NURS 327 Midterm Exam

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

-Avoiding placement of pillows or blanket rolls under the patient's knees -Encouraging early ambulation -Assisting the patient with leg exercises

The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply.

-Client's comorbid conditions -Type of procedure be performed -Changes in neurologic function due to the procedure -Prior effectiveness in relieving the pain

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.

-Complete a respiratory assessment after the procedure. -Educate the client about the need to cleanse the thoracic area. -Apply pressure to the puncture site after the procedure

When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)

-Decreased gag reflex -Increased presence of collagen in alveolar walls -Decreased presence of mucus

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.

-Need for teaching is increased. -The client will leave the hospital sooner than in the past. -The client must be prepared to take on more self-care than he or she may have done in the past.

Why would a client with COPD report feeling fatigued? Select all that apply.

-The client is using all expendable energy just to breathe. -Lung function gradually decreases over time in clients with COPD.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)

-The patient talks incessantly. -The patient avoids communication with the nurse. -The patient repeatedly asks questions that have previously been answered

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking?

1 to 2 months

A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?

A tracheostomy

While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?

Biot's respiration

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Post-discharge diet

When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?

Rapid, thready pulse

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

Record the observation

Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order?

Rectal

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:

Remove the patch after 12 hours.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output.

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to

Report decreased congestion.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is:

Respiratory acidosis.

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 mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?

Venous thromboemboli

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?

Wheezes

A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is

"I should expect to have pain."

The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?

"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."

When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?

"You shouldn't experience a headache after this type of anesthesia."

A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?

A lung volume reduction

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

Anemic Hypoxia

What is the most commonly prescribed treatment for the common cold?

Antihistamines

Which action by the nurse indicates understanding of one basic principle of providing effective pain management?

Awakening a new postoperative client to take pain medication

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

Cancer

A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?

Crackles

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

Daily doses of isoniazid, 300 mg for 6 months to 1 year

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

Which factor increases blood urea nitrogen (BUN)?

Gastrointestinal bleeding

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply.

Glucose level Protein level Albumin level

A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe?

IV penicillin G; single dose

The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.)

Immunization programs Sanitation techniques Regulated health practices

Which measure may increase complications for a client with COPD?

Increased oxygen supply

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis

A nurse would implement droplet precautions for a client with which condition? Select all that apply.

Mumps Parvovirus B 19 Pertussis

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply

Open reduction of a fracture Cystoscopy Arteriography Paracentesis

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2

A nurse implements aseptic technique as a means to break the chain of infection at which element?

Portal of entry

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps

An adult client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse's response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?

Suction the client's airway secretions.

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH?

The lungs eliminate carbonic acid by blowing off more CO2.

An client is described as having pectus carinatum. What would be the physical manifestation of this condition?

The sternum protrudes and the ribs are sloped backward.

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management?

There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position?

Turn the client to enable assessment of all the patient's lung fields.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?

Up to 2 hours before surgery

The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain?

Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

b. 5% DW

It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to

manage decreased energy levels

The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse

obtains a light, mirror, gauze, and curved hemostats.