Nur 101 unit 3 review

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is a) "His infection is causing him to breathe harder." b) "He is using his chest muscles to help him breathe." c) "His lung muscles are swollen so he is using abdominal muscles." d) "He will require additional testing to determine the cause."

"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing. 1352

The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says a) "An older person may breathe more shallowly than a younger person." b) "Smoking only once in a while will not make a person addicted to smoking." c) "An upright position will help someone breathe with less effort." d) "A physically fit athlete breathes more slowly than a sedentary person."

"Smoking only once in a while will not make a person addicted to smoking." Explanation: During adolescence, more than 3000 young men and women begin smoking every day, and most will become addicted before age 20. One reason for this finding is that adolescents don't believe they will become addicted to tobacco when they start to smoke. 1357

A nurse uses an oxygen analyzer to measure the percentage of oxygen delivered to a client. When checking the percentage of oxygen in the room air, what should the reading of the analyzer be if there is a normal mixture of oxygen and other gases in the environment? a) 0.24 b) 0.25 c) 0.23 d) 0.21

0.21 Explanation: If there is a normal mixture of oxygen and other gases in the environment, the oxygen analyzer will indicate 0.21 (21%). An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. The nurse or respiratory therapist first checks the percentage of oxygen in the room air with the analyzer. If there is a normal mixture of oxygen and other gases in the environment, the analyzer indicates 0.21 (21%). When the analyzer is positioned near or within the device used to deliver oxygen, the reading should register at the prescribed amount (greater than 0.21). 1375

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: You are preparing to insert an oropharyngeal airway into an adult patient's mouth. Arrange the following steps in the correct order. 1. Assess level of consciousness and gag reflex. 2.Glide the curved tip along the hard palate. 3. Rotate the airway 180 degrees as airway passes the uvula. 4.Auscultate breath sounds. 5.Measure for correct size. 6. Position patient on his or her side.

1. Assess level of consciousness and gag reflex. 5. Measure for correct size. 2. Glide the curved tip along the hard palate. 3. Rotate the airway 180 degrees as airway passes the uvula. 4. Auscultate breath sounds. 6. Position patient on his or her side P.1380

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult? a) 150 to 200 mm Hg b) 100 to 120 mm Hg c) 50 to 100 mm Hg d) 10 to 60 mm Hg

100 to 120 mm Hg Explanation: The appropriate suction pressure for a wall unit for an adult is 100 to 120 mm Hg. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis. 1392

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 15 breaths per minute b) 12 to 20 breaths per minute c) 30 to 60 breaths per minute d) 20 to 30 breaths per minute

30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute. 1355

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving? a) 28% b) 23% c) 36% d) 32%

32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%. 1377

The obstetric nurse is assisting the delivery of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: a) 34 to 36 weeks. b) 36 to 38 weeks. c) 32 to 34 weeks. d) 30 to 32 weeks.

34 to 36 weeks. Explanation: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli. 1356

A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a) 4 L/minute b) 6 L/minute c) 10 L/minute d) 1 L/minute

6 L/minute Explanation: In general, if a flow rate of 6 L/minute fails to raise a patient's oxygen saturation level satisfactorily, a mask should be used 1377

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a patient's arterial blood. What range is considered a normal value for SpO2? a) 65% to 70% b) 75% to 80% c) 85% to 90% d) 95% to 100%

95% to 100% Explanation: A range of 95% to 100% is considered normal SpO2; values less than 85% indicate that oxygenation to the tissues is inadequate. 1363

36 hours after having surgery, a patient have a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is mot important to include in the patient's nursing care plan/ A. Document the finding and continue to monitor the patient B. Administer pyuretics, as prescribed C. Increase the frequency of assessment to every hour and notify the HCP D. increase the frequency of the wound and contact the HCP for antibiotics prescription

A (The assessment findings are normal for this stage of healing following healing following surgery. The patient is in the inflammatory stage of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, swelling at the site of injury. T patient also has generalize body response, including ildl y elevated temperature, leukocytosis, and generalized malaise)

A nurse is measuring the depth of a patients puncture wound. Which technique is recommended? A. Moisten sterile, flexible applicator it saline and gently into the wound at a 90 degree angle with the tip down B. Draw the shape of the wound and describe how deep it appears in centimeter C. Gently insert the applicator into the wound and move t in as clockwise direction D. insert a calibrated probed gently into the wound and mark the point that is even with surrounding skin surface with a marker

A (measure the depth of the wound, The nurse should perform hang QBE OUT ON GLhygiene w an put on glove: moitel steril, flexor applicatr with the saline OVES; MOITN THE STERIL, FLEXIABLE APPLIACATOR with the sline inserted it gently into the wound at a 90 degree angle with the tip dowm; Makr the point on the swab that is even with the surround skin surface, or graps the applicator with the ehtumb and forefingrer at the psin correespinfin tothe wound's ,argin; and remove the swab and measure the epth with the rule)

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing a) Bronchiolitis b) Bronchiectasis c) Bronchitis d) A bronchospasm

A bronchospasm Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucous production increases, and inflammatory chemical mediators cause bronchospasm. 1364

The nurse would expect to recommend an oxygen tent fro which of the following patients? a) An elderly patient who is unable to get out of bed b) An adult patient who has COPD c) A comatose patient who has a head injury d) A child who will not leave a facemask or cannula in place

A child who will not leave a facemask or cannula in place Explanation: Oxygen tents are often used in children who will not leave a facemask or nasal cannula in place. The oxygen tent gives the patient freedom to move in the bed or crib while humidified oxygen is being delivered; however, it is difficult to keep the tent closed, because the child may want contact with his or her parents. It is also difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50%. 1377

In which of the following clients would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking antibiotics for a urinary tract infection c) A client taking amlodipine for hypertension d) A client taking opioids for cancer pain

A client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. 1355

A patient who has a large ABD wound suddenly cells out for help because the patient feels as though something is falling out of her incision. Inspection reveal a gaping open wound with tissue bulging outward. In which order shod the nurse perform the following interventions? Arrange first to last. A. Notify the HCP of the situation B. Cover the exposed tissue with sterile tissue moistened with sterile 0.9% sodium chloride solution C. Place the patient in the low fowler's position

A, B, C ( Dehiscence an escviartion is a posoperative energency that requires pomt surgical repair. Y e cirrect order of implemetation ny the nurse is to plasyt eh patient in low fowelrs piosioint, coner the tiseu etiwh setlis towes msnr eih slainsk and notyf the HCP)

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statement accurately describe a characteristic of wound drainage? Select all that apply. A. A serous drainage ic composed of a clear portion of the blood and serous membrane B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood C. Bright-red sanguineous drainage indicates fresh bleeding ad darker drainage indicates older bleeding D. Purulent is composed of WBC, dead tissue, and bacteria E. purulent drainage is thin, cloudy and watery and must have a musty or foul odor F. Serosanguineous drainage can be dark yellow or green depending on the causative organism

A, B, C, D (Serous drainage is composed of primarily of the clear, serous portion of the blood and serous membrane. Serous drainage is clear and watery. Sanguineous drainage consist of large number of RBC and loos like blood. Bright-red sanguineous is indicate of fresh bleeding, where as a darker drainage is nfacle older bleeding, purulent drainage is made u of WBC, liquified death tissue debris, and both dead and alive bacteria. Purulent drainage is thick often has a musty or foul odor, and varies in color , depending o the causative organism. Seriosanguineous drainage is a mixture of serum and RBC. It is light pink to blood tinged)

The nurse is cleaning an open ABD wound that has unapproximated edges. What are the accurate steps in this procedure? Select all that apply. A. use standard precautions or transmission-based precautions when indicated\ B> Moisten the sterile gauze or swab prescribed cleansing agent and squeeze out excess solution C. Clean the wound in full or half circles beginning on the outside and working toward the center D. Work outward from the incision in lines that are parallel to it from the dirty areas to clean E. Clean at least 1 in beyond the end of the new dressing if one is being applied F. Clean to at least 3 in beyond the wound if a new dressing is not being applied

A, B, E ( the correct procedure is Use standard precaution and appropriate transmission-based precautions when indicated moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess fluid, use a new swab or gauze for each circle, clean the wound in full or half circles beginning toward the center going outward, clean at least 1in beyond the new dressing, cleansing at least 2 in beyond the wound margins if a dressing is not being applied.)

A nurse who is changing dressing of a postoperative patients in the hospital documents various phase of wound healing on the patient charts. Which statements accurately describe these 3 stages? Select all that apply? A. Hemostasis occurs immediately after initial injury B. A liquid called exudate is formed during the proliferative phase C. WBC mobile to the wound in the inflammatory phase D. Granulation tissues form during the inflammatory phase E. During the inflammatory phase, the patient has generalized body response F. A scar formed during the proliferation phase

A, C, E (Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood component out into the inured are, WBC, mainly leukocytes, macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase the patient has generalize the body response, inclienf thn mciel tedeleva temperature, leukocytosis, and generalize malaise. New tissue call granulation tissue forms the foundation of scar development tissue in the proliferation phase. New collagen continues be deposited in the maturation phase which forms scars)

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A. CORRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic. B. CORRECT: Malaise indicates that the infection is affecting the whole body, and therefore systemic. E. CORRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

A. CORRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies. B. CORRECT: Reporting of communicable and infectious diseases assists with determining public health policies. C. CORRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. E. CORRECT: Reporting of communicable and infectious diseases assists with monitoring for common‑source outbreaks.

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor

A. CORRECT: Restlessness is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. B. CORRECT: Tachypnea is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. E. CORRECT: Pallor is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A. CORRECT: The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. B. CORRECT: The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. CORRECT: This helps move mucus and contaminated material away from the stoma for easy removal.

A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts.

A. CORRECT: The nurse should apply suction pressure only while withdrawing the catheter, not while inserting it. D. CORRECT: The nurse should not reuse the suction catheter unless an inline suctioning system is in place. E. CORRECT: To prevent hypoxemia, the nurse should limit each suctioning session to two to three attempts and allow at least 1 min between passes for ventilation and oxygenation.

A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer prescribed antituberculosis medications. D. Recommend a screening test for family members.

A. CORRECT: The safety risk to the nurse and others is transmission of the infection. The first action is to place the client on airborne precautions.

A nurse is discussing the infection process at a staff education session. Which of the following examples are appropriate for the nurse to include when discussing the direct contact mode of transmission? (Select all that apply.) A. A client vomits on a nurse's uniform. B. A nurse has a needle stick injury. C. A mosquito bites a hiker in the woods. D. A nurse finds a hole in his glove while handling a soiled dressing. E. A person fails to wash her hands after using the bathroom.

A. CORRECT: Transmission from a client's emesis is identified as person-to-person or direct contact. E. CORRECT: Transmission from a client's contaminated hands is identified as person-to-person or direct contact.

A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse recognize as atypical indications of an infection? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation

A. CORRECT: Urinary incontinence is an atypical indication of infection in an older adult client. C. CORRECT: Acute confusion is an atypical indication of infection in an older adult client. E. CORRECT: Agitation is an atypical indication of infection in an older adult client.

You are caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which of the following items should you place in the patient's room to respond appropriately to accidental disconnection of the chest tube from the drainage device? a) A Heimlich valve b) Two rubber-tipped clamps c) An unopened bottle of sterile water d) A spare chest tube insertion kit

An unopened bottle of sterile water Explanation: Keep bottle of sterial saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water. 1379

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for what? a) Atelectasis b) Pneumothorax c) Hemothorax d) Tachypnea

Atelectasis Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding. 1353

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of a) Epiglottitis b) Bronchospasm c) Croup d) Atelectasis

Atelectasis Explanation: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis. 1352

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound c. Débride the wound. d. Change the dressing frequently.

B (Red wound are in the proliferation stage a of healing and reflect the color of the normal granulation tissue. Wound in this stage need proliferation with nursing interventions that include cleansing use of moist dressing changes, and changing of dressing only when necessary and or nason the product manufactures recommendations. T cleanse the uell o wounds, nursing intervention include the use of wound cleansers and irrigating the wound. The eschar found in ht black wounds requires debridement before the wound can heal)

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According ti the recognized staging systems, this pressure injury would be classified as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B (Stage 2 pressure injury involves the partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open / ruptured serum-filled blister)

A nurse is developing a care plan for an 86 year old patient who has been admitted for right hip arthroplasty. Which assessment finding indicate a high risk for pressure injury development for this patient? Select all that apply A. The patient takes time to thing about responses B> The patient is 86 years old C. The patient reports inability to control urine D. The patient is scheduled for a hip arthytroplasty E. Lab findings BUN 12 and creatinine 0.9 F. The patient reports increase pain in the right hip when repositioning in the bed or chairt

B, C, D, F (Pressure fiction , and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; Incontinence contributes ti prolonged moisture on the skin as well as negative effects related to urine in contract with skin; hip surgery involves decreased mobility during the post operative period, as well as pain pain with movement, contributing to immobility; and increases immobility. All of these factors are related to an increases risk pressures injury development. Apathy pressure injury development. Dehydration is a risk for a pressure injury)

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field. C. CORRECT: Prolonged exposure to air contaminates a sterile field. D. CORRECT: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that may result in contamination from secretions.

B. CORRECT: The nurse should wear a mask when within 3 ft of the client. C. CORRECT: The nurse should place a surgical mask on the client during transport to another area of the facility. E. CORRECT: A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.

B. CORRECT: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve the client's dyspnea (difficulty breathing). Fowler's position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the nurse can better assess and determine the cause of the client's dyspnea.

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 min. D. CORRECT: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

A nurse assessing a patient's respiratory effort notes that the patient is breathing eight shallow breaths/minute. Which of the following oxygen delivery systems should the nurse use for this patient? a) Oxygen mask b) Bag and mask c) Oxygen hood d) Nasal cannula

Bag and mask Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube. Bag and mask devices are frequently referred to as Ambu bags ("air mask bag unit") or BVMs ("bag-valve-mask" device). 1383

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? a) Vesicular b) Bronchovesicular c) Bronchial d) Adventitious

Bronchial Explanation: Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds. 1360

As a part of a regular check-up, the nurse performs a physical examination on the client. How should the nurse test for capillary refill time? a) By bending the client's foot upward toward the leg b) By assessing the apical and radial pulses simultaneously c) By noting localized skin discolorations d) By pressing a nail bed until it blanches

By pressing a nail bed until it blanches The nurse should perform capillary refill time test by pressing a nail bed until it blanches. Pressure is released, and the time it takes for the nail to return to its original color is noted. This capillary refill time is ordinarily less than 3 seconds. Localized skin colorations are assessed to determine bruises, redness, or mottling. Homan's sign is elicited by bending the client's foot upward toward the leg. Assessment of the apical and radial pulses simultaneously is done to determine whether all heartbeats are being perfused to distant pulse sites. 1388

A nurse providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A.The therapy is used to collect excess blood loos and prevent the formation of a scab B. The therapy will prevent infection, ensuring that wound heals with less scar tissue C. The therapy provides a moist environment and stimulates blood flow to the wound D. The therapy irrigates the wound to keep it free from debris and excess wound fluid

C (Negative pressure wound therapy promotes wound healing and wound closer through the application of uniform negative pressure on the wound bed, reduction in bacteria int he wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, ad the growth of new blood vessels. It is used to treat a variety if acute or chronic wounds, wounds with heavy drainage, wounds failing to heal , or healing slowly)

A patient was in an automobile accident and received a wound across his neck and cheek. After surgery to repair the wound the patient says, "I am so ugly now." Based on this what nursing diagnosis would be most appropriate? A. pain B. impaired skin integrity C. Disturbed body image D. disturb thought process

C (Wounds cause emotional as well as physical stress)

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates the patient understands the explanation? A/ I can expect discomfort in the area where the cold is applied B. I should expect more drainage form the incision after the the ice has been placed C. I should see less swelling and redness with the cold treatment D. My incision may bleed more when the ice is first applies

C (The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local telese of pain-producing substances, decreases the metabolic needs and capillary permability. The resulting effects include decreased edema, coagulation of the blood at wound sites oromirtion of comofoot, decreased drainage from wound and decreases bleeding)

The nurse assess the wound fof a patient who was cut in the upper thigh with a chainsaw. The nurse documents the presences of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A. Enhanced heading due to the presence of sugar and proteins B. Delayed healing due to dead tissue present in the wound C. Decreased effectiveness of antibiotics against bacteria D.impaired skin integrity due to overhydration of the cells of the wound E. Delayed healing due to dehydrated and dying cells F. Decreased effectiveness if patient's normal immune process

C,F ( wound biofilms are the result of wound bacteria growing in clumps ,embedded in a thick self- made, protective slimy barriers of sugars an proteins. Thus barriers contributes to decrease effectiveness of antibiotics against the bacteria and decreases the effectiveness of the normal immune response by the patient. Necrosis int he wound delays healing. Maleration or overhydration of cels related to urinary and fecal incontinence can lead to impaired skin integrity. Desication is the process of drying up , in which the cells dehydrated and die in dry environment)

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.

C. CORRECT: A disadvantage of this oxygen delivery device is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary. D. CORRECT: Oxygen toxicity is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation. The client should report any of these promptly. E. CORRECT: Oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.

A charge nurse is discussing the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."

C. CORRECT: Monitoring antimicrobial levels ensures that therapeutic levels are maintained.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of facial tissues nearby for the client to use during the dressing change.

C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. CORRECT: The inner wrappings of any objects the nurse dropped onto the sterile field are sterile. The nurse may touch them with sterile gloves. D. CORRECT: Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves. E. CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

It is a red air-quality day in your city. This means the air is stagnant, with high pollution levels and high humidity. Which client is most likely to experience shortness of breath? a) Teenager with contact dermatitis b) Middle-aged adult with hypertension c) Child with asthma d) Young adult without disease

Child with asthma Explanation: Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucous production and contribute to bronchitis and asthma. While pollution is not good for any group of individuals it would be less of an impact on the person with hypertension or dermatitis. 1357

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body? a) Parkinson's disease b) Chronic anemia c) Graves' disease d) Pancreatitis

Chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. 1355

Assessment of a client with a respiratory disorder reveals rounded and enlarged fingers. The nurse documents this finding as which of the following? a) Hypoxemia b) Wheeze c) Clubbing d) Cyanosis

Clubbing Explanation: Clubbing refers to the finding that the tips of the fingers and toes become rounded and enlarged. It is believed that long-term tissue hypoxia causes the release of a substance that causes dilation of the vessels of the fingertips. Cyanosis is a bluish skin discoloration caused by a desaturation of oxygen on the hemoglobin in the blood. Wheeze is a low pitched snoring or moaning sound heart during expiration. Hypoxemia refers to low levels of oxygen in the blood. 1353

The nurse is assessing a patient with lung cancer. What manifestations may suggest that the patient has chronic hypoxia? a) Constipation b) Cyanosis c) Edema d) Clubbing

Clubbing Explanation: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many patients with respiratory or cardiac disease. Clubbing is believed to be caused by long-term tissue hypoxia which causes the release of a substance that causes dilation of the vessels of the fingertips (Lewis, et al., 2007). Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and chronic obstructive pulmonary disease. 1353

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia? a) Decreased respiratory rate b) Decreased blood pressure c) Hyperactivity d) Confusion

Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. 1353

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from a) Congestive heart failure b) Lung cancer c) Myocardial infarction d) Pulmonary embolism

Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure. 1361

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? a) Expand the thoracic cavity. b) Elevate the ribs and sternum. c) Contract the abdominal muscles. d) Relax the respiratory muscles.

Contract the abdominal muscles. Explanation: The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration. 1352

Which of the following medications are administered in the home or the hospital to relieve inflammation in the lung tissue? a) Bronchodilators b) Corticosteroids c) Expectorants d) Antibiotics

Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation. 1372

A nurse is assessing the breath sounds of a newborn. Which of the following is an expected finding for this developmental level? a) Bruits b) Clear sounds c) Wheezes d) Crackles

Crackles Explanation: Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. 1355

The nurse auscultates a patient with soft high pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as a) Rales b) Wheezes c) Vesicular d) Crackles

Crackles Explanation: A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema. 1361

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe? a) Wheezing in the upper lobes b) Expiratory stridor c) Crackles in the lower lobes d) Inspiratory stridor

Crackles in the lower lobes Explanation: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products. 1361

A nurse is learning about religious dietary restrictions at a nursing conference. Which of the following religious meal selections should the nurse understand is appropriate? a) Orthodox Jews: Grilled shrimp b) Mormons: Toast with coffee c) Orthodox Jews: Grilled pork chop d) Hindus: Vegetable plate

D

A patient admitted with a non-healing surgical wound. Which nursing action is most effective in preventing infection in the wound? A. Using sterile dressing supplies B. suggesting dietary supplements C. Applying antibiotic D. Performing careful hand hygiene

D (Although all the answer may help in preventing wound infections, careful hand washing is the most important)

A nurse is developing a care plan related to prevention of pressure injuries for residents n a long-term care facility. Which action accurately . describes a priority intervention in preventing a patient for developing a pressure injury?] A. Keeping the head to the be elevated as often as possible B. massing er bony promineces C. repositioning bed bound patient every 4 hours D. using a mild cleansing agent when cleansing the skin

D (To prevent injuries, the nurse should cleanse the skin routinely and when tant soiling occurs by using a mild cleanser with minimal fricition, and avoiding hot water. the nurse should minimize the effect of tearing force by limiting the amount of time the head of the be is elevated when possible. Bony prominences should not be massaged, and baed bound patient should be repositioned very 2 hours)

A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests the client is experiencing postherpetic neuralgia? A. Linear clusters of vesicles present on the client's right shoulder B. Purulent drainage from both of the client's eyes C. Decreased white blood cell count D. Report of continued pain following resolution of rash

D. CORRECT: Pain that persists following resolution of the vesicular rash is an indication of postherpetic neuralgia.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D. CORRECT: The illness stage is when the client experiences signs and symptoms specific to the infection.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one furthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster

D. CORRECT: Vesicles that follow along a unilateral dermatome can indicate herpes zoster.

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? a) Pursed-lip breathing b) Diaphragmatic breathing c) Deep breathing d) Incentive spirometry

Deep breathing Explanation: The nurse should teach deep breathing techniques to the client who tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed volume of inspired air. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration. 1368

Which of the following is a disadvantage of using a face tent to administer oxygen to a client with facial trauma? a) Delivers an inconsistent amount of oxygen b) Creates a risk of suffocation c) Permits condensation to form in the tubing d) Dries nasal mucosa at a higher flow

Delivers an inconsistent amount of oxygen Explanation: When using a face tent to administer oxygen to a client with facial trauma, the nurse should remember that the amount of oxygen the client actually receives may be inconsistent with what is prescribed because of environmental losses. A partial rebreather mask creates a risk of suffocation. A nasal cannula dries the nasal mucosa at a higher flow. A venturi mask permits condensation to form in tubing, which diminishes the flow of oxygen. 1376

Oxygen and carbon dioxide move between the alveoli and the blood by a) Osmosis b) Hyperosmolar pressure c) Diffusion d) Negative pressure

Diffusion Explanation: Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure. 1361

A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case? a) Use a nasal strip. b) Receive annual immunizations. c) Drink liberal amounts of fluids. d) Avoid strenuous exercises.

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness. 1356

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? a) Dry suction water seal b) Dry suction/one-way valve system c) Traditional water seal d) Wet suction

Dry suction/one-way valve system Explanation: The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory. 1379

When performing a physical assessment of an adult patient complaining of dyspnea, the nurse is aware that which of the following is an abnormal finding? a) The chest contour is slightly convex, with no sternal depression b) Auscultation of low-pitched, soft sounds over the peripheral lung fields c) Symmetrical movement of the chest d) Dullness over the lung fields with percussion

Dullness over the lung fields with percussion Explanation: Percussion that produces dullness over the lung fields occurs when fluid or solid tissue replaces normal lung tissue. Normal assessment findings include a slightly convex chest contour with no sternal depression and symmetrical chest movement. Vesicular breath sounds described as low-pitched, soft sounds over the peripheral lung fields are also a normal respiratory assessment finding. 1360

Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Eat smaller meals that are high in protein b) Snack on high-carbohydrate foods frequently c) Eat one large meal at noon d) Contact the physician for Ensure

Eat smaller meals that are high in protein Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength. 1367

A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a) Administration of inhaled corticosteroids b) Educating the client on the use of incentive spirometry c) Educating the client on pursed-lip breathing techniques d) Oropharyngeal suctioning twice daily

Educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery. 1368

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a) Encouraging the client to decrease the number of cigarettes smoked daily b) Encouraging the client to consume two to three quarts of clear fluids daily c) Positioning the client supine d) Creating an environment that is likely to reduce anxiety

Encouraging the client to consume two to three quarts of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position. 1367

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal? a) Respiratory rate of 18 breaths per minute b) Vesicular breath sounds audible over peripheral lung fields c) Resonance on percussion of lung fields d) Fine crackles to the bases of the lungs bilaterally

Fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings. 1361

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Nasal cannula b) Oxygen analyzer c) Flow meter d) Humidifier

Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen. 1375

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? a) Nasal strip b) Flowmeter c) Nasal cannula d) Oxygen analyzer

Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client. 1374

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? a) Low blood pressure b) High respiratory rate c) High temperature d) Low pulse rate

High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase. 1364-1365

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test? a) Measure the percentage of hemoglobin saturated with oxygen. b) Perform the arterial puncture to obtain the specimen. c) Measure the partial pressure of oxygen dissolved in plasma. d) Implement measures to prevent complications after arterial puncture.

Implement measures to prevent complications after arterial puncture. Explanation: During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases. 1362

A client suffering from chronic obstructive pulmonary disease complains that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to a) Decrease exercise and increase rest periods b) Take a cough suppressant to decrease coughing c) Increase her fluid intake to thin secretions d) Eat small frequent meals to conserve energy

Increase her fluid intake to thin secretions Explanation: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to thin secretions. 1370

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is a) Risk for ineffective airway clearance related to infection as evidenced by dyspnea and yellow-green sputum b) Impaired gas exchange related to increased carbon dioxide and irritability c) Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter d) Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema

Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter Explanation: Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation. 1364

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? a) Inhibition of bacterial colonization b) Increase in the mucous escalator c) Inhibition of mucus removal d) Decreased production of mucus

Inhibition of mucus removal Explanation: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection. 1366

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? a) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible. b) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. c) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. d) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. Explanation: The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible. 1369

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can cause the nasal mucosa to dry in case of high flow. c) It can result in an inconsistent amount of oxygen. d) It can create a risk of suffocation.

It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss. 1375

A nurse formulates the diagnosis of fluid volume excess for a client. Which of the following precautions should the nurse suggest to the client? a) Have small portions of meat b) Have nonfat or skim milk products c) Monitor intake and output carefully d) Have lean cuts of meat and fish

Monitor intake and output carefully Explanation: The nurse should suggest to the client with excess fluid volume to monitor intake and output carefully. The client who needs to restrict fat in the diet should use lean cuts of meat and fish, eat small portions of meat, and eat nonfat or skim milk products 1367

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry technique? a) Monitor the amount of oxygen saturation in the blood b) Monitor the pressure of oxygen dissolved in plasma c) Calculate the pressure of carbon dioxide dissolved in plasma d) Calculate the percentage of hemoglobin saturated with oxygen

Monitor the amount of oxygen saturation in the blood Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. 1361

Which of the following oxygen delivery systems is most commonly used because it does not impede eating or speaking? a) Oxygen hood b) Nasal cannula c) Oxygen mask d) Oxygen tent

Nasal cannula Explanation: A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a patient requires a higher concentration of oxygen than a nasal cannula can deliver. Oxygen hoods and tents are generally used to deliver oxygen to infants and children. 1375

A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Simple oxygen mask b) Partial rebreather mask c) Venturi mask d) Nasal cannula

Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%. 1375

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Nasal cannula b) Face tent c) Simple mask d) Non-rebreather mask

Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill. 1375

A patient with a diagnosis of stage II Alzheimer disease also has a history of chronic obstructive pulmonary disease (COPD). Which of the following medication delivery systems is most appropriate for this patient? a) Metered-dose inhaler without spacer b) Metered-dose inhaler with spacer c) Dry powder inhaler d) Nebulizer

Nebulizer Explanation: Inhalers differ in the amount of dexterity that is required in order to deliver an accurate dose, but each requires some degree of coordinated activity on the part of the patient. For a patient with decreased cognition, a nebulizer may be more appropriate on account of the fact that the patient passively inhales the entire dose. 1372

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which of the following oxygen delivery systems should the nurse utilize? a) Simple mask b) Venturi mask c) Non-rebreather mask d) Nasal cannula

Non-rebreather mask Explanation: A non-rebreather mask is the only device that can deliver FIO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FIO2 of 55%. A nasal cannula delivers a maximum FIO2 of 44%. A simple mask delivers a maximum FIO2 of 60%. 1377

While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique? a) Consolidated portions of the lung b) Fluid-filled portions of the lung c) Pattern of thoracic expansion d) Presence of pleural rub

Pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation. 1360

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Pneumonia b) Pleural effusion c) Tachypnea d) Wheezes

Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion. 1378

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of which of the following? a) Asthma b) Pneumonia c) Alcohol abuse d) Croup

Pneumonia Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup is a common condition in young children that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center. 1352

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing a) Poor tissue perfusion b) Congestive heart failure c) Anemia d) Malnutrition

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition. 1353

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to alternate eating and using a nebulizer during meal time. b) Encourage the client to eat immediately before breathing treatments. c) Provide six small meals daily. d) Provide three large meals daily.

Provide six small meals daily. Explanation: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises. 1365

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Thoracentesis b) Pulse oximetry c) Peak expiratory flow rate d) Spirometry

Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled and evaluate lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes. 1361

A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation? a) Remove the airway, turn the patient to the side and provide mouth suction, if necessary. b) Leave the airway in place and notify the physician for further instructions. c) Ask the patient to extend the neck slightly to adjust the airway. d) Immediately remove the airway and reinsert it because it has probably inadvertently caused the gag reflex.

Remove the airway, turn the patient to the side and provide mouth suction, if necessary. Explanation: If the patient vomits as the oropharyngeal airway is inserted, quickly position the patient onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. Reinsertion of airway, leaving it in place and extension of the neck can result in further complications related to aspiration. 1395

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? a) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. b) If the client is experiencing redness around the mask, remove and apply powder to the mask. c) Adjust the mask so it fits tightly around the face. d) For a mask with a reservoir, fill the reservoir half-full of oxygen.

Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. Explanation: To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step. Remove the mask and dry the skin every two to three hours if the oxygen is running continuously; do not use powder around the mask. 1400

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) Respiratory muscles becomes weaker b) Increased mouth breathing and snoring c) Increased use of accessory muscles for breathing d) Diminished coughing and gag reflexes

Respiratory muscles becomes weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults. 1356

A nurse is providing care to an infant who is at risk for developing respiratory complications. Which of the following would lead the nurse to notify the physician that the infant is experiencing breathing difficulties? a) Soft rustling sounds on auscultation b) Gasping c) Retraction of ribs d) Panting respirations

Retraction of ribs Explanation: An infant with breathing difficulty will have retraction of ribs during inspiration. Apart from this, flaring of the nostrils is another notable sign of air hunger and extraordinary breathing effort. Soft rustling sounds on auscultation are normal findings. Gasping, and panting respirations are more typically found in adults. 1358

Which of the following nursing skills requires the nurse to use sterile technique? a) Administering nebulizers b) Administering oxygen by face mask c) Suctioning a tracheostomy d) Providing oxygen by nasal cannula

Suctioning a tracheostomy Explanation: Suctioning is always a sterile procedure, whereas the administration of oxygen and nebulized medications require clean technique. 1383

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) A secondary source of oxygen should be available in case of power failure. b) The chest tube should not be separated from the drainage system unless clamped. c) Filters need to be cleaned regularly to avoid unpleasant taste or smell. d) A nasal cannula should be used to administer oxygen when cleaning the opening.

The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula. 1378-1379

You are preparing an educational inservice about endotracheal suctioning using an open suctioning system. Which of the following concepts should you plan to include? a) The patient should be suctioned until pulmonary secretions have been cleared. b) The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube. c) If the patient's endotracheal tube has been in place for longer than 7 days, the suction catheter can be reused but it needs to be replaced every 24 hours. d) Before suctioning, the wall suction unit should be adjusted to deliver 130 to 150 mm Hg of negative pressure.

The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube. Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.1404

The nurse is caring for a client who requires long-term oxygen therapy. However, the client is adequately oxygenated at a lower flow. What type of device should the nurse use to deliver oxygen to the client in this case? a) CPAP mask b) Nasal catheter c) Transtracheal oxygen d) Oxygen tent

Transtracheal oxygen Explanation: The nurse should use a transtracheal oxygen device for a client who requires long-term oxygen therapy and who is adequately oxygenated at a lower flow. A transtracheal catheter is a hollow tube inserted within the trachea to deliver oxygen. A CPAP mask is used for clients with sleep apnea; oxygen tents are used to care for active toddlers. A nasal catheter is used for clients who tend to breathe through the mouth or experience claustrophobia when a mask covers their face. 1378

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

True Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis. 1379

You are preparing to perform tracheal suctioning on a 3-year-old child. Which of the following actions is most appropriate? a) Use an 18F suction catheter and limit suction to no longer than 20 seconds. b) Use a 14F suction catheter and limit suction to no longer than 15 seconds. c) Use a 5F suction catheter and limit suction to no longer than 5 seconds. d) Use a 6F suction catheter and limit suction to no longer than 10 seconds.

Use a 6F suction catheter and limit suction to no longer than 10 seconds. Explanation: For a 3-year-old child, use a 6F suction catheter and limit suction to no longer than 10 seconds. 1406

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? a) Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. b) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. c) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. d) Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align and insert the suction catheter no further than an additional 1 cm.

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align and insert the suction catheter no further than an additional 1 cm. Explanation: Guidelines to determine suction catheter depth include the following: using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align and insert the suction catheter no further than an additional 1 cm. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the patient, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm. 1404

Which of the following describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? a) When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch. b) When holding the airway on the side of the patient's face, it should reach from the tip of the ear to the nostril times two. c) When holding the airway on the side of the patient's face, it should reach from the opening of the mouth to the back angle of the jaw. d) The airways come in standard sizes determined by the height and weight of the patient.

When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch. Explanation: The nasopharyngeal airway length is measured by holding the airway on the side of the patient's face. The airway should reach from the tragus of the ear to the nostril plus 1 inch. The diameter should be slightly smaller than the diameter of the nostril. Answer B describes the measurement for an oropharyngeal airway. 1393

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin? a) Vitamin B12 b) Folic acid c) Vitamin C d) Vitamin A

a

A 45-year-old female client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with her morning labs and the result is 98 mg/dL. How would the nurse interpret this blood glucose? a) Normal b) Severely elevated c) Low d) Mildly elevated

a

A 66-year-old woman has atrial fibrillation for which she is on warfarin therapy. She asks the nurse if she has any dietary restrictions. The nurse would need to monitor the client's intake of: a) spinach. b) broccoli. c) mangos. d) bananas.

a

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires nursing intervention? a) "Taking megadoses of vitamins will help me increase muscle mass quickly." b) "The milk I drink has calcium added to it." c) "Eating raw vegetables is good, because cooking may alter the vitamin content in food." d) "I understand that my body does not manufacture vitamins."

a

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention? a) "My favorite drink is coffee with sugar." b) "I'll monitor my intake of fruit juice." c) "At every meal, I eat a small portion of lean meat." d) "I like to eat eggs for breakfast."

a

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in? a) Overweight b) Obese c) Underweight d) Healthy weight

a

A nurse is caring for a client who has been admitted on the medical surgical unit. Which statement by the nurse about obtaining an initial weight is correct? a) "I need to get your weight at this time with our scales." b) "It is not necessary to get your weight until the morning." c) "Please tell me what your current weight is." d) "I can use the weight we got in the clinic before you came to the hospital."

a

A nurse is caring for a patient with COPD. What would be expected finding upon assessment of this patients? A. dyspnea B. hypotension C. decreased respiratory rate D. decreased pulse rate

a

A nurse is estimating caloric requirements for a female patient whose healthy weight is 120 pounds and whose activity level is moderate. This patient's recommended total daily calories is: a) 1,680 b) 1,200 c) 1,560 d) 1,440

a

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter B. Notify the primary care provider C. check the airway for the appropriate size for the patient D. Place the patient on his of her back

a

A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client? a) Drink juice for majority of fluid intake. b) Make fruits and vegetables at least half of total food intake. c) Drink nonfat or 1% milk. d) Eat a variety of enjoyable foods, but less quantity.

a

An athlete wants to increase the intake of complex carbohydrates and asks the nurse about potential sources. Which of the following foods is considered a complex carbohydrate? a) Pasta b) Eggs c) Peanuts d) Honey

a

During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her infant age 6 months. What does the nurse inform the mother? a) New foods should be introduced one at a time for a period of five to seven days. b) It is too early to add solid foods to the infant's diet. c) Adding solid foods is fine at this age, but avoid iron-fortified foods. d) A new solid food should be introduced daily to the infant's diet for a week.

a

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the: a) RDA level b) AI level c) EAR level d) UL level

a

The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardiometabolic syndrome? a) 36-year old with obesity who smokes b) 59-year old with lupus who exercises three times weekly c) 23-year old with ankle fracture and anxiety d) 44-year old with hypertension and undernutrition

a

The nurse is teaching a new mother who is not breast-feeding her infant. What nutrient must be supplemented by the mother? a) Iron b) Vitamin C c) Protein d) Calcium

a

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key clockwise until right

a

What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg? a) 24.8 b) 20.2 c) 22.4 d) 26.2

a

Which of the following is a fat-soluble vitamin? a) Vitamin E b) Vitamin C c) Vitamin B6 d) Vitamin B12

a

You are the nurse caring for a client with an enlarged thyroid gland. You anticipate which nutritional deficiency is linked to the client's condition? a) Iodine b) Potassium c) Magnesium d) Sodium

a

A nurse is teaching a client about nutrition. Which facts should the nurse include about fat-soluble vitamins? Select all that apply. a) Fat-soluble vitamins are A, D, E, and K. b) Fat-soluble vitamins must be attached to a protein for transport in the blood. c) Deficiencies of fat-soluble vitamins can occur with malabsorption syndromes. d) The body excretes all excess water-soluble vitamins. e) Deficiencies may take hours or days to develop.

a b c

The nurse is assessing adequate nutrition for residents of a long-term care facility. Which strategies are recommended to address age-related changes affecting nutrition? Select all that apply. a) Eat a high-fiber diet for slowed intestinal peristalsis. b) Avoid cold liquids with decreased peristalsis in the esophagus. c) Eat more protein for lowered glucose tolerance. d) Serve a variety of foods at each meal for loss of sense of taste and smell. e) Avoid eating right before bedtime for gastroesophageal reflux. f) Offer large meals at frequent intervals for reduction in appetite and thirst sensation.

a b e

A nurse is inserting a nasogastric tube in a client with an ileus. Which actions would be appropriate for the nurse to use to confirm correct placement of the tube? Select all that apply. a) Aspirate stomach contents to check pH level. b) Listen for gurgling at the end of the nasogastric tube. c) Measure tube length and tube marking. d) Do a radiographic examination. e) Auscultate injected air over the epigastric space.

a c d

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply. a) Pregnant or lactating women b) Non-smokers c) Middle-age adults d) Strict vegetarians e) Adolescents

a d e

Which clients, at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? (Select all that apply.) a) people with substance abuse problems b) individuals who prefer to purchase food from local farmers c) children of middle-income parents d) older adults living on fixed incomes e) pregnant teenagers

a d e

Which assessment and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely asses the patient before, during , and after the procedure B. Hyperoxygenate the patient before and after suctioning C. Limit the application of suction to 20 to 30 seconds D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve E. Use an appropriate suction pressure F. Insert the suction catheter no further than 1 cm pas the length of the tracheal or endotracheal tube

a, b, d, e

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A. A patient diagnosed with Rubella B. A patient diagnosed with Diphtheria C. A patient diagnosed with varicella D. A patient diagnosed with tuberculosis E. A patient diagnosed with MRSA F. A patient diagnosed with Adenovirus infection

a, b, f

A nurse is caring for patient in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A. Providing a bed bath for a patient B. Visibly soiled hands after changing the bedding of a patient C. Removing gloves when patient care is complete D. Inserting a urinary catheter for a female patient E. Assisting with a surgical placement of a cardiac stent F. Removing old magazines from a patients table

a, c, d, f

Choice Multiple question - Select all answer choices that apply. A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. a) Monitor the client's respiratory rate. b) Check the devices used to deliver oxygen. c) Observe the breathing pattern and effort. d) Note the amount of oxygen administered. e) Check the symmetry of the client's chest.

a• Monitor the client's respiratory rate. e• Check the symmetry of the client's chest. c• Observe the breathing pattern and effort. Explanation: When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort of the client. The nurse should also auscultate for lung sounds. Additional assessments include recording the heart rate and blood pressure, determining the client's level of consciousness, and observing the color of the skin, mucous membranes, lips, and nailbeds. However, the nurse does not note the amount of oxygen administered to the client, or check the device that is used to deliver oxygen to the client during the physical assessment. 1358

Choice Multiple question - Select all answer choices that apply. Which of the following statements about oxygen tents are true? Select all that apply. a) They are often used for children who will not leave a mask or cannula in place. b) It is difficult to maintain a consistent level of oxygen in the tent. c) An oxygen tent restricts freedom of movement, leading to frequent noncompliance. d) The nurse must frequently assess for hyperthermia. e) Frequent linen and clothing changes should be anticipated. f) Use of an oxygen tent decreases the ability of a parent to comfort the child.

a• They are often used for children who will not leave a mask or cannula in place. e• Frequent linen and clothing changes should be anticipated. b• It is difficult to maintain a consistent level of oxygen in the tent. f• Use of an oxygen tent decreases the ability of a parent to comfort the child. Explanation: The purpose of an oxygen tent is to permit freedom of movement without the use of a nasal cannula or face mask. 1377

A client has a history of long-term alcohol abuse. Which of the following nutrients would need to be required in increased amounts? a) Niacin b) Vitamin B c) Vitamin C d) Calcium

b

A client has a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements. The client's expected outcome is: a) to maintain a clear liquid diet. b) to consume 80% of diet tray for each meal. c) to gain 5 lb in one day. d) to eat dessert after every meal.

b

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? a) regulation of osmotic pressure in the blood b) maintenance of normal bowel elimination c) production of hemoglobin to carry oxygen to tissues d) promotion of energy storage in adipose tissue

b

A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support? a) Low random blood glucose levels b) Low serum albumin levels c) Proteinuria d) Increased white blood cells

b

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? a) Vitamin B b) Vitamin D c) Vitamin A d) Vitamin C

b

A nurse is caring for a client who has a nasointestinal tube inserted. The nurse is checking placement using gastric aspirate to check the pH level. Which of the following findings should the nurse expect if the tube is in the duodenum? a) The stomach pH is 4.5. b) The stomach pH is 7.5. c) The stomach pH is 5.5. d) The stomach pH is 6.5.

b

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient oxygen saturation levels? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure

b

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? A. The age of the patient B. The size of the endotracheal tube C. The type of secretions to be suctioned D. The height and weight of the patient

b

A nurse is conducting a health history interview for an older adult. Which question or statement should the nurse prioritize for nutritional assessment? a) "When did you first notice that you had this sore on your heel?" b) "Which prescribed and over-the-counter medicines do you take?" c) "What kinds of foods did you prepare when you were younger?" d) "Why don't you consider eating more meat? You need protein."

b

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight? a) 135 lb/ 61.2 kg b) 145 lb/ 65.7 kg c) 140 lb/ 63.5 kg d) 130 lb/ 58.9 kg

b

A nurse is using personal protective equipment when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? A. The nurse puts on the PPE after entering the patients room B. The nurse works from " clean: areas to "dirty" areas during bath C. The nurse personalized the care by substituting glasses for goggles D. The nurse removes PPE after bath to talk with the patient in the room

b

A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James? a) Ideal body weight (IBW) b) Overweight c) Obese d) Underweight

b

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? A. It is the personal preferences of the nurse whether of no to use clean technique B. The use of the clean technique is safe for the home setting C. Surgical asepsis is the only safe method to use in a home setting D. It is grossly negligent to recommend clean technique

b

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following exposure? A. Report the incident to the appropriate person and file and incident report B. Wash the exposed area with warm water and soap C. Consent to PEP at appropriate time D. setup counseling session regarding safe practice to protect self

b

A school nurse is performing an assessment of student who states, " I'm too tired to keep my head up in class." The student has a low grade fever. The nurse would interpret these findings indicating which stage of infection? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period

b

A woman age 20 years has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources from the woman's diet? a) impaired tissue growth and repair b) impaired vitamin absorption c) decreased production of antibodies d) decreased water absorption in the colon

b

AN emergency department nurse is using a manual resuscitation bag to assist with ventilation in a patient with lung cancer who has stopped breathing on his own? What is the appropriate step in this procedure? A. tilt the patient's head forward B. Hold the masks tightly over the patient's mouth and nose C. Pull the patient's jaw backward D. Compress the bag twice the normal respiratory rate for the patient

b

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of: a) anabolism. b) negative nitrogen balance. c) positive nitrogen balance. d) digestion.

b

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? a) Offer larger meals and encourage the client to eat as much as is comfortable. b) Try to ensure that the client's food is attractive and sufficiently warm. c) Offer nutritional supplements and explain the potential benefits of each. d) Reduce the frequency of meals in order to allow the client to develop an appetite.

b

The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR? a) a client who is asleep b) a client who has a fever c) an older adult client d) a client who is fasting

b

The nurse is caring for four older adult clients. Which does the nurse identify as highest risk for cardiometabolic syndrome? a) 72-year old who is 66 inches (167.64 cm) tall b) 70-year old with a body mass index (BMI) of 34.8 c) 68-year old with osteoarthritis d) 66-year old who is of normal weight

b

The nurse is helping a client with low-fat dietary order to eat breakfast. Which food will the nurse remove from the dietary tray? a) coffee b) whole milk c) egg whites d) wheat toast

b

The nurse maintains the head of the bed elevated 30 degrees for a client who is receiving continuous tube feedings in order to prevent: a) residual. b) aspiration. c) leakage. d) coughing.

b

What consideration based on gender would a nurse make when planning a menu for a male client with well-defined muscle mass? a) Men have a higher need for minerals. b) Men have a higher need for proteins. c) Men have a lower need for vitamins. d) Men have a lower need for carbohydrates.

b

Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease? a) total serum cholesterol of 200 mg/dL; HDL 50 mg/100 mg/dL b) total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL c) total serum cholesterol of 150 mg/dL; HDL 43 mg/100 mg/dL d) total serum cholesterol of 190 mg/dL; HDL 60 mg/100 mg/dL

b

Which food choice should the nurse include in the plan of care for client who wants to increase the dietary intake of omega-3 fatty acids? a) granola b) salmon c) spinach d) low-fat milk

b

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? a) Place the client in the Trendelenburg position to facilitate the fluid aspiration process. b) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. c) Continue to instill air until fluid is aspirated. d) Use a small syringe and insert 10 mL of air.

b

Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2000 calories daily? a) sodium less than 2000 mg b) total fat less than 65 g c) saturated fat greater than 20 mg d) cholesterol greater than 300 mg

b

A 6-year-old is being cared for on an inpatient unit for treatment of intestinal malabsorption syndrome. Which might be signs of calcium deficiency? Select all that apply. a) Pale mucous membranes b) Hypertension c) Enlarged skull d) Bowed legs

b c d

A nurse is working with a 54-year-old obese man who is interested in losing weight. He asks the nurse why trans fats are so bad for you. The nurse's response includes which answers? Select all that apply. a) Trans fats raise HDL levels. b) Trans fats raise cholesterol levels. c) Trans fats raise LDL levels. d) Trans fats lower HDL levels.

b c d

The nurse is teaching a parent of a toddler about healthy eating habits. Which practices will the nurse recommend? (Select all that apply.) a) Promote food preferences in early childhood. b) Educate self and family about nutrition. c) Make time available for food preparation. d) Encourage healthy body image. e) Establish patterns for meals.

b c d e

The nurse is teaching an older adult client about different types of proteins that can be eaten. Which food will the nurse identify that contain dietary protein? (Select all that apply.)` a) butter b) fish c) nuts d) poultry e) beans

b c d e

A nurse who is planning a diet for a client who has anorexia chooses nutrients that supply energy to the body. Which nutrients are these? Select all that apply. a) Minerals b) Lipids c) Protein d) Water e) Carbohydrates f) Vitamins

b c e

Which measures are used by the nurse to confirm the correct placement of a nasogastric feeding tube? Select all that apply. a) auscultating injected air b) monitoring carbon dioxide levels c) measuring tube length d) instilling fluid into the tube e) measuring the pH level of aspirated contents

b c e

Which clients would the nurse expect to have an increase in BMR? Select all that apply. a) an adult who has hypersomnia b) a toddler who is having a growth spurt c) an older adult client who is in a long-term care facility d) a teenager who has been fasting to lose weight e) an adolescent who has a fever f) an adult who is going through an emotional time due to divorce

b e f

A nurse is performing hand hygiene after providing patient care. The nurse's hands are NOT visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. A. Removes all jewelry including platinum wedding band B. Washes hand to 1 in above the wrist C. Uses approximately one teaspoon of liquid soap D. Keeps hands higher than elbows when placing under faucet E. Uses friction motion when washing for at least 20 seconds F. Rinses throughly with water flowing toward fingertips

b, c, e, f

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Refrain from exercise B. Reduce anxiety C. Eat meals 1 to 2 hours prior to breathing treatments D. Eat high-protein/ high calorie diet E. Maintain a high-fowler's position when possible F. Drink 2 to 3 pints of clear fluids daily

b, d, e

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin? a) Folic acid b) Vitamin A c) Vitamin B12 d) Vitamin C

c

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient? a) Potassium b) Vitamin C c) Vitamin K d) Calcium

c

A client who has bleeding tendencies has a deficiency in which vitamin? a) Vitamin C b) Vitamin A c) Vitamin K d) Vitamin B

c

A client who is taking supplements complains of severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely? a) Riboflavin b) Folate c) Niacin d) B complex

c

A nurse documents a client's hemoglobin as 8 g/dL. What nutritional condition does this biochemical data signify? a) Malnutrition b) Dehydration c) Anemia d) Malabsorption

c

A nurse is assessing the nutritional needs of clients. Which criteria indicates that a client most likely needs total parenteral nutrition (TPN)? a) Residual of more than 100 mL b) Presence of dumping syndrome c) Absence of bowel sounds d) Serum albumin level of 2.5 g/dL or less

c

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pnemonia

c

A nurse is caring for a client who has a vitamin B12 deficiency. Which food would the nurse recommend to help with this deficiency? a) Broccoli b) Pork c) Liver d) Cantaloupe

c

A nurse is caring for a patient with chronic lung disorder who receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs B. he nurse adjust the fit of the cannula so it fits snug and tight against the skin C. The nurse encourages the patient to breathe through the nose with the mouth closed D. The nurse adjusts the flow rate to 6 L/ min or more

c

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? A. Remove gown, goggles, mask, gloves, and exit the room. B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. C. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene. D. Remove goggles, mask, gloves, gown, and perform hand hygiene.

c

A nurse is following the principles of medical sepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A. The nurse carries the patient's soiled lines close to the body to prevent spreading microorganism into the air B. The nurse places the soiled bed lines and hospital gowns on the floor when making the bed C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal D. The nurse cleans the most soiled items in the patient's bathroom first and follows with a cleanser

c

A nurse is preparing a sterile field using packaged sterile drape for a confused patient which is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? A. Ask another nurse to hold the hand of the patient and continue setting up the field B. Remove the instrument that was touched by the patient and continues setting up the sterile field C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand D. No action necessary since the patient has touched his or her own sterile field

c

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this? A. Instruct the assistant to notify the primary care provider B. Assess the patient's vital signs C. Remove the tape, adjust the depth to ordered depth and reapply the tape D. No action is required as depth will adjust

c

A nurse teaches a student nurse about the role fats play in the human body. What is the major storage form of fat? a) lipids b) trans fats c) triglycerides d) cholesterol

c

A nurse who is caring to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? A. A 60 year old patient who smokes two packs a day B. A 40 year old patient who had a WBC 6000/mm3 C. A 65 year old patient who has an indwelling urinary catheter in place D. A 60 year old patient who is a vegetarian and slightly underweight

c

At what percentage of weight over ideal weight is a person considered obese? a) 60% b) 40% c) 20% d) 100%

c

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate? a) Delegate feeding assistance to the unlicensed assistive personnel. b) Allow the client privacy during mealtime. c) Assess when client generally eats meals. d) Contact the healthcare provider to prescribe an appetite stimulant.

c

Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is: a) obese. b) underweight. c) extremely obese. d) normal weight.

c

Which food eaten with peanut butter would provide the client with complete protein? a) Carrots b) Tofu (soybean curd) c) Milk d) Wheat bread

c

Which nursing action associated with successful tube feedings follows recommended guidelines? a) Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. b) Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. c) Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. d) Prevent contamination during enteral feedings by using an open system.

c

Which vitamin is found only in animal foods? a) Vitamin C b) Vitamin D c) Vitamin B12 d) Vitamin A

c

A nurse is caring for a client receiving total parenteral nutrition (TPN). Which facts should the nurse understand about TPN therapy? Select all that apply. a) TPN is an isotonic solution. b) Lipids are added to decrease caloric value. c) TPN requires a PICC line or central venous access. d) TPN has a high glucose concentration. e) TPN has three primary components: proteins, carbohydrates, and fats. Submit your answer

c d e

Total parenteral nutrition (TPN) has been ordered for a client. The nurse is aware that the assessment criteria for ordering TPN is what? Select all that apply. a) Intact gastrointestinal tract b) Tolerating a full fluid diet c) Client is not able to absorb nutrients properly d) Renal or hepatic failure e) A debilitating condition for more than 2 weeks

c d e

The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply. a) Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. b) Insert a nasointestinal tube. c) Have the emesis basin nearby in case client begins to vomit. d) Ask the client if he needs to pause before continuing insertion. e) Give small air boluses until gastric contents can be aspirated. f) Continue to advance tube when the client relates that he is ready.

c d f

The nurse researches factors that may alter nutrition. Which statements accurately describe factors that influence nutritional status? Select all that apply. a) During adulthood, there is an increase in the basal metabolic rate (BMR) with each decade. b) Because of the changes related to aging, the caloric needs of the older adult increase. c) Men and women differ in their nutrient requirements. d) During pregnancy and lactation, nutrient requirements increase. e) Trauma, surgery, and burns decrease nutrient requirements. f) Nutritional needs per unit of body weight are greater in infancy than at any other time in life.

c d f

A client has developed dysphagia secondary to a cerebrovascular accident. The nurse is aware that the client is at risk for: a) confusion. b) gastritis. c) incontinence. d) aspiration.

d

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing? a) Vitamins b) Fats c) Carbohydrates d) Protein

d

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to what? a) Pain level during infusion b) Ability to reposition c) Nausea or vomiting d) Fluid and electrolyte levels

d

A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake? a) Allow the client to eat when he wants to. b) Feed the client his meal while in bed. c) Discourage family from visiting during meals. d) Encourage the client to eat in the dining room.

d

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first? a) Pour a premeasured amount of tube feeding formula into the nasogastric tube. b) Flush the nasogastric tube with the ordered amount of water. c) Check gastric residual. d) Aspirate stomach contents and check pH.

d

A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if she sees a laboratory result of: a) Transferrin 360 mg/dL b) Hemoglobin 12 mg/dL c) Blood urea nitrogen (BUN) 17 mg/dL d) Hematocrit 35%

d

A nurse is caring for a client who had an appendectomy earlier in the day. The client now has bowel sounds and is passing flatus. Which food is appropriate for the nurse to serve to the client at this time? a) Chopped fruit b) Sherbet c) Ensure d) Apple juice

d

A nurse is caring for a client who has a decrease in appetite. Which actions by the nurse would be appropriate? a) Move the bedside commode to the other side of the bed away from the meal tray. b) Give medications with the meal tray. c) Ask for double portions for the client. d) Assist with oral hygiene before serving the meal tray.

d

A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition? a) Total parenteral nutrition b) Metabolizing nutrition c) Nasogastric feed d) Peripheral parenteral nutrition

d

A nurse is caring for a client who reports frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved? a) Carbonated beverages b) Boiled vegetables c) Mashed potatoes d) Clear fruit juices

d

A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first? a) Check placement of the tube. b) Flush the tube with the ordered amount of water. c) Aspirate gastric contents with a syringe. d) Elevate the head of the bed.

d

A nurse is suctioning the nasopharyngeal airway of a a patient to maintain a patients airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient would vomit during suctioning B. The secretions appear to be in the stomach content C. The catheter touches an unsterile surface D. A nosebleed is noted with continued suctioning

d

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? a) Glucose levels will decrease with illness and stress. b) Calibrate the glucose meter every six months. c) Use a forearm sample with signs and symptoms of hypoglycemia. d) Blood from the fingertips shows changes in glucose more quickly than other testing sites.

d

A nurse is teaching an adolescent client about nutrition following a hospital admission. What should the nurse understand about adolescent nutrition? a) Adolescents tend to eat meals at home. b) Adolescents eat their food slowly. c) Nutritional needs decrease during adolescence. d) Childhood nutrition problems may worsen during adolescence.

d

A nurse providing care of patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this action? A. Notify the healthcare provider B. Apply an occlusive dressing on the site C. Asses the patient for signs of respiratory distress D. Put on gloves and insert the chest tube in a bottle of sterile saline

d

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? A. Place the bottle cap on the table with the edges down. B. Hold the bottle inside the edge of the sterile field. C. Hold the bottle with the label side opposite the palm of the hand. D. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

d

A nursing caring for an obese 62 year old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? A. imbalanced nutrition B. Impaired physical mobility C. Chronic pain D. Infection

d

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with the bathing and hygiene tasks even if the patient feels capable of performing them alone B. Teach the patient not to talk about the procedure, just perform it at his or her best ability C. Teach the patient to take short shallow breathes when performing hygiene measures D. Group personal care activities into smaller steps, allowing rest periods between activities

d

A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What is the term for this type of nutrition? a) Percutaneous endoscopic jejunostomy tube (PEJ) b) Partial or peripheral parenteral nutrition (PPN) c) Percutaneous endoscopic gastrostomy tube (PEG) d) Total parenteral nutrition (TPN)

d

A woman consumes pasta, grains, and other carbohydrates for which purpose? a) Weight loss b) Source of fiber c) Weight gain d) Energy

d

The nurse caring for patients in hospital setting institutes CDC standards precaution recommendations for which category patients? A. Only the patients with diagnosed infections B. Only the patients with visible blood, body fluids, or sweat C. Only patient with nonintact skin D. All patients receiving care in hospitals

d

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: A. Keep splashes on the sterile field to a minimum. B. Cover the nose and mouth with gloved hands if a sneeze is imminent. C. Use forceps soaked in a disinfectant. D. Consider the outer 1 inch of the sterile field as contaminated.

d

The nurse is caring for a patient who has dysphagia and is unable to eat independently. While assisting the patient in eating, which of the following actions is most appropriate for the nurse? a) Encourage the patient to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm. b) Arrange food items in a clock face pattern and inform the patient what time on a clock corresponds to each food item. c) Create a positive social environment by asking the patient about childhood food memories. d) Speak to the patient, but reduce the number of distractions while patient is eating.

d

What health problem may occur in a person who is on a low-carbohydrate diet for a long period of time? a) obesity b) infection c) fatigue d) ketosis

d

Which laboratory test is the best indicator of a client in need of TPN? a) Hematocrit b) Creatinine c) Hemoglobin d) Serum albumin

d

Which method of feeding would a nurse normally provide if a client can attempt eating regular meals during the day and is prepared to ambulate and resume activities? a) Ambulatory feeding b) Intermittent feeding c) Continuous feeding d) Cyclic feeding

d

When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? (Select all that apply.) a) creatinine b) BUN c) CBC with differential d) lipoprotein level e) triglyceride level f) cholesterol level

d e f

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I will be careful not to shake the canister before using it" B. "I will hold the canister upside down when using it" C. "I will inhale the medications through nose." D. " I will continue to inhale when the cold propellant is in my throat." E. " I will only inhale one spray with one breath." F. "I will activate the device while continuing to hale."

d, e, f

Choice Multiple question - Select all answer choices that apply. You are caring for a patient who will have a chest tube removed within the next hour. Which of the following interventions should you plan to implement. Select all that apply. a) Ask the patient to bear down, then slowly withdraw the chest tube. b) Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed. c) Anticipate obtaining a chest x-ray after the chest tube has been removed. d) Administer prescribed pain medication 15 to 30 minutes before chest tube removal. e) Teach the patient about relaxation exercises to be used during chest tube removal.

d• Administer prescribed pain medication 15 to 30 minutes before chest tube removal. e• Teach the patient about relaxation exercises to be used during chest tube removal. c• Anticipate obtaining a chest x-ray after the chest tube has been removed. Explanation: An occlusive dressing should be used. 1379

A normal pulse oximetry reading indicates that the body's oxygen demands are being met. a) False b) True

false 1363

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's ... a) blood pH b) sodium and potassium levels c) age d) hemoglobin level

hemoglobin level Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry. 1361