Nursing 330 Exam 3 questions resp/gi/gu
A nurse is a ministering 250 MG of antibiotic intramuscularly. Available is 3G/ 5 mL. How many milliliters should the nurse administer?
0.4mL Desired 250 g Have 3g Convert units measurements 1g/1000mg =3g X=3000 Available dose is 5ml Have/quantity=desired 3000mg/5ml = 250/x ml X=0.416666
A nurse is preparing to administer methylphenidate to a client who has an opioid induced constipation. Available is methylphenidate 8 mg per 0.4 mL. How many milliliters should the nurse administer?
0.6 mL The desired does is 12 mg the dose available is 8 mg the quantity of the dose available is .4 mL. Have divided by quantity equals desired does 8 mg divided by 0.4 mL equals 12 mg divided by X milliliters zero. 6 mL should be administered 8mg/ 0.4mL = 20mL 12mg/ 20mL =0.6 mL to be administered
A nurse is caring for an adolescent client with pneumonia and a prescription for cefpodoxime 5mg/kg PO every 12 hours for the next 5 days. The client weighs 88 lbs. how many mg should the nurse administer.
200mg 2.2lb/ 1kg=88 lb 88lb/2.2= 40 kg 5mg x 40kg = 200mg
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A) oral mucosa B) conjunctiva C) earlobes D) soles of the feet
A) oral mucosa According to the evidence-based practice the nurse should monitor for the clients tongue and lips for manifestations of central cyanosis because I gnosis is the most evident in areas with minimal pigmentation
A nurse is preparing to instill 840 mL of enteral nutrition via a clients Gastrostomy tube over 24 hours using the infusion pump. The nurse should set the infusion pump to deliver how many milliliters per hour?
35ml/hour The volume the nurse should infuse is 840 mL. The total infusion time is 24 hours. 840 mL divided by 24 hours equals 35 mL per hour infusion rate
A nurse is reviewing the medication list for a client who has a new diagnosis of small bowel obstruction. The nurse should withhold which of the following medications? A) senna B) ibprofen C) omeprazole D) zolpidem
A) senna Laxatives are contraindicated in clients who have fecal impaction, and acute abdominal surgery to prevent preparation. Because the bowel does not allow for any passage of store with a complete towel obstruction, laxatives will increase abdominal cramping and discomfort
A nurse is preparing to administer antibiotic X over 20 minutes. Available is antibiotic X in 50 mL of 0.9% sodium chloride (NSS). The drop factor of the manual IV tubing is 20 GTT/ML. The nurse should set the manual IV infusion to deliver how many GTT/min?
50 Calculating GTT/min. The quantity of those available is 20 GTT/min. The total infusion time is 20 minutes. The volume the nurse should infuse at is 50 mL. There is no need to convert the units of measurement. 20 gtt/1 mL x 50ml/20 min =50
A nurse is caring for a client who is to receive liquid medications via a Gastrostomy tube. The client is prescribed phenytoin 250mg. The amount available is phenytoin oral solution 25 mg/ 5 mL. How many milliliters should the nurse administer per dose?
50 ml 250mg/25mg x5ml =50 ml
A nurse is caring for a client who is post operative following an appendectomy and is prescribed D5 lactated ringer's at 150 mL per hour by continuous IV infusion for 12 hours. The drop factor of the manual IV tubing is 20 GTT per milliliter. The nurse should set the manual IV infusion to deliver how many GTTs per minute?
50gtt/min Volume equals 150 mL per hour. Total infusion time one hour. Conversion measurement of one hour is 60 minutes. 150 mL divided by 60 minutes times 20 GTT per milliliter equals 50 GTT per minute
A nurse is caring for a client who is receiving oxygen at 2 L per minute via nasal cannula. The nurse recognizes that the client is receiving which of the following inspired oxygenation concentrations? A) 28% B) 36% C) 50% D) 70%
A) 28% The nurse should recognize that the flow rate of 2 L per minute via nasal cannula delivers an oxygen concentration about 28%
A nurse is caring for a client who has a late Stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into bed with another client who becomes upset and frightened. Which of the following action should the nurse take? A) Assist the client to the correct room B) place a client in restraints C) re-orientate the client to time and place D) move the client to a room at the end of the hall
A) Assist the client to the correct room Assisting the client to the correct run protects both clients. It helps re-orientate the client who is unable to find her own room, and it protects the other client from an invasion of her personal space
A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medication should the nurse instruct the client to use to abort an acute asthma attack? A) abutyryl B) formoterol C) salmeterol D) beclomethasone
A) abutyryl Albuterol is an inhaled short acting beta two agonist used to rescue medications to relieve an acute asthma attack. This dilates the airways decreases wheezing and improves oxygenation
A nurse is caring for a child who is experiencing status asthmatics. Which of the following interventions is the priority for the nurse to take? A) administer a short acting b2 agonist (SABA) B) obtaining a peak flow reading C) administering an inhaled glucocorticoid D). Determine the cause of the acute excaberation
A) administer a short acting b2 agonist (SABA) When using the urgent versus non-urgent approach to client care the nurse to determine that the priority nursing action is to administer a nebulizer Thai does SABA to relieve bronchial constriction and improve ventilation
A nurse is caring for a client who has gastrointestinal bleeding. Which of the following action should the nurse take first? A) assess orthostatic blood pressure B) explain the procedure for an upper and gastrointestinal series C) administer pain medication D) test the clients emesis for blood
A) assess orthostatic blood pressure Using the nursing process, the first action the nurse should take to assess the client is by measuring the clients orthostatic blood pressure. This action determines if the client is hypovolemic an established as a baseline for further measurements
A nurse is caring for a client who has the pneumonia and a prescription for oxygen therapy at 5 L per minute via nasal cannula. Which of the following action should the nurse take? A) attach a humidifier bottle to the base of the flowmeter B) remove the nasal cannula while the client eats C) secure the oxygen tubing to the bed sheet near the clients head D) apply petroleum jelly to the nares as needed to smooth mucous membranes
A) attach a humidifier bottle to the base of the flowmeter Oxygen therapy can dry mucous membranes the nurse should attach a humidifier to the base of the flowmeter to help the client receive oxygen greater than 4 L per minute via nasal cannula.
A nurse is caring for a client who is post operative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer to the client? (Select all that apply) A) broth B) grape juice C) nonfat milk D) custard E) lemon gelatin
A) broth B) grape juice E) lemon gelatin Fat free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable. Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice. Lemon gelatin is an acceptable component of a clear liquid diet along with sugar, honey, hard candy and ice pops
A nurse is caring for a client who has heart failure in histories of asthma. The nurse reviews the providers orders and recognizes that a clarification is needed for which of the following medications? A) carvediol B) fluticasone C) captipril D) isosorbide dinitrate
A) carvediol Medications that block beta-2 receptors are contraindicated in clients with asthma
A nurse is preparing to administer a soapsuds enema to a client who has constipation. As the nurse explains the procedure, the client states, the doctor didn't tell me I was supposed to receive an enema. Which of the following nursing actions is appropriate at this time? A) check the clients medical record for the providers prescription B) explained to client that the provider prescribe the procedure C) assure the client that enemas are common and prescribe for constipation D) inform the charge nurse that the client refused the enema
A) check the clients medical record for the providers prescription The nurse should use the clients medical record to verify the provider prescribed an enema for the client
A nurse is caring for an older adult client who has had surgery for intestinal obstruction and has a NG tube to wall suction. Which of the following intervention should the nurse include in the clients post operative plan of care? (Select all that apply) A) discontinue suctioning when assessing for peristalsis B) irrigate the NG tube with 0.9 sodium chloride irrigation solution C) play sequential compression devices on bilateral lower extremity's D) reposition the client from side to side every two hours E) encourage the use of an incentive spirometry every two hours while the client is awake
A) discontinue suctioning when assessing for peristalsis B) irrigate the NG tube with 0.9 sodium chloride irrigation solution C) play sequential compression devices on bilateral lower extremity's D) reposition the client from side to side every two hours The nurse should turn off suction while auscultating the abdomen to determine the return of peristalsis because the suction mask any present bowel sounds. The client requires the NG tube for gastric decompression, so the nurse must make sure it remains patent. Irrigation of the NG tube with normal Celine irrigation solution every four hours will ensure patency. Sequential compression devices improve blood flow for clients who have Mobility limitations and help prevent Venus thromboembolism in the lower extremities. The nurse should re-position the client from side to side at least every two hours but should also assist with early ambulation to improve ventilation and help mobilize secretions. An incentive spirometry meter should be used every hour while the patient is awake
A nurse is providing teaching discharge information to a client who has a new prescription for home oxygen. Which of the following instruction should the nurse include in the teaching? A) do not adjust the oxygen flow rate B) check your oxygen equipment each week C) store on use oxygen tanks horizontally D) do not use for blankets in your bed
A) do not adjust the oxygen flow rate This ensures that the patient receives the prescribed rate
A nurse is teaching a client who has asthma how to use a metered dose inhaler ( MDI). The nurse identifies the sequence of steps the client should follow. A) inhale deeply then exhale completely, please lips around the mouthpiece firmly to direct the spray into the airways, breathe deeply over 2 to three seconds while pushing down on the canister, holding breath for 10 seconds, exhale slowly through pursed lips, wait 60 seconds between each puff B) Place lips firmly around the mouthpiece, breathe in deeply over 2 to three seconds while pushing down on the canister, inhale deeply and exhale completely, hold her breath for 10 seconds, exhale slowly through pursed lips, wait 60 seconds between each puff C) Place lips firmly around the mouthpiece, inhale deeply then exhale completely, breathe in deeply over 2 to three seconds while pushing down on the canister, exhale through through pursed lips, hold breath for10 s
A) inhale deeply then exhale completely, please lips around the mouthpiece firmly to direct the spray into the airways, breathe deeply over 2 to three seconds while pushing down on the canister, holding breath for 10 seconds, exhale slowly through pursed lips, wait 60 seconds between each puff
A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for Docusate sodium. Which of the following statements by the client indicates an understanding of teaching? A) it might take up to three days for the medication to work B) I will take the medication for diarrhea C) I should drink 4 ounces of water when I take this medication D) I can take this medication along with mineral oil
A) it might take up to three days for the medication to work This is a stool softener and the therapeutic effect might take up to 3 days to achieve
A nurse is teaching a client who has constipation about a high fiber diet. Which of the following foods should be included as a source of fiber? (Select all that apply) A) kidney beans B) blackberry C) refined cereal D) whole wheat bread E) lean turkey
A) kidney beans B) blackberry D) whole wheat bread
A nurse is caring for a client who has a dire vertical disease. When palpating the clients abdomen in which of the following location should the nurse expect the client to report abdominal pain A) lower left quadrant B) upper left quadrant C) lower right quadrant D) upper right quadrant
A) lower left quadrant The nurse should expect the client to have abdominal pain in the left lower quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high-pressure moves fecal content from the rectum causing pouch formation
A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent and IV bolus. 10 minutes into the infusion of the third does, the client reports that IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse first take? a) stop the infusion B) call the provider C) elevate the head of bed D) auscultate the clients breath sounds
A) stop the infusion When using the airway breathing circulation approach to client care, the nurse should place the priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis in the first action should be taken to withdraw this medication
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestation should indicate to the nurse that the child's appendectomy is perforated? A) sudden decrease in abdominal pain B) absent Rovsing sign C) flaccid acid D) low grade fever
A) sudden decrease in abdominal pain A sudden decrease in abdominal pain, should indicate to The nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread to the whole abdomen
A nurse is teaching a client who has asthma about how to use an a butyryl inhaler. Which of the following actions should the client indicates as an understanding of teaching? A) the client hold his breath for 10 seconds after inhaling the medication B) the client takes a quick inhalation while releasing the medication from the inhalator C) and the client exhales as the medication is released from the inhaler D) the client wait 10 minutes between inhalation
A) the client hold his breath for 10 seconds after inhaling the medication The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of dosage can be delivered properly to the airways. Do use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling
A nurse is caring for a client who has nausea and a prescription for metoclopramide and I had intermittent IV bolus every four hours as needed. The client asked the nurse how metoclopramide will relieve her nausea. Which of the following exclamation should the nurse provide? A) the medication relieves nausea by promoting gastric emptying B) the medication works by decreasing gastric acid secretions C) The medication relieves nausea by slowing parastatals D) The medication works by relaxing gastric muscles
A) the medication relieves nausea by promoting gastric emptying Reglan is a gastrointestinal stimulant used to relieve nausea, vomiting, heartburn, stomach pain, bloating and persistent feeling of fullness after meals Reglan worked by promoting gastric emptying
A nurse is caring for a child who has an acute appendicitis. Which of the following results should the nurse anticipate when reviewing the clients laboratory values? A) white blood cell count of 17,000 MM3 B) neutrophils 3000 MM3 C) red blood cell count 4.2 million MM3 D) lymphocytes 3000 MM3
A) white blood cell count of 17,000 MM3 The expected reference range for white blood cell count for a child is 5000 to 10,000 MM3. A white blood cell count of 17,000 MM3 is elevated. The nurse should expect to see an elevated white blood cell count because appendicitis is an acute bacterial infection
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the providers orders, the nurse recognizes that clarification is needed with which of the following medications? A)propranolol B) theophylline C) montelukast D) prednisone
A)propranolol Medications that beat a block to receptors are contraindicated in clients with asthma
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? A) hyperglycemia B) adrenocortical insufficeny C) Severe hydration D) rebound pulmonary congestion
B) adrenocortical insufficeny Prednisone is a quarter steroid and is similar to cortisol the glucorcocticod Ramon produced by the adrenal glands. It relieves inflammation and it is used to treat certain forms of arthritis, severe allergies, auto immune disorders, and asthma. Administration of this can compress production of the glucocortoifs, and an abrupt withdrawal of the drug which can lead to a syndrome of adrenal insufficiency
A home health nurse visit a client who has the pneumonia and is receiving oxygen at 2 L per minute via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurses priority? A) increase the oxygen flow to 3 L per minute B) assess the clients respiratory status C) call emergency services for the client D) had the client cough and expectorate the secretions
B) assess the clients respiratory status The first action the nurse should take is using the nursing process is to collect data from the client. The nurse should immediately assess the clients respiratory status before determining an appropriate intervention
A nurse is providing discharge teaching's to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply) a) verify the oxygen flow rate every other day B) check the cannula position on a regular basis C) check the tops of the ears for skin breakdown D) post no smoking signs in a prominent location in the home E) apply petroleum appointment to nails if they become dry and irritated
B) check the cannula position on a regular basis C) check the tops of the ears for skin breakdown D) post no smoking signs in a prominent location in the home The cannula position should be verified every eight hours or more often if needed. The tops of the years the nears and nasal mucous membrane should be assessed regularly for skin breakdown. The family is instructed to post no smoking signs in a prominent location in the home because oxygen increases the risk for injuries. The rate of oxygen flow should be checked daily. And the client should use water-based lubricant or Celine nasal spray to reduce dryness or irritation. Oxygen has a high combustion potential and petroleum products are combustile
A nurse is caring for a school age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply) a) symptoms are continuous throughout the day B) daytime symptoms occur more than twice a week C) nighttime symptoms occur approximately twice a month D) minor limitations occur with normal activity E) peak expiratory flow PEF is greater than or equal to 80% of the predicted value
B) daytime symptoms occur more than twice a week D) minor limitations occur with normal activity E) peak expiratory flow PEF is greater than or equal to 80% of the predicted value Daytime symptoms in a child who has persistent asthma typically have daytime symptoms more than twice per week but not daily a child who has mild persistent asthma will have some minor limitations with normal daily activities and PEF will be greater equal to 80% of the predicted value
A nurse is preparing to measure a clients level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? A) finger B) earlobe C) toe D) skinfold
B) earlobe The earlobe is rarely edematous and is less affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. And acids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test should the nurse expect to see? A) decreased white blood cells B) increased Serum amylase C) decreased serum lipase D) increased serum calcium
B) increased Serum amylase With a cute para Titus serum amylase rises within 24 hours of the start of the clients symptoms. White blood cell count usually elevates. Serum lipase generally elevate.
A nurse is performing pulmonary hygiene for a client who has Pneumonia And position the client on his left side in the transdelenbutg position. From which of the following long segment should the nurse expect secretions to meet mobilized with the client in this position? A) lateral segment of the left lower lobe B) lateral segment of the right lower lobe C) posterior segment of the right middle lobe D) posterior segment of the right lower lobe
B) lateral segment of the right lower lobe The nurse would position the client in the left lateral transdelenburg position had lower than feet to help drain the lateral segment of the right lower lobe
A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client in which of the following clinical manifestations? A) metabolic acidosis B) metabolic alkalosis C) respiratory acidosis D) respiratory alkalosis
B) metabolic alkalosis Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid
A nurse is prioritizing care for two clients at the start of the shift. The first client, who is one day post operative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of six on a scale of 0 to 10. The second client, who has a newly inserted pre-cutaneous Gastrostomy tube, requires a feeding tube, dressing change, and daily weight. Which of the following nursing action should the nurse plan to complete first? A) way the second client B) obtain vital signs on both clients C) administer pain medications to the first client D) change the dressings of both clients
B) obtain vital signs on both clients Using the nursing process as an organization GEN framework, the nurse should obtain vital signs on the two clients to determine if there is any emergent problems
A nurse is administering platelets to a client following a large G.I. bleed. The client reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? A) notify the provider B) stop the infusion C) collect a urine sample from the client D) return the platelet bag and tubing to the blood bank
B) stop the infusion The greater risk is to the client injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore the first action the nurse to take is to stop the perfusion
A nurse is teaching a client who has a new prescription for Dostie. Which of the following information should the nurse include in the teaching? A) do not take this medication before bedtime B) take this medication with a full glass of water C) expect abdominal pain with this medication D) at the take this medication on an empty stomach
B) take this medication with a full glass of water The nurse should instruct the client to take this medication with a full glass of water unless contra indicated to reduce the risk of constipation
A nurse is preparing a teaching plan for a client who has chronic constipation secondary to a regular bowel habits. Which of the following should the nurse plan to include in the teaching? A) the client should drink 2 to 38 ounce glasses of water each day B) the client should follow a high fiber diet to establish bowel regularity C) the client should try to take all of the required dietary fibers with the morning meal D) the client should be taught that the goal of therapy is to have a bowel movement daily
B) the client should follow a high fiber diet to establish bowel regularity The client who has chronic constipation should consume a diet with high fiber food sources, including bran and complex carbohydrates. To achieve maximum benefit fiber should be spread throughout the day. Water intake should be at least 8 ounce glasses daily.
A nurse is teaching the parent of a child who is to start a metered dose inhaler MDI to treat asthma. Which of the following information should the nurse include in the teaching? A) the spacer increases the amount of medication delivered to the oropharynx B) the space or increases the amount of medication delivered to the lungs C) and heal rapidly using the space or with the MDI D) cover exhalation slots of the spacer with lips went in hailing
B) the space or increases the amount of medication delivered to the lungs
A nurse is admitting an Infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? A) bulging anterior fontanel B) bradypnea C) 3% weight loss D) capillary refill three seconds
C) 3% weight loss A weight-loss greater than 10% is a manifestation of severe dehydration in an infant
A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? A) I'll rinse my mouth after taking this medicine B) I'll take this medication when I get an asthma attack C) I'll take this medication once a day in the evening D) I'll use a spacer device when I inhale this medication
C) I'll take this medication once a day in the evening
A nurse is assessing a client for hypoxemia During an asthma attack. Which of the following manifestation should the nurse expect? A) nausea B) dysphasia C) agitation D) hypotension
C) agitation This is due to neurological changes from poor oxygen exchange
A nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instruction should the nurse include in the teaching? A) limiting drinking milk B) take NSAIDs for pain C) avoid drinking alcohol D) limit strenuous exercise
C) avoid drinking alcohol The nurse should teach the client to avoid drinking alcohol because it increases manifestations of gastritis
A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting an NG tube in to the client, which of the following findings should the nurse anticipate? A) from the pink drainage B) dark amber drainage C) coffee ground drainage D) greenish yellow drainage
C) coffee ground drainage Coffee ground drainage or MSS indicates the presence of blood. The coffee ground appearance is the result of affects of methemoglobin on the hemoglobin
A nurse is caring for a client who is HIV-positive and has one day post operative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A) talking to the client at the bedside B) administering an intermittent IV bolus medication C) completing a dressing change D) administering and Im injection
C) completing a dressing change Standard precautions require personal protective equipment when there is a risk of contact with body fluid. A dressing change does present a risk for coming into contact with body fluids
A nurse in a providers office is assessing an older adult client who son reports that the client has been sick with a respiratory illness for the past six days. Which of the following assessment findings is a manifestation of pneumonia in an older adult client? A) Bradycardia B) night sweats C) Confusion D) narrowed pulse pressure
C) confusion Weakness and anorexia are manifestations of pneumonia is in an older adult client
A nurse suspects anaphylaxis when caring for a client following an initial administration of oral antibiotic for treatment of pneumonia which of the following should the nurse says a priority intervention? A) Insert an IV line B) count the respiratory rate C) administer oxygen D) prepare equipment for into Bashan
C) count the respiratory rate
A nurse is teaching a client who has a prescription of a nasogastric tube NG to treat a polyuric obstruction. Which of the following rationales for the use of a nasal gastric tube should the nurse include in the teaching? A) determine the pH of the gastric secretions B) supply nutrients be a tube feedings C) decompress the stomach D) administer medications
C) decompress the stomach A poly uric obstruction also called gastric outlet obstruction is caused by Adema, scarring, or spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client that because the stomach is dilated it may contain undigested food, it may deep compress, necessitating the placement of the NG tube
A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A) delivers a constant rate of specific concentration of oxygen B) Delivers a high concentration of oxygen C) delivers a low concentration of oxygen D) restricts the clients ability to eat speak or drink
C) delivers a low concentration of oxygen The nasal cannula is set to about 24% to 44%
The nurse is caring for a client who has the pneumonia . Which of the following actions should the nurse take to promote thinning of the respiratory secretions? A) encourage the client to ambulate frequently B) encourage coughing and deep breathing C) encourage the client to increase fluid intake D) encourage regular use of incentive spirometry
C) encourage the client to increase fluid intake Increasing fluids to 1500 to 2500 mL per day promotes liquefaction and thinning of pulmonary secretions, which improves the clients ability to cough and remove the secretions
A nurse is teaching an older adult client who reports constipation. Which of the following instruction should the nurse include in the teaching? A) bear down when defecating B) drink 4 to 5 glasses of water daily C) increase dietary intake of raw vegetables D) limit activity
C) increase dietary intake of raw vegetables The client should increase dietary intake of raw vegetables to provide fiber in the diet, which increases to a book and move the stool through the Colin to prevent constipation. The older adult client should drink 6 to 8 glasses of fluids each day, which is recommended to keep stool soft and prevent constipation. The older adult client should avoid bearing down as it can cause the development of hemorrhoids. Activity should be increased to increase peristalsis and prevent constipation
A nurse is reviewing the providers prescription for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take? A) administer an antacid B) provide a bulk foreman agent C) insert a nasogastric tube D) apply a truss
C) insert a nasogastric tube The nurse should expect to insert a nasogastric tube for a client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus
A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect? A) perechiae on the chest and abdomen B) White blood cell count of 16,000/MM3 C) negative throat culture D) severe hyperemia of pharyngeal mucosa
C) negative throat cultures A client who has bacterial pharyngeal usually has a throat culture positive for beta hemolytic streptococcus
A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point? A) left lower quadrant B) left upper quadrant C) right lower quadrant D) right upper quadrant
C) right lower quadrant McBurney's point is located by drawing a line from the Naval to the right iliac crest. Divide the line into three equal links. McBurney's point is midway between the naval to the iliac crest. Pressure over this point will elect pain in the clients with appendicitis
A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A) hyper active bowel signs B) increase urinary output C) rigid abdomen D) frequent bowel movements
C) rigid abdomen A rigid, board like abdomen is a manifestation or peritonitis
A nurse is caring for a client who has endotracheal tube and is receiving mechanical ventilation. Which of the following intervention should the nurse take to reduce the risk of ventilator associated pneumonia? A) position the head of the clients bed in the flat position B) turn the client every four hours C) rinse the clients mouth with an anti-microbe solution every two hours D) perform hand hygiene prior to suctioning the client endotracheal tube
C) rinse the clients mouth with an anti-microbe solution every two hours The nurse should brush the clients teeth every eight hours and rinse the clients mouth every two hours to reduce the growth of bacteria
A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. To the following instruction should the nurse provide? A) check the pulse after medication administration B) take the medication with meals C) rinse the mouth after medication D) limit caffeine intake
C) rinse the mouth after medication The use of glucocorticoid By metered dose inhaler can allow fungal overgrowth in the mail. Rinsing them out after administration can lessen the likelihood of this complication
A nurse is caring for a three year old child who has been admitted with acute diarrhea and dehydration which of the following findings indicate that oral rehydration therapy has been effective? A) heart rate 130 bpm B) respiratory rate of 24 per minute C) urine specific gravity of 1.0 15 D) capillary refill greater than three seconds
C) urine specific gravity of 1.0 15 The expected reference range of uterine specific gravity is 1.01021. 025. As a result of 1.015 indicates that the child is hydrated. A result greater than 1.025 indicates dehydration. Dehydration results when the total output of fluid exceeds the total intake. Infants and children who have diarrhea and dehydration should be treated first with oral rehydration therapy, such as Pedialyte and infalyate. After rehydration, oral rehydration therapy can be alternated with a low sodium solution, such as water, breast milk, lactose-free formula, or half strength Lactose containing formula
A nurse is assessing a client who has hypoKalmia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A) Hyperactive reflexes B) extreme thirst C) weak, irregular pulse D) hyperactive bowel signs
C) weak, irregular pulse Common manifestations of potassium depletion include a week and irregular pulse, muscle weakness, fatigue, and venticular dysrhythmias
A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects of the nurse instruct the client to report to the provider? A) sedation B) increased appetite C) white coating in the mouth D) dry oral he goes in membranes
C) white coating in the mouth This is an I handed glucocorticoid and long acting beta2 adrenergic Agnes combustion inhalation medication that is used for daily management of asthma. If it is not a rescue medication. An adverse effect of the medication is oral pharyngeal candidiasis. The nurse should instruct the client to gargle after each use use a spacer to reduce the amount of drug in the mouth and throat and report any white patches inside the mouth or on the tongue to the provider
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes? A) decrease mucus in stool B) Decrease tarry black stool C) decrease watery stools D) Decrease fat and stools
D) Decrease fat and stools This is a combination of pancreatic enzymes used to increase digestion of fats, carbohydrates and proteins. The client should expect a reduction of fat in the stool. Pancrelipase Can cause hyperglycemia as well as nausea and vomiting
A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? A) blurred vision B) palpations C) constipation D) depression
D) Depression This can cause behavioral changes, depression, hallucinations, suicidal Idelation. The nurse should instruct the client to report any adverse effects in a change in medication might be prescribed
A nurse is providing discharge teaching's to a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A) I will be able to tell how much oxygen I am getting by looking at the flowmeter B) I should call my doctor if I find it hard to concentrate C) I will make sure my visitor smoke outside D) I will wear synthetic clothing and woolen socks when I use my oxygen
D) I will wear synthetic clothing and woolen socks when I use my oxygen Woolen in synthetic material can generate static electricity. Because oxygen is flammable gas, the client should wear cotton clothing and use cotton blending in blankets
A nurse is creating a plan of care to maintain skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following intervention should the nurse include in the plan? A) soak in a sits bath for 20 minutes after each stool B) administer a soap suds enema to clean the colon C) clean with anti-micro scrub and vigorously dry D) White perennial area with warm water and a ply a barrier cream
D) White perennial area with warm water and a ply a barrier cream The nurse should instruct the client to wipe the perennial area and apply a barrier cream to decrease skin breakdown when in contact with fecal material. The nurse could also plan to have the patient soak for 10 minutes two or three times a day after each stool
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescription should the nurse clarify? A) maintain NPO status B) monitor oral temperature every four hours C) medicate the client for pain every four hours as needed D) administer sodium bio phosphate and sodium phosphate
D) administer sodium bio phosphate and sodium phosphate Animals and laxatives are contra indicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for Peritonitis
A nurse in an urgent care center is caring for a client who has an acute asthma exacerbation. Which of the following actions is the nurses highest priority? A) initiating oxygen therapy B) providing immediate rest for the client C) positioning the client in high Fowlers D) administering a nebulized beta adrenergic
D) administering a nebulized beta adrenergic Greatest risk to the client safety is airway obstruction. Beta adrenergic Medications act as bronchial dilator's. They provide prompt relief to airway obstructing by relaxing bronchial are smooth muscles and are the initial priority intervention when a client has an acute asthma exacerbation
A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medication should the nurse expect to administer? A) fluticasone B) budesonide C) montelukast D) albuterol
D) albuterol This is considered a rescue medication due to its rapid onset of action asthma is a chronic inflammatory disease of the airways. Asthmatic episodes are associated with airflow limitations or reversible obstruction. Albuterol is used for the treatment of acute exaggerations of asthma by promoting bronchial dilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or in preparation. The inhaled medication has more rapid onset of an action then the oral form and also reduces the risk for adverse effects such as irritability, tremors, nervousness and insomnia
A nurse is implementing a plan of care for a client who has aids with reoccurring Pneumonia . Which of the following actions should the nurse take? A) encourage fluid intake of 1500 mL per day B) position had a bed at 10° C) cough and deep breathe every eight hours D) attain a sputum and culture
D) attain a sputum and culture The nurse should obtain a sputum culture to determine which antibiotics is needed for the organism that is causing the Pneumonia
A nurse is providing education to a school age child who has a new diagnosis of asthma. Which of the following statement should the nurse include in teaching? A)take cromolyn sodium at the first sign of breathing difficulty B) you should stop playing basketball but you can swim instead C) use the peak expiratory flow meter once per week D) avoid triggers that can cause an attack
D) avoid triggers that can cause an attack The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollen, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers. The child should use a peak expiratory flow meter once or twice per day participation of sports is prohibited when asthma is not adequately controlled abutyryl should be used as a first sign of asthma where chromolyn sodium is a mast cell stabilizer
A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of a long-term in adequate oxygenation? A) restlessness B) retractions C) dependent edema D) clubbing of the fingers
D) clubbing of the fingers The nurse should expect at the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen in the edge of the fingers and ends of the toes can increase in size
A nurse in the emergency department is assessing an older adult client who has community acquired pneumonia which of the following findings should the nurse expect? A) equal pupils B) hypertension C) tympany upon chest percussion D) confusion
D) confusion Confusion is due to hypoxemia
A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplement should the nurse recommend? A) ginseng B) coenzyme Q-10 C) cranberry juice D) flaxseed
D) flaxseed The nurse should recommend the client use flaxseed's to treat constipation which is a high fiber product
A nurse is planning care for a client who has diverticulitis. Which of the following menu selection should the nurse include in the plan? A) turkey sandwich with celery sticks B) sliced ham with green salad C) pork tenderloin with green peas D) grilled chicken breast with white rice
D) grilled chicken breast with white rice Both of these items are low in fiber which is advised during the inflammation of diverticulitis. In the presence of diverticulitis a high fiber diet is indicated
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adrenal carcinoma. The client has had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A) decrease in respiratory rate from 20 to 16 per minute B) increase in urinary output from 30 mL to 50 mL per hour C) increase in temperature from 37.5 degrees south CS238.6°C D) increase in heart rate from 88 to 110 per minute
D) increase in heart rate from 88 to 110 per minute Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of the blood loss or in adequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock compenstory the heart rate is greater than 100 bpm. Ashok progresses, the heart rate continues to accelerate and becomes more than 150 bpm. In the final irreversible or refractory stage, the heart rate becomes very erratic and may develop asystole.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? A) hypoglycemia B) hypertension C) polyuria D) oral candidiasis
D) oral candidiasis It can cause this or even thrust therefore the client should rinse her mouth with water. It can also cause hyperglycemia
A nurse is caring for a child who has acute gastritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A) broth B) water C) diluted apple juice D) oral rehydration solution
D) oral rehydration solution This is a fluid of choice for infants and children who have dehydration due to diarrhea
A nurse is caring for a client who has pneumonia. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? A) administer oxygen 2 L per minute B) administer prescribed analegestic medication C) encourage coughing and deep breathing D) raise the head of the bed
D) raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head of the net can be extended, which promotes the patient's airway. This is the first action that should be taken and is least invasive
A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24) The nurse should tell the client that this medication might cause which of the following adverse effects? A) drowsiness B) constipation C) Oliguria D) tachycardia
D) tachycardia This can increase cardiac stimulation
A nurse is auscultating the breath sounds of a Client who has asthma. When the client exhales, the nurse here is continuous high-pitched squeaking sounds. The nurse should document this as which of the following advent tacious breath sounds? A) crackle B) rhonchi C) stridor D) Wheezes
D) wheezes Wheezes are often audible without a stethoscope
A nurse is administering several medications via a clients gastrostomy tube. At which of the following time should the nurse instill 15 to 30 mL of warm water? (Select all that apply) a) after each medication B) before aspirating gastric contents C) when the flow of medication shows gravity slow D) prior to administering each medication E) after giving multiple medications
a) after each medication D) prior to administering each medication E) after giving multiple medications Instilling water after each medication promotes flow and prevent clogging and chemical mixing of the medications within the tube. After instilling medications, the nurse should use sterile water to flush the tubing because chemicals and tapwater could interact with some medications. Instilling water through the tube before administering medication clears the tube of remains stomach content after aspiration and helps keep the two patent. Before instilling medications, the nurse should use their water to flush the tube because chemicals in tapwater could interact with some medications. After administering several medications via the tube, the nurse should instill another 15 to 30 mL of warm water to clear the tube
A nurse is teaching a client who has constipation which of the following should the nurse discuss as a cause for constipation? (Select all that apply) a) excessive laxative use B) ignoring the urge to defecate C) in adequate fluid intake D) increase fiber in the diet E) increased activity
a) excessive laxative use B) ignoring the urge to defecate C) in adequate fluid intake Chronic use of laxative causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can alter bowel habits such as constipation. Reduce fluid intake slows the passage of food Through the intestine and can cause hardening of the stool
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect? (Select all that apply) a) poor skin turgor B) bradycardia C) hypotension D) pale yellow urine E) flat neck veins
a) poor skin turgor C) hypotension E) flat neck veins Frequent vomiting and diarrhea causes dehydration which manifests as skin and lacks elasticity. Frequent vomiting and diarrhea causes dehydration which manifests as postural hypotension. And also manifest as flat neck beans when the client is laying supine. Urine color manifest as a dark yellow or concentrated color and tachycardia presents
