"If the spacer makes a whistling sound, I am breathing in too rapidly."

The daughter of a client diagnosed with bilateral breast cancer has been counseled about genetic testing. She has decided not to be tested, despite the client's insistence. How does the nurse respond to the daughter's decision?

"It is your decision. You can always call if you change your mind."

The nurse is teaching a client about genetic counseling. Which statement by the client indicates that the teaching has been effective?

"Just because I have the trait does not mean that I will get the disease."

client who is to undergo cardiac catheterization should be taught which essential information by the nurse?

"Keep your affected leg straight for 2 to 6 hours."

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her?

"Make sure he always has wire cutters with him."

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care?

"My leg might turn very white after the surgery."

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire?

"My scrubs are sterile."

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction?

"Pain medication will take away my pain."

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching?

"These stockings will prevent blood clots."

The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching?

"The intranasal vaccine can be given to everybody in the family."

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response?

"This may be caused by a genetic trait."

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan?

"You will not be contagious to the people you have been living with."

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic?

"Your concerns are valid; we can review some steps to limit disease progression."

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? (Select all that apply.)

-Bakers. -Coal miners. -Furniture refurnishers. -Potters.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.)

-Chest discomfort or pain -Tachycardia -Fatigue

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.)

-Chest pain relieved by sitting upright -Sudden-onset chest pain relieved by anti-inflammatory agents -Pain in the chest described as sharp or stabbing

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.)

-Cold right foot -Numbness and tingling of right foot -Mottling of right foot and lower leg

In analyzing a three-generation pedigree for a client, which questions help determine the genetic implications of a health trait? (Select all that apply.)

-Do affected or unaffected individuals have children affected by the trait? -Is the trait expressed equally among male and female family members or is it expressed unequally? -Is the trait present in every generation, or does it skip one or more generations? -Is a pattern evident, or does the trait appear to be sporadic?

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.)

-Elevated C-Reactive protein levels -Smoking

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.)

-Has maintained a low-sodium, no-added-salt diet -Has lost 3 pounds since last seen in the clinic -Has cut down on caffeine

When assessing for hypertension in an infant, the nurse will expect the infant to exhibit which signs? (Select all that apply.)

-Irritability -Head rubbing -Waking up screaming in the night

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.)

-Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL -Smoking -Type II DM

A client with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? (Select all that apply.)

-Maintain the client upright for 30 minutes after eating. -Provide small, frequent meals. -Teach the client to "tuck" the chin down in the forward position to swallow.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.)

-Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. -The medications may cause nausea. The client should take them at bedtime.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.)

-Sinus bradycardia -Fatigue -Anorexia

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.)

-Troponin 3.2 ng/mL -Myoglobin 234 mcg/L

A 5-year-old child is brought to the Emergency Department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis is suspected. What are the most appropriate nursing interventions? (Select all that apply.)

-Vital signs -Medical history -Assessment of breath sounds -Emergency airway equipment readily available

Asthma is classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include: (Select all that apply.)

-lung function. -frequency of symptoms. -frequency and severity of exacerbations.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first?

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing.

After receiving change-of-shift report about these four clients, which client should the nurse assess first?

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions

Which client is at greatest risk for slow wound healing?

A 47-year-old obese man with diabetes

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation?

A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN?

A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index

Which statement is true about the role of a gene in the synthesis of a specific protein?

A gene contains the code for a specific protein.

Because the absorption of fat-soluble vitamins is decreased in children with cystic fibrosis, supplementation of which vitamins is necessary?

A, D, E, K

A client with a family history of polycystic kidney disease, an autosomal dominant disorder, states to the nurse, "I would like to be genetically tested for the disease, but I don't want my family to know the results." How does the nurse respond?

Assures the client that confidentiality will be maintained

Which statement reflects correct cardiac physical assessment technique?

Auscultate the aortic valve in the second intercostal space at the right sternal border.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit?

Administering preoperative antibiotics and anxiolytics

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first?

Adjust oxygen flow rate to keep O2 saturation at 93% to 100%.

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?

Adjust the position of the oxygen tubing.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN?

Administer a clonidine patch for hypertension.

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action?

Administer oxygen.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest?

Adventitious breath sounds

Where does gas exchange occur?

Alveolus

Which statement about diagnostic cardiovascular testing is correct?

An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography.

Which client has the most urgent need for frequent nursing assessment?

An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year, 2-pack-per-day smoking history and is receiving 50% oxygen through a Venturi mask

A diagnosis of rheumatic fever is being ruled out for a child. Which lab test(s) is/are the most reliable? (Select all that apply.)

Antistreptolysin-O titer (ASO) titer

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?

Ask the client whether CPAP has been used consistently at night.

As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do?

Asks the client to sign the consent form

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first?

Assess the airway, breathing, and circulation.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first?

Assess the client's respiratory status.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first?

Auscultate the client's posterior breath sounds.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do?

Avoid Cystic Fibrosis Foundation-sponsored events.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)?

B-type natriuretic peptide (BNP) of 760 ng/dL

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease?

Barrel chest

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture?

Blood pressure 192/102 mm Hg

In conducting a postoperative assessment of a client, what is important for the nurse to examine first?

Breathing pattern

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do?

Calmly continues talking

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first?

Encourage the client to slow his breathing rate.

Which assessment finding is of greatest concern in a client with emphysema?

Bronchial breath sounds heard at the bases

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma?

Brother is allergic to peanuts.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client?

By maintaining oxygen saturations greater than 88%

Which medication, when given in heart failure, may improve morbidity and mortality?

Carvedilol (Coreg)

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first?

Check the resident's oxygen saturation

A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety?

Check to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider?

Client with pressure in the mid-abdomen and profound diaphoresis

What is the greatest risk factor for lung cancer?

Cigarette smoking

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order?

Ciprofloxacin (Cipro) 400 mg IV every 12 hours

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)?

Circulating RN who has been employed in the hospital OR for 7 years

During surgery, who is most responsible for monitoring for possible breaks in sterile technique?

Circulating nurse

Who is the most likely person to administer blood products in an operating suite?

Circulating nurse

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer?

Class II, can perform desk job

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse?

Client on warfarin (Coumadin) with epistaxis with profuse bleeding

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?

Client states that she is able to sleep on one pillow.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition?

Client stating that the year is 1967

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit?

Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse?

Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention?

Client with acute allergic reaction

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit?

Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask.

The RN has received report about all of these clients. Which client needs the most immediate assessment?

Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first?

Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min.

Which client is best to assign to an LPN/LVN working on the telemetry unit?

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client would be best to reschedule?

Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)?

Client with pleural effusion who has had 1200 mL removed by thoracentesis

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room?

Client with possible pulmonary tuberculosis who currently has hemoptysis

Which action does the nurse implement for a client with wound evisceration?

Cover the wound with a sterile, warm, moist dressing.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds?

Crackles

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist?

Creatinine, 1.9 mg/dL

An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for?

Cricothyroidotomy

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider?

Daily weight monitoring

A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention?

Decreasing respiratory rate

The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action?

Determine the cause of the obstruction.

What is the purpose of genetic testing?

Determines whether a mutation exists

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which actions would be best for the RN to accomplish?

Develop the discharge teaching plan in conjunction with the client.

When teaching the client and family about genetic counseling, what information does the nurse include in the teaching plan?

Diagnostic genetic testing determines the risk for a specific disorder.

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure?

Diet-controlled diabetes mellitus

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding?

Diminished peripheral pulses in the lower extremities

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?

Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question?

Dopamine (Intropin)

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first?

Draw aerobic and anaerobic blood cultures.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first?

Draw blood for glucose, electrolyte, and complete blood count values.

Which nursing intervention is the priority in preparing a client for pulmonary function testing (PFT)?

Ensure no smoking 6 hours before the test.

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained?

Ensure that drapes will minimize perianal exposure.

Which method is the best way to prevent outbreaks of pandemic influenza?

Early recognition and quarantine

The nurse should instruct a child to remain completely still during which procedure in which high frequency sound waves are translated into images by a transducer?

Echocardiography

A client is admitted to the medical floor with a new diagnosis of lung cancer. How does the nurse assist the client initially with the anxiety associated with the new diagnosis?

Encourage the client to ask questions and verbalize concerns.

Which symptom of pneumonia may present differently in the older adult than in the younger adult?

Fever

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. Which prescription does the nurse implement first?

Furosemide (Lasix)

What is the term for the opening between the vocal cords?

Glottis

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse?

Having a small glass of juice at 7:00 a.m

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques?

Increased risk for sunburn

What is the effect of gene mutation and amino acid sequencing on insulin and blood sugar control?

Ineffective insulin is produced.

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area?

Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider?

Intravenous furosemide

What pain management does a client who has been admitted to the postanesthesia care unit typically receive?

Intravenous opioid analgesics

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client?

Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol)

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client?

It would help decrease the bronchospasm.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension?

Kidney disease

A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition?

Liquid nonsteroidal anti-inflammatory drugs (NSAIDs)

A client has just arrived in the postanesthesia care unit following a successful tracheostomy procedure. Which nursing action must be taken first?

Listen to lung sounds.

A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list?

Lorazepam (Ativan)

A client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned?

Lung sounds may indicate absorption atelectasis

Which client has the highest risk for cardiovascular disease?

Man who smokes and whose father died at 49 of myocardial infarction (MI)

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation?

Marfan syndrome

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs?

Mean arterial pressure (MAP) is 58 mm Hg.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU?

Monitor blood pressure and pulse.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client?

Montelukast (Singulair)

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client?

Mucolytics thin secretions, making them easier to expectorate.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory?

Obtain client vital signs and a resting electrocardiogram (ECG).

Which nursing action may be delegated to a nursing assistant working on the medical unit?

Obtain daily weights for several clients with class IV heart failure.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery?

PaO2 of 65 mm Hg

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning?

Pad bony prominences

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?

Pain radiating to the shoulder

Colostomy surgery is categorized as what type of surgery?

Palliative

The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement?

Picture Board

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period?

Picture board

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention?

Pink, frothy sputum

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?

Pedal pulses

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first?

Performs a complete neurologic assessment and notifies the health care provider

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control?

Picks the gauze up without touching the surgeon

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first?

Place the client in a negative air pressure room.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea?

Place the client in high-Fowler's position with the legs down.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN?

Plan client and family teaching regarding upcoming pulmonary function testing.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider?

Platelets 32,000/mm3

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?

Pneumothorax

After gastric surgery, a client arrives in the postanesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant?

Position the client on the left side.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?

Positions the client to alleviate dyspnea

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client?

Post-cough emesis

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions?

Potassium 3.0 mEq/L

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth?

Prevent radiation scatter when the beam hits metal in the mouth

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority?

Prison staff and inmates

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do?

Provides a mask to the visitor

Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client?

RN who has 5 years of experience in the delivery room.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription?

Serum potassium level of 2.8 mEq/L

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider?

Serum troponin I level

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler?

Short-acting beta agonists

How does the nurse position a client with postoperative nausea and vomiting?

Side-lying, with the head in a neutral position

Which vascular assessment by the student nurse requires intervention by the supervising nurse?

Simultaneously palpating the bilateral carotids

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit?

Snoring sounds when inhaling

Which clinical manifestation in the client with facial trauma is the nurse's first priority?

Stridor

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?

Suction the tracheostomy using sterile technique.

Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?

Suctioning the client

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client?

Supplemental pain reduction is needed.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately?

Swelling and tenseness in the affected area

Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma?

Tachypnea

What is the function of the turbinates?

They increase the surface area of the nose for heating and filtering.

Why is it important to wear sterile gloves during a dressing change?

They protect both the client and the nurse from infection.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first?

Talk to the client.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first?

Talk to the operating team

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes?

Teach the importance of incentive spirometry.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance?

Teaches workers how to use a mask

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse?

The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

All of these client assignments have been made by the charge nurse. Which assignment is questionable?

The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon?

The affected extremity becomes purple and cold

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins?

The client develops wheezes and dyspnea after eating crab or lobster.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam (Valium) 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?

The client is receiving oxygen at 4 L/min.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders?

The client is symptom-free between exacerbations.

The nurse is assigned to all of these clients. Which client should be assessed first?

The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer?

The client will be treated for 5 to 7 days.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best?

The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective?

The client's weight decreases by 2.5 kg.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason?

The dye causes an osmotic diuresis.

Which statement is consistent with an autosomal dominant pattern of inheritance for a specific trait or characteristic?

The genotype cannot be predicted from the phenotype.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?

The nurse obtains a bedside commode before administering furosemide.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication?

The risk for hypotension

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg?

This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first?

Throat culture

A client has a fever of 104° F (40° C). In which direction, if any, does this shift the oxygen-hemoglobin dissociation curve?

To the right

Which is considered a mixed cardiac defect?

Transposition of the great arteries

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included?

Women may experience extreme fatigue and dizziness as sole symptoms.

It is important that a child with Group A ß-hemolytic streptococci (GABHS) infection be treated with antibiotics to prevent:

acute rheumatic fever

One of the goals for children with asthma is to prevent respiratory infection. This is because respiratory infection:

can trigger an episode or aggravate an asthmatic state.

An important nursing responsibility when a dysrhythmia is suspected is to:

count the apical rate for 1 full minute and compare it with the radial rate.

The school nurse is called to the cafeteria because a child "has eaten something he is allergic to." The child is in severe respiratory distress. FIRST the nurse should:

have someone call for an ambulance/paramedic rescue squad.

The doctor suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent:

increased pulmonary vascular congestion

Cystic fibrosis may affect singular or multiple systems of the body. The primary factor responsible for possible multiple clinical manifestations is:

mechanical obstruction caused by increased viscosity of mucous gland secretions

A 4-year-old girl is brought to the emergency room. She has a "froglike" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should

notify the physician immediately and be prepared to assist with a tracheostomy or intubation

Nursing care of the infant or child with congestive heart failure would include:

organizing activities to allow for uninterrupted sleep

The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of:

pneumothorax.

An immediate intervention when an infant chokes on a piece of food would be to

position the infant in a head-down, face-down position and administer five quick blows between the shoulder blades.

A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates:

soothing inflamed mucous membrane

A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate the breathing to use it effectively. The nurse should suggest that he use a:

spacer.

A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is:

squatting.

An early sign of congestive heart failure that the nurse should recognize is:

tachypnea

The primary therapy for secondary hypertension in children is:

treatment of underlying cause.

The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37° C. The nurse suspects croup and should recommend:

trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.

When caring for a child after a tonsillectomy, the nurse should

watch for continuous swallowing.