NUR130 final

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

The nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). The nurse instructs the client as follows: (Select all that apply.)

-Take a slow, deep inhalation from the device. -Activate the MDI once. -The device may increase delivery of the MDI medication

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care?

The client entered a clinical trial through the National Cancer Institute

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:

Gallbladder

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part

Patient health education provided by the nurse

is an independent function of nursing practice.

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply

-Clay-colored stools -Dark urine -Jaundice - Pruritis

Which step of the nursing process determines whether the client understands the health teaching that is provided?

Evaluation

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried chicken

A patient with a "Do Not Resuscitate" (DNR) order requires large doses of a narcotic for pain that rates a 10 on a 0-10 scale. After the patient requests pain medication, the nurse assesses a respiratory rate of 12 breaths per minute. What intervention by the nurse would be considered ethical?

Give the pain medication without fear of respiratory depression.

The nurse is caring for a client who is being evaluated for lipid-lowering medication. The client's laboratory results reveal the following: total cholesterol 230 mg/dL, LDL 120 mg/dL, triglyceride level 310 mg/dL. Which class of medications would be most appropriate for the client based on these laboratory findings?

Nicotinic acid

The nurse is admitting a client with a diagnosis of diverticulitis and assesses that the client has a boardlike abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action?

Notify the health care provider.

The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS?

Oligoclonal bands

Which of the following medications is classified as a proton pump inhibitor (PPI)?

Omeprazole

Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply

-Direct vasodilators may cause headache and tachycardia. -With thiazide diuretics, monitor serum potassium concentration

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Hyperkalemia

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Modified Trendelenburg

Therapeutic communication techniques between client and nurse facilitate continuity of care. Which of the following identifies the value of therapeutic communication? Select all that apply.

-Allows the nurse to display interest in the client and the communication -Helps the nurse to assist the client to explore and understand his or her problems

A patient comes to the clinic with the complaint, "I think I have an ulcer." What is a characteristic associated with peptic ulcer pain that the nurse should inquire about? Select all that apply

-Burning sensation localized in the back or mid-epigastrium -Feeling of emptiness that precedes meals from 1 to 3 hours -Severe gnawing pain that increases in severity as the day progresses

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply

-Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. -Renew the supply every 6 months. -Take the tablet in anticipation of any activity that can produce pain. -Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.

Which term refers to the first portion of the small intestine?

Duodenum

Which factor refers to a client's experiential readiness to learn?

Educational history and life experience

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and famotidine. Before the client is discharged, the nurse should provide which instruction?

"Avoid aspirin and products that contain aspirin."

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which explanation from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?

"Infuse I.V. fluids at 83 ml/hour."

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide?

"Practice meticulous foot care.

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:

Acute attacks with full recovery or residual deficit upon recovery.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

Which colloid is expensive but rapidly expands plasma volume?

Albumin

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate?

An inspiratory-expiratory (I:E) ratio of 2:1

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

Which is the initial stage of grief, according to Kübler-Ross?

Denial

Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall?

Hernia

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy

A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client?

Respect the client's and family members' choices

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention

alcohol abuse and smoking

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?

"Don't take aspirin while you're taking warfarin."

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary?

"I do not need to rinse my mouth with this type of inhaler."

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb in 1 day."

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess:

Trousseau's sign.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange

Using a Venturi mask to deliver oxygen as ordered

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply

-Administer pain-relieving medication -Administer electrolytes -Administer plasma -Assist the client to a semi-Fowler position

A client is being treated in the ED for respiratory distress coupled with pneumonia. The client has no medical history. However, the client works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which order based on the client's immediate needs?

Administration of antibiotics

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

The nurse is working on a busy cardiac unit caring for four hypertensive clients. Which client description would the nurse assess first because the client is at an increased risk for malignant hypertension?

A client with anorexia and history of no healthcare insurance

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

Aorta

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Aortic insufficiency

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis

Which measurement should a nurse use to monitor the respiratory status of a client with pulmonary edema?

Arterial blood gas (ABG) analysis

Which intervention should a nurse perform during the grieving period when caring for a dying client?

Avoiding criticizing or giving advice

Which term refers to the period of time during which mourning of a loss takes place?

Bereavement

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?

Black and tarry

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which characteristic would the nurse be most likely to find?

Black and tarry appearance

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?

Blurred vision, intention tremor, and urinary hesitancy

A client is experiencing symptoms that are suspected to be related to systemic lupus erythematosus. What cutaneous symptom occurs in about 50% of clients affected by this disease?

Butterfly-shaped rash on the face over the bridge of the nose and cheeks

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Cerebral edema

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?

Ineffective peripheral tissue perfusion

Crohn's disease is a condition of malabsorption caused by which pathophysiological process?

Inflammation of all layers of intestinal mucosa

Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply.

Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone)

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Jugular vein distention

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario?

Lioresal

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart?

Nitroprusside

Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply.

Pain Fatigue Spasticity Depression Numbness

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

Potassium

Which adrenergic inhibitor acts directly on the blood vessels, producing vasodilation?

Prazosin

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg

Progressive

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

What therapeutic communication technique validates what the nurse believes to be the main idea of an interaction?

Restating

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Shock

A nurse is providing a class on osteoporosis at the local seniors' center. Which of the following statements related to osteoporosis is most accurate?

Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis.

The nurse is caring for a client who has developed obvious signs of pulmonary edema. What is the priority nursing action

Stay with the client.

Which of the following are signs/symptoms of perforation?

Sudden, severe upper abdominal pain

Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks?

Systemic lupus erythematous (SLE)

When a client is in the compensatory stage of shock, which symptom occurs?

Tachycardia

A patient taking metronidazole (Flagyl) for the treatment of H. pylori states that the medication is causing nausea. What suggestion can the nurse provide to the patient to alleviate this problem?

Take the medication with meals to decrease the nausea.

A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?

Ulcerative colitis

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to:

combat inflammation

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

electrocardiogram (ECG) results

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has?

peptic ulcer disease

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for:

rupture of the appendix.

A client admitted for treatment of a gastric ulcer is being prepared for discharge. The client will follow a regimen of antacid therapy. Discharge teaching should include which instructions? Choose all that apply

-"Continue to take antacids even if your symptoms subside." -"You may be prescribed H2-receptor antagonists for up to 1 year."

A client is instructed to follow a low-fat diet after an inflammatory attack of the gallbladder. Which vitamins will the nurse recommend the client supplement due to the client's dietary restrictions? Select all that apply.

-A -D -K -Essential fatty acids

Which situation would be appropriate for ethics committee review? Select all that apply

-Client refusal of a lifesaving blood transfusion because of religious preference -Placing a 21-year-old client with cystic fibrosis on the double-lung transplant list -Institutional participation in gene chip technology directed at disease prevention

A terminally ill patient asks the nurse, "Am I dying?" How will the nurse's response be influenced by moral obligation? (Select all that apply.)

-Communicate the patient's wishes to the family. -Consult with the physician. -Provide correct information to the patient

The diagnosis of pulmonary hypertension associated with chronic obstructive pulmonary disease (COPD) is suspected when which of the following is noted? Select all that apply

-Dyspnea and fatigue disproportionate to pulmonary function abnormalities -Right ventricular enlargement -Elevated plasma brain natriuretic peptide (BNP) -Enlargement of central pulmonary arteries

The nurse is caring for a client newly diagnosed with coronary artery disease (CAD). While developing a teaching plan for the client to address modifiable risk factors for CAD, the nurse will include which factor(s)? Select all that apply

-Elevated blood pressure -Obesity

In providing nursing management to a client post-varicose vein surgery, the nurse would include which of the following teaching measures? Select all that apply

-Exercise -Elastic stockings

The nurse is caring for a client who has just returned from the PACU after surgery for peptic ulcer disease. For what potential complications does the nurse know to monitor? Select all that apply.

-Hemorrhage -Perforation -Penetration -Pyloric obstruction

A nurse cares for a client with a disorder of the endocrine function of the pancreas. Which hormones or enzymes may be impacted by this disorder? Select all that apply.

-Insulin -Glucagon -Somatostatin

A client has just received a diagnosis of hypertension after the completion of diagnostics. What can the client do to decrease the consequences of hypertension? Select all that apply.

-Lose weight. -Manage stress effectively.

A client involved in a motor vehicle collision has awakened from a coma and asks for his wife, who was killed in the same accident. The family does not want the client to know at this time that his wife was killed. The family wants all nursing staff to tell the client that the wife was air lifted to another hospital, has a severe head injury, and is in the ICU. Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instructions, the nurse faces an ethical dilemma. The steps of ethical analysis can assist the nurse with decision making. Select from the list below all the steps that are correct.

-Recognize the ethical, legal, and professional dimensions involved. -Collect information. -List the alternatives. -Decide and evaluate the decision.

A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply.

-Reduces myocardial oxygen consumption -Dilates blood vessels -Decreases ischemia -Relieves pain

A client is admitted to the emergency room with a blood pressure reading of 200/130 mm Hg. What are this client's therapeutic goals? Select all that apply

-Reduction of the mean blood pressure by 25% within the first hour. -Achievement of a goal pressure of about 160/100 within 2 to 6 hours. -Reduction to a target goal pressure over a period of days.

A client with CAD has been prescribed a transdermal nitroglycerin patch. What instructions should the nurse provide to to the client? Select all that apply

-Remove the transdermal patch at night and reapply in the morning. -Store the patch in its original container when not in use.

The immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following? Select all that apply.

-Susceptibility -Abnormal innate and adaptive immune responses -Autoantibodies immune complexes -Inflammation -Damage

What disease processes contribute to chronic heart failure? Select all that apply.

-Tachydysrhythmias -Valvular disease -Renal failure

A client has been diagnosed with right-sided heart failure based on symptomology. The cardiologist will confirm this suspicion through diagnostics. Which diagnostics are used to reveal right ventricular enlargement? Select all that apply

-electrocardiogram -chest radiograph -Echocardiography

The nurse is caring for a client with respiratory distress caused by pneumonia who recently became homeless after losing his job. He also tells the nurse that the stress of losing both his job and his home has caused his wife to move in with one of their adult children. The nurse hears him say, "I just don't know what to do. I wish I were a better human being. I've never really done anything right." The nurse will attend to this client's needs in what order?

1)The client's respiratory distress 2)The client's homelessness 3)The client's estrangement from his wife 4)The client's feeling about himself 5)The client knowing what to do

A nurse educator is providing information to a small group of clients about hypertension. A participant asks what her target blood pressure should be. The nurse is aware of the target goals of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). Which of the following reflects the goal for blood pressure readings for people without co-morbidities?

140/90 or lower

A nurse is caring for a client who has had extensive abdominal surgery and is in critical condition. The nurse notes that the complete blood count shows an 8 G/dL hemoglobin and a 30% hematocrit. Dextrose 5% in half-normal saline solution is infusing through a triple lumen central catheter at 125 mL/hr. The physician orders include the following: o Gentamicin 80 mg IV piggyback in 50 mL D5W over 30 minutes o Zantac 50 mg IV piggyback in 50 mL D5W over 30 minutes o One unit of 250 mL of PRBCs (packed red blood cells) over 3 hours o Flush the nasogastric tube with 30 mL normal saline every 2 hours. How many milliliters should the nurse record as the intake for the 8-hour shift? Enter the correct number ONLY.

1470

A client returns from the operating room after receiving extensive abdominal surgery. He has 1,000 mL of lactated Ringer's solution infusing via a central line. The physician orders the IV fluid to be infused at 125 mL/hr plus the total output of the previous hour. The drip factor of the tubing is 15 gtt/min, and the output for the previous hour was 75 mL via Foley catheter, 50 mL via nasogastric tube, and 10 mL via Jackson Pratt tube. For how many drops per mintue should the nurse set the IV flow rate to deliver the correct amount of fluid? Enter the correct number ONLY

65

The nurse is caring for a client diagnosed with unstable angina who is receiving IV heparin. The client requires bleeding precautions. Bleeding precautions include which measure?

Avoid continuous BP monitoring

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?

Butterfly rash

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation?

Encourage the family members to express their feelings and listen to them in their frank communication

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

Which particular area(s) should be examined to assess peripheral edema

Feet, ankles

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia

The nurse caring for a client with a leg ulcer has finished assessing the client and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include?

Imbalanced nutrition: less than body requirements

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority

Impaired gas exchange

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive

Influenza

Which communication technique is helpful in health teaching about relevant aspects of a client's well-being and self-care?

Informing

Which term refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?

Intermittent claudication

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse.

Health education of a client by the nurse

is an independent function of nursing practice.

The physician is ordering a test for the hypertensive client that will be able to evaluate whether the client has experienced heart damage. Which diagnostic test would the nurse anticipate to determine heart damage?

Multiple gated acquisition scan (MUGA)

When a nurse can legally order the primary interventions to achieve a goal, which part of the nursing process is being developed?

Nursing Diagnosis

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

Using strict hand hygiene

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects

respiratory alkalosis


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