NRS-3015 Exam 3 Practice Questions

A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears in an adverse effect of this medication" B. "Have your skin test repeated in 4 months to show a positive result" C. "Expect your urine and other secretions to be orange while taking this medication" D. "Remember to take this medication with a sip of water just before your first bite of each meal"

"Expect your urine and other secretions to be orange while taking this medication" Rationale: Tinnitus is not an adverse effect of rifampin. However, the nurse should inform the client that rifampin can cause gastrointestinal disturbances. The nurse should inform the client that the purified protein derivative skin test results will continue to show positive, even after the disease is no longer active. The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise. The nurse should instruct the client to take rifampin 1 hr before or 2 hr after a meal.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat more cheese because I can't drink milk." b. "I need to avoid foods with vitamin D because I am allergic to milk." c. "I will stop taking my calcium supplements if they irritate my stomach." d. "I will add broccoli and kale to my diet."

"I will add broccoli and kale to my diet." Rationale: The nurse should recommend broccoli and kale, which are good sources of calcium as alternatives to milk products.

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify provider if there is a fluctuation of drainage in the tubing with inspection" B. "I will notify the provider if there is a continuous bubbling in the water seal chamber" C. "I will not

"I will notify the provider if there is a continuous bubbling in the water seal chamber" Rationale: Fluctuation of drainage in the tubing with inspiration is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client. However, this finding does not require notification of the provider.Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.Drainage of 60 mL in the first hour after surgery is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client, but notification of the provider is not required at this time.Small, dark-red blood clots are an expected finding for a client who is postoperative after chest surgery. The nurse should continue to monitor the client, but notification of the provider is not required at this time.

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "I will use clean technique when suctioning a client's ETT" B. "I will use a rotating motion when removing the suction catheter" C. "I will suction the oropharyngeal cavity prior to suctioning the ETT" D. "I will suction a client's ETT every 2 hours"

"I will use a rotating motion when removing the suction catheter" Rationale: The nurse should use sterile technique when performing endotracheal suctioning to avoid the introduction of pathogens into the sterile respiratory system. The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway. The nurse should suction the endotracheal tube prior to suctioning the nonsterile oropharyngeal cavity to prevent cross contamination. The nurse should suction the endotracheal tube only when needed. Routine suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms.

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should conserve energy by limiting my physical activity." b. "I will wait until my pain is at least six out of ten before I use the PCA." c. "I will limit my daily fluid intake to two to three glasses." d. "I will use the incentive spirometer every hour."

"I will use the incentive spirometer every hour." Rationale: Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should identify this statement as indicating an understanding of the teaching.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a. "If my stockings feel tight, I'll just roll them down for a while." b. "I'll put on my elastic stockings at the first sign of swelling." c. "When I sit down to watch television, I'll be sure to put my feet up." d. "It's okay to cross my legs as long as it's for less than an hour."

"When I sit down to watch television, I'll be sure to put my feet up." Rationale: Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride b. Dextrose 5% in lactated Ringer's c. 3% sodium chloride d. 0.45% sodium chloride

0.45% sodium chloride Rationale: A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution. The 3% sodium chloride is a hypertonic solution. Lactated Ringer's solution contains sodium and other electrolytes and is not indicated for hypernatremia.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr c. Bumetanide 8 mg/day d. 100 mL of dextrose 10% in water with 10 units of insulin

0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr Rationale: This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. 1/2 cup chopped celery b. 1 cup plain yogurt c. 1 slice whole grain bread d. 1/2 cup cooked tofu

1 cup plain yogurt Rationale: One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.

nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. 1 large hard-boiled egg b. 1 cup bran cereal c. 1/2 cup almond d. 1 cup cooked spinach

1 large hard-boiled eggs Rationale: One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.Cereal has 112 mg. Almonds 193 mg and spinach 157 mg.

A nurse is caring for a client who was in a motor‑vehicle accident. The client reports chest pain and difficulty breathing. A chest x‑ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3 − 24 mEq/L B. pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3 − 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3 − 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3 − 29 mEq/L

A Rationale: A. CORRECT: A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis. B. These ABGs are within the expected reference range and reflect homeostasis. C. Metabolic acidosis is not indicated for this client. D. Metabolic alkalosis is not indicated for this client.

A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia

A Rationale: A. CORRECT: Assess for ECG changes. Potassium levels can affect the heart and result in arrhythmias. B. Constipation is a manifestation of hypokalemia. C. Polyuria is a manifestation of hypokalemia. D. Paresthesia is a manifestation of hypokalemia.

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A Rationale: A. CORRECT: Hyperkalemia, an increase in blood potassium, is a laboratory finding associated with diabetic ketoacidosis. B. Hyponatremia, a decrease in blood sodium, is a laboratory finding associated with heart failure. C. Hypernatremia, an increase in blood sodium, is a laboratory finding associated with Cushing's syndrome. D. Hypocalcemia, a decrease in blood calcium, is a laboratory finding that is found in clients following a thyroidectomy.

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer."

A Rationale: A. CORRECT: Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis. B. Respiratory acidosis can occur in a client who has myasthenia gravis. C. Respiratory acidosis can occur in a client who has asthma. D. Respiratory acidosis can occur due to cancer.

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A Rationale: A. CORRECT: Three tap water enemas can result in a decrease in blood sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution. B. 0.9% sodium chloride is an isotonic solution and will not produce these results. C. 5% dextrose with 0.45% sodium chloride is an isotonic solution with 20 mEq of K+ at 80 mL/hr and would not produce these results. D. Antibiotic therapy would not produce these results

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone

A & C Rationale: A. CORRECT: Fentanyl is a pain medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. B. Furosemide is a diuretic used to release fluid from the body. C. CORRECT: Midazolam is a sedative medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. D. Famotidine is an H2 receptor antagonist given to treat upset stomach and heartburn. E. Dexamethasone is a corticosteroid used to treat inflammation, such as arthritis or an immune disorder.

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A. A client who has epistaxis B. A client who has amyotrophic lateral sclerosis C. A client who has pneumonia D. A client who has emphysema

A client who has epistaxis Rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.The nurse should identify that a client who has amyotrophic lateral sclerosis can receive nasopharyngeal suctioning.The nurse should identify that a client who has pneumonia can receive nasopharyngeal suctioning.The nurse should identify that a client who has emphysema can receive nasopharyngeal suctioning.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A. A client who is 48hr postoperative following a total arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A client who is 48hr postoperative following a total arthroplasty Rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A, B, & E Rationale: A. CORRECT: The client who has a pneumothorax can experience tachypnea related to respiratory distress caused by the injury. B. CORRECT: The client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. C. The client who has a pneumothorax can experience tachycardia related to respiratory distress and pain. D. The client who has a pneumothorax can experience an increase in the use of accessory muscles as respiratory distress occurs. E. CORRECT: The client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced acute drug toxicity

A, B, D, & E Rationale: A. CORRECT: A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. B. CORRECT: A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. C. Hemoglobin of 15.1 mg/dL is within the expected reference range. A client who has a low hemoglobin is at risk for developing ARDS D. CORRECT: A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. E. CORRECT: A client who experienced acute drug toxicity is at risk for developing ARDS due to damage to the central nervous system.

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A, B, D, E Rationale: A. CORRECT: Dyspnea is a manifestation present with fluid volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling to breathe to obtain oxygen. B. CORRECT: Edema is a manifestation present with fluid volume excess. Weight gain can be a result of edema. C. Tachycardia and bounding pulses are manifestations related to fluid volume excess. D. CORRECT: Hypertension is a manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess fluid. E. CORRECT: Weakness is a manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low‑grade fever E. Tachypnea

A,B,D,E Rationale: A. CORRECT: Decreased skin turgor is a manifestation present with fluid volume deficit. Skin turgor is decreased due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a manifestation present with fluid volume deficit. Urine is concentrated due to lack of fluid in the vascular system, causing a decreased profusion of the kidneys and resulting in an increased urine specific gravity. C. Tachycardia is a manifestation present with fluid volume deficit due to an attempt to maintain a normal blood pressure. D. CORRECT: Low‑grade fever is a manifestation present with fluid volume deficit. Low‑grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should nurse take? (Select all that apply) A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution C. Instruct the client to take deep breath during the procedure D. Position the client laterally on the affected side before the procedure E. APply pressure to the site after the procedure

A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution E. APply pressure to the site after the procedure Rationale: The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. The application of pressure decreases the risk for bleeding at the procedure site.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? a. Administer IV fluids to the client evenly over 24 hr. b. Provide the client with a salt substitute. c. Assess the client for pitting edema. d. Encourage the client to rise slowly when standing up. e. Weigh the client every 8 hr.

A.Administer IV fluids to the client evenly over 24 hr D.Encourage the client to rise slowly when standing up E. Weigh the client every 8 hr Rationale: Administer IV fluids to the client evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension.Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.

A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best methods for the nurse to use to determine the effectiveness of the current treatment regimen? A. Blood pressure B. Capillary refill C. Arterial blood gases D. Heart rate

ABG Rationale: The nurse should monitor the client's blood pressure, which provides important information regarding the client's circulatory status. However, another assessment is the priority. The nurse should monitor the client's capillary refill, which provides information about peripheral circulation. However, another assessment is the priority. When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance. The nurse should monitor the client's heart rate, which provides important information regarding the client's circulatory status. However, another assessment is the priority.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority? A. Provide a quiet environment B. Encourage use of incentive spirometry every 1 to 2 hr C. Obtain a blood sample for electrolyte study D. Administer heparin via continuous IV infusion

Administer heparin via continuous IV infusion Rationale: The nurse should provide a client who has a pulmonary embolism with a quiet environment to promote rest and conserve oxygen. However, another intervention is the nurse's priority. The nurse should encourage a client who has a pulmonary embolism to use an incentive spirometer to improve oxygenation and ventilation. However, another intervention is the nurse's priority. The nurse should obtain a blood sample from a client who has a pulmonary embolism to send to the laboratory for coagulation studies, electrolyte levels, and a CBC. However, another intervention is the nurse's priority. When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is developing a plan of care for a client who has active tuberculosis. Which of the following isolation precautions should the nurse include in the plan? A. Airborne B. neutropenic C. Contact D. Droplet

Airborne Rationale: because TB is respiratory infection that is spread through the air- negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Should not enter without N95- initiate protective environment precautions for clients who need protection from outside infections, such as client who are receiving bone marrow transplants. should initiate contact precautions for infection that are transmitted by direct contact- scabies, MRSA. droplet precautions for clients who have infection that transmitted by large droplets in air and by being within 3ft of client- influenza- should wear surgical mask within 3 ft.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prdnisone C.Fluticasone/salmeterol D. Albuterol

Albuterol. Rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.The nurse should administer cromolyn sodium, an anti-inflammatory agent, for maintenance therapy of asthma, rather than for treatment during an acute asthma attack.The nurse should administer prednisone following an acute attack to promote anti-inflammatory effects.The nurse should administer fluticasone/salmeterol for maintenance therapy of asthma because it combines a glucocorticoid and a long-acting beta2-adrenergic agonist.

A nurse in ED is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen B. Increase the rate of IV fluids C. Administer pain medication D. Initiate cardiac monitoring

Apply oxygen Rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen. The nurse should increase the rate of the IV fluids to increase cardiac output. However, another action is the nurse's priority. The nurse should administer pain medication to decrease discomfort and anxiety. However, another action is the nurse's priority. The nurse should initiate cardiac monitoring because the client is at risk for dysrhythmias and right ventricular failure. However, another action is the nurse's priority.

A nurse is caring a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A.. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

Artificial airway cuff leak Rationale: An excess of secretions in the airway causes the high-pressure alarm to sound.Kinks in the tubing can cause an obstruction, which causes the high-pressure alarm to sound.An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.Biting on the endotracheal tube causes the high-pressure alarm to sound.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a. Monitor the client's bowel sounds b. Review the client's daily laboratory results. c. Auscultate the client's lungs. d. Palpate the client's peripheral pulses.

Auscultate the client's lungs Rationale: Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety."

B Rationale: A. Antibiotics are given to treat infection. B. CORRECT: Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption. C. Corticosteroids are given to treat inflammation. D. Benzodiazepines are given to treat anxiety.

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hyperkalemia

B Rationale: A. An increase in calcium is not indicated with nasogastric losses due to suctioning. B. CORRECT: Monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium. C. Hyperphosphatemia is not indicated with nasogastric losses due to suctioning. D. A decrease in potassium can occur from nasogastric losses due to suctioning.

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should the nurse include? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.

B, D, & E Rationale: A. Antibiotics are given to treat bacterial infections. This would not be indicated for SARS. B. CORRECT: Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered to treat severe hypoxemia. C. SARS is caused by the coronavirus. There are no effective antiviral medications to treat this virus. D. CORRECT: Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway. E. CORRECT: Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.

A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema

Blood-tinged sputum rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor. The nurse should expect an increase, rather than a decrease, in tactile fremitus because of tumor tissue or fluid replacing airspaces.The nurse should expect a dullness or flat sound, rather than resonance, upon percussion because of the presence of masses in the lungs. The nurse should expect cyanosis of the lips and fingertips. However, peripheral edema is not an expected finding for a client who has lung cancer.

A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate

Bounding peripheral pulses Rationale: Fluid overload results in increased vascular volume and places a greater workload on the heart. Thus, an expected finding is bounding peripheral pulses.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.49 F), and SaO, 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.

C Rationale: A. Obtaining a chest x-ray to determine the level of injury to the lungs is important, but is not the priority action at this time. B. Preparing the client for chest tube insertion is important to facilitate lung expansion and restore normal intrapleural pressure, but is not the priority action at this time. C. CORRECT: According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to restore optimal breathing because the client is experiencing dyspnea and has decreased lung sounds. D. Initiating V access to administer medications is important, but is not the priority action at this time.

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower their chin to their chest.

C Rationale: A. Applying a blood pressure cuff to the client's arm is performed to assess for Trousseau's sign. B. Placing the stethoscope bell over the client's carotid artery is performed to auscultate a carotid bruit. C. CORRECT: Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face. D. Asking the client to lower their chin to their chest is performed to assess for range of motion of the neck.

nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3 − 28 mEq/L B. pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3 − 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3 − 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3 − 29 mEq/L

C Rationale: A. These arterial blood gases indicate metabolic alkalosis. B. These arterial blood gases indicate respiratory alkalosis. C. CORRECT: An aspirin toxicity would result in arterial blood gas findings of metabolic acidosis. D. These arterial blood gases indicate metabolic alkalosis.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes b. Cardiac rhythm c. Peripheral sensation d. Bowel sounds

Cardiac rhythm Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except? a. Confusion b. Peripheral edema c. Facial flushing d. Hyperreflexia

Confusion Rationale: A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur. Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal set C. Container of sterile water D. Nonadherent pads

Container of sterile water Rationale: The nurse should empty the collection chamber in the drainage system or replace it before the drainage reaches the bottom of the tube. Therefore, it is not necessary to have an extra drainage system easily accessible for the client. The nurse should retrieve a suture removal set when the chest tube is removed. However, it is not necessary to have a suture removal set easily accessible for the client. The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax. The nurse should provide nonadherent, airtight, sterile petrolatum gauze when the chest tube is removed. However, it is not necessary to have to have nonadherent pads easily accessible for the client. If the chest tube is accidentally removed, the nurse should cover the wound with dry, sterile gauze.

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid‑base imbalances to result from vomiting for 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D Rationale: A. Respiratory acidosis is not indicated for this client. B. Respiratory alkalosis is not indicated for this client. C. Metabolic acidosis is not indicated for this client. D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D rationale: A. Moist skin is a manifestation of fluid volume excess. \ B. Distended neck veins are a manifestation of fluid volume excess. C. Increased urinary output is a manifestation of fluid volume excess. D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit.

A nurse is caring for a client in a long‑term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake. B. Check for peripheral edema. C. Encourage the client to ambulate to promote oxygenation. D. Monitor for orthostatic hypotension.

D rationale: A. Offer fluids when the client has manifestations of dehydration. B. Monitor for poor skin turgor when the client has manifestations of fluid volume deficit. C. Keep the client in bed and assist them to the bathroom as needed because they are at risk for falling due to manifestations of dehydration. D. CORRECT: Monitor for orthostatic hypotension because they have manifestations of dehydration due to decreased circulatory volume

a nurse is care for client who is postoperative and has respiratory rate of 9/min secondary to general anesthesia effect incisional pain. which following ABG value indicates client is experiencing respiratory acidosis? A. pH 7.50, PO2-95, PaCO2-25, HCO3-22 B. pH 7.50, PO2-87, PaCO2-35, HCO3-30 C. pH 7.30, PO2-90, PaCO2-35, HCO3-20 D. pH 7.30, PO2-80, PaCO2-55, HCO3-22

D. pH 7.30, PO2-80, PaCO2-55, HCO3-22 Rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased O2Sat C. Urinary retention D. Increased pain level

Decreased O2Sat Rationale: Bleeding at the surgical site requires intervention by the nurse because hemorrhage is a complication of the procedure. However, there is another finding that is the priority for the nurse to report to the provider. When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction. Urinary retention is a complication following a surgical procedure using general anesthesia and requires assessment by the nurse. However, there is another finding that is the priority for the nurse to report to the provider. An increased pain level is a complication following a surgical procedure and requires intervention by the nurse to promote comfort. However, there is another finding that is the priority for the nurse to report to the pro

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased heart rate d. Increased blood pressure

Decreased muscle strength Rationale: Hyperkalemia can cause muscle weakness. The nurse should monitor the client's muscle strength.

A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of anthrax? a. dry cough b. rhinitis c. sore throat d. swollen lymph nodes

Dry cough Rationale: A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis. hinitis is not a manifestation of inhalation anthrax; however, rhinitis is typically seen with colds and influenza. A sore throat is not a manifestation of inhalation anthrax; however, a sore throat is typically seen with colds and influenza. Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax.

nurse is assessing a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.) A. Tachycardia B. Hypertension C. Bounding pulses D. Hyperreflexia E. Dysrhythmia F. Tachypnea

E & F Rationale: A. Tachycardia is an expected finding for a client who has respiratory acidosis or metabolic alkalosis. B. Hypertension is an expected finding of respiratory acidosis. C. Bounding pulses is an expected finding for respiratory acidosis due to hypertension. D. Hyperreflexia is an expected finding for a client who has metabolic alkalosis. E. CORRECT: Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis. F. CORRECT: Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

Elevated temperature Rationale: Rhonchi on inspiration is an expected finding for clients who have emphysema. The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections. Chronic overinflation of the lungs and flattening of the diaphragm lead to the appearance of a barrel-shaped chest, which is an expected finding of emphysema. Diminished breath sounds are an expected finding for clients who have emphysema due to limited chest excursion and air trapping.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050

Hematocrit 34% Rationale: This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.

A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow back and over the chest to support the arm B. High-Fowler's position with the arms supported on the overbed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the HOB to 15 degree

High-Fowler's position with the arms supported on the overbed table Rationale: A lateral position promotes alignment of the back and can be a good position for sleeping. However, this position does not promote maximum chest expansion to facilitate breathing. The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table. The semi-Fowler's position, which has the head and trunk elevated to a 30° to 45° angle, does not promote maximum chest expansion to facilitate breathing. Supine position allows the diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise chest expansion. This position does not promote maximum chest expansion to facilitate breathing.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure

Hyperactive deep-tendon reflexes Rationale: Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling.

Discharge teaching to a client who has a temporary tracheostomy. Which statement by client indicates an understanding of the teaching? A. I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma B. I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage C. I should remove the old twill ties after the new ties are in place D. I should apply suction while inserting catheter into my tracheostomy tube.

I should remove the old twill ties after the new ties are in place Rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A nurse is providing a preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is appropriate? a. after the surgeon removes the lung, you will not need to cough b. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough c. don't worry, you will have a pump that delivers pain medication as you need it, so you will have very little pain d. I will show you how to splint your incision while coughing.

I will show you how to splint your incision while coughing rationale: The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The client who had a pneumonectomy should cough to clear secretions from the remaining lung. Pain medication reduces pain to a tolerable level. However, it does not necessarily keep the client pain-free. Additionally, telling the client not to worry is a barrier to communication and provides false reassurance. The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? A. I will monitor my heart rate every day while taking this medication B. I will make sure I have this medication with me all the time C. I will need to carefully rinse my mouth after I take this medication D. I will take this medication every night even if I don't have symptoms

I will take this medication every night even if I don't have symptoms. Rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening- Client who take SABA should monitor heart rate because tachycardia is AE of these medications- who take SABA should have their medication all the time with them - to relieve bronchoconstriction during asthma attack- who take inhaled glucocorticoids should rinse their mouths and gargle after use because oral candidiasis is AE

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions. b. Administer phosphate. c. Initiate diuretic therapy. d. Prepare the client for hemodialysis.

Implement seizure precautions Rationale: The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a. Assist with intubation. b. Initiate high-flow oxygen therapy. c. Administer a rapid-acting diuretic. d. Provide cardiac monitoring.

Initiate high-flow oxygen therapy Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24mEq/L D. Intercostal retractions

Intercostal retractions Rationale: The nurse should identify that decreased bowel sounds is an expected finding for a client who has ARDS. The nurse should identify that an oxygen saturation of 92% is within the expected reference range for a client who has ARDS. The nurse should identify that a CO2 of 24 mEq/L is within the expected reference range for a client who has ARDS. The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A. Skin turgor B. Urine output C. Weight D. Mental status

Mental status Rationale: The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration. Therefore, assessing the client's mental status is the priority.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

Nonrebreather mask Rationale: The oxygen flow rate via nasal cannula is 1 to 6 L/min and provides oxygen at a concentration of 24% to 44%. It does not provide the highest level of oxygen for a client who is in respiratory distress. The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2. A simple face mask delivers oxygen concentrations between 40% and 60% and has open exhalation ports that allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress. The partial rebreather mask delivers oxygen concentrations of 60% to 75%.

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a. Hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse

Orthostatic hypotension Rationale: Hypokalemia can lead to hypotension. The nurse should monitor the client for orthostatic hypotension.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a. PaO2 b. PaCO2 c. Sodium d. Bicarbonate

PaCo2 Rationale: With respiratory alkalosis, the PaCO2 level is decreased.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome? a. tympanic temp 38 C (100.4 F) b. PaO2 50 mmHg c. rhonchi d. hypopnea

PaO2 50 mmHg Rationale: Although the client's temperature is not within the expected reference range, it is not a clinical manifestation of ARDS. The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. The client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway. The client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing, and indicates the presents of an increase in the work of breathing.

A nurse is an emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? A. Arterial pH.7.50 B. PaCo2 25 mmHg C. SaO2 92% D. PaO2 58 mmHg

PaO2 58 mmHg Rationale: should expect the client who have lower partial pressures of oxygen. should expect pH level to decrease because respiratory failure can cause respiratory acidosis. should expect client's CO2 level to rise with acute respiratory failure. should expect the client to have a decrease in O2 saturation.

A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? a. hyperventilate the client to 100% O2 prior to obtaining the specimen b. apply ice to the site after obtaining the specimen c. perform an Allen's test prior to obtaining the specimen d. Release pressure applied to the puncture site 1 min after the needle is withdrawn.

Perform an Allen's test prior to obtaining the specimen Rationale: The nurse should not administer oxygen prior to the blood draw, because the test measures the client's arterial blood gases when breathing room air. The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3 C (99.1F)

Persistent cough Rationale: Pallor is an important finding because it can indicate blood loss. However, another assessment finding is the nurse's priority. Insertion site pain is an important finding because untreated pain can result in shallow respirations. However, another assessment finding is the nurse's priority. When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency. A temperature of 37.3° C (99.1° F) is an important finding because it can indicate infection. However, another assessment finding is the nurse's priority.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? a. Sodium 152 mEq/L b. Chloride 102 mEq/L c. Magnesium 1.8 mEq/L d. Potassium 6.1 mEq/L

Potassium 6.1 mEq/L Rationale: Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should identify that which of the following assessments is the priority? A. Presence of gag reflex B. Pain level rating using a 0 to 10 scale C. Hydration status D. Appearance of the IV insertion site

Presence of gag reflex Rationale: Greatest risk to the client is aspiration due to a depressed gag reflex.At risk for increased pain, hydration (due to NPO for 4-8hrs which increase risk for dehydration), and for phlebitis (should assess redness, warmth, and drainage at IV insertion site) but not priority

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pused-lip breathing with exertion

Productive cough with green sputum Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing techniques accomplishes Which of the following? a. increases O2 intake b. promotes carbon dioxide elimination c. uses the intercostal muscles d. strengthens the diaphragm

Promotes carbon dioxide elimination Rationale: The client who uses pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. The nurse should increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using chest-wall muscles. The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using the diaphragm.

A nurse is creating a plan for care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals B. Have the client sit up in a chair for 2-hr periods three times per day C. Provide a diet that is high in calories and protein D. Combine activities to allow for longer rest periods between activities

Provide a diet that is high in calories and protein Rationale: The nurse should provide diet is high in calories and protein and low in carbohydrates. should schedule respiratory treatment before meals. should provide short period of activity frequently throughout the day. should schedule activities that are short in duration with adequate rest periods between to prevent fatigue.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? a. Instruct the client to cough forcefully. b. Assist the client with ambulation. c. Provide calming interventions. d. Discontinue the PCA.

Provide calming interventions Rationale: The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

Respiratory acidosis Rationale: Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is reviewing the medical record of a client who had diabetes mellitus and is recieving regular insulin by continous IV infustion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a. Urine output of 30 mL/hr b. Blood glucose of 180 mg/dL c. Serum potassium 3.0 mEq/L d. BUN 18 mg/dL

Serum potassium 3.0 mEq/L Rationale: This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035

Serum sodium 142 mEq/L Rationale: Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 142 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective.BUN is elevated. HCT is elevated and USG is elevated.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? a. Hepatic failure b. Abdominal pain c. Slow peripheral pulses d. Increase in cardiac output

Slow peripheral pulses Rationale: Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a. Sodium 128 mEq/L b. Potassium 4.8 mEq/L c. Calcium 9.1 mg/dL d. Magnesium 2.0 mEq/L

Sodium 128 mEq/L Rationale: This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort

A nurse is assessing a patient who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Decreased fremitus B. SaO2 95% on RA C. T 38.8C (101.8F) D. Bradypnea

T 38.8C (101.8F) Rationale: increased fremitus is an expected finding for a client who has bacterial pneumonia.An oxygen saturation level of lower than 95% is an expected finding for a client who has bacterial pneumonia.An elevated temperature is an expected finding for a client who has bacterial pneumonia.Tachypnea is an expected finding for a client who has bacterial pneumonia.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis

Tachycardia Rationale:

A nurse working in an ED is caring for a client following an acute chest trauma. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

Tracheal deviation to the unaffected side Rationale: A client who has a tension pneumothorax will not have collapsed neck veins on the affected side. Distended neck veins are an expected finding. A client who has a tension pneumothorax will not have collapsed neck veins on the unaffected side secondary to a tension pneumothorax. Distended neck veins are an expected finding. The trachea of a client who has a tension pneumothorax does not deviate to the affected side. The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution. b. Repeat the potassium level. c. Withhold the medication. d. Monitor for paresthesia.

Withhold the medication Rationale: The greatest risk to this client is injury from hyperkalemia. Therefore, the priority action is to withhold the oral potassium and notify the provider.

A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for Which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

absence of breath sounds Rationale: A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. A client who has asthma experiences an expiratory wheezing during an acute asthma attack. A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound often heard without a stethoscope. A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snore-like noises produced in the throat.

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider the nurse should document this finding as which of the following? a. friction rub b. crackles c. crepitus d. tactile fremitus

crepitus Rationale: A friction rub is a scratching or squeaking sound the nurse can hear when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. Crackles, which are sometimes called rales, are wet, popping sounds the nurse can hear when auscultating the client's lungs. This condition occurs when there is fluid in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia. Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. eat high-calorie foods first b. increase intake of water at meals c. perform active rang-of-motion exercises before meals d. keep saltine crackers nearby for snacking

eat high-calorie foods first Rationale: The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first. Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at mealtimes to reduce the feeling of early satiety. The client should rest before meals to decrease dyspnea while eating. The client should keep foods on hand for snacking, but should avoid dry and salty foods, which can place the client at risk for aspiration and make the client's mouth dry.

A nurse is providing discharge teaching to a client who is postoperative following a rhinopasty. Which of the following instructions should the nurse include? a. apply warm compresses to the face b. take aspirin 650 mg by mouth for mild pain c. close your mouth when sneezing d. lie on your back with your head elevated 30 degrees when resting

lie on your back with your head elevated 30 degrees when resting Rationale: The client should apply cold compresses to his face to decrease swelling. he client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation. The client should open her mouth when sneezing to reduce straining on the incisional site. The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. pericardial friction rub b. weight gain c. night sweats d. cyanosis of the fingertips

night sweat Rationale: A pericardial friction rub is a clinical manifestation of rheumatic carditis. Anorexia and weight loss are clinical manifestations of tuberculosis. Night sweats and fevers are clinical manifestations of tuberculosis. Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

pH 7.26, Pa02 84mm hg, PaC02 38 mmhg, HCO3- 20 mEq/L Rationale: When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L' c. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L Rationale: An elevated pH and HCO3- with a PaCO2 within the expected reference range indicates metabolic alkalosis.

A nurse is caring for an older client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for Which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis d. metabolic acidosis

respiratory acidosis Rationale: Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. Excessive vomiting also places a client at risk for development of metabolic alkalosis. Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk for the development of metabolic acidosis.

A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client? a. lying flat on the affected side b. prone with the arms raised over the head c. supine with the head of the bed elevated d. sitting while leaning forward over the bedside table

sitting while leaning forward over the bedside table Rationale: When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism a. sudden onset of dyspnea b. tracheal deviation c. bradycardia d. difficulty swallowing

sudden onset of dyspnea Rationale: Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. Tracheal deviation is an indication of pneumothorax. Tachycardia is a clinical manifestation of pulmonary embolism. Difficulty swallowing is an indication of many conditions, including oral cancer.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? a. clamp the chest tube if there is continuous bubbling in the water seal chamber b. keep the chest tube drainage system at the level of the right atrium c. tape all connections between the chest tube and drainage system d. empty the collection chamber and record the amount of drainage every 8 hrs.

tape all connections between the chest tube and drainage system. Rationale: The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. how to eliminate environmental triggers that precipitate attacks b. the client's perception of the disease process and what might have triggered past attacks c. the client's med regimen d. manifestations of respiratory infections

the client's perception of the disease process and what might have triggered past attacks Rationale: Although it is important for the nurse to discuss how to eliminate environmental triggers that precipitate asthma attacks, there is another point the nurse should discuss first. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? a. the client is unable to speak b. the client's airway secretions were last suctioned 2 hrs ago c. the client coughs and expectorates a large mucous plug d. the nurse auscultates coarse crackles in the lung fields

the nurse auscultates coarse crackles in the lung fields Rationale: The client who has a tracheostomy with an inflated cuff in place is unable to speak. The nurse should assess the need for suctioning every 2 hr and then suction as necessary. The nurse should assess the client's airway after coughing and only suction the client's secretions if the client is not able to cough and expectorate secretions. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that Which of the following findings is an adverse effect of this medication? a. hallucinations b. pruritis c. hand and foot syndrome d. tinnitus

tinnitus Rationale: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that Which of the following is the purpose of the treatments? a. to encourage deep breaths b. to mobilize secretions in the airways c. to dilate the bronchioles d. to stimulate the cough reflex

to mobilize secretions in the airways Rationale: Chest physiotherapy does not encourage deep breaths. However, once airway secretions are mobilized and expectorated, the client might be able to breathe deeper. The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity. Chest physiotherapy does not dilate the bronchioles; however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways. Chest physiotherapy does not stimulate the cough reflex; however, the mobilization of secretions can increase the client's ability to cough up secretions.

A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. total lung capacity b. vital lung capacity c. functional residual capacity d. residual volume

total lung capacity Rationale: Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. Functional residual capacity measures the amount of air in the lungs after normal expiration. Residual volume measures the amount of air in the lungs after forced expiration.

A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? a. if the test is positive, it means you have an active case of TB b. if the test is positive, you should have another TB skin test in 3 weeks c. you must return to the clinic to have the test read in 2 or 3 days d. a nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance.

you must return to the clinic to have the test read in 2 or 3 days Rationale: The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.