Nursing Part 2

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

"I will set up your bath for you, and you can use the call button to let me know if you need help."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardiometabolic syndrome?

36-year old with obesity who smokes

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

The nurse is planning hygiene measures for a client admitted with right-sided weakness secondary to a stroke. The client is alert and oriented, has difficulty moving the right side, and has minor difficulty speaking. When creating the plan of care, what nursing interventions would be important to include? Select all that apply.

> Assist the client with bathing to ensure hygiene needs are met. >Assist the client with physical mobility to preserve and promote increased function. >Assess the skin integrity for any potential alterations or breakdown. >Have the client evaluated for swallowing to prevent aspiration.

A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action?

Administer acetaminophen as prescribed.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

File, rather than cut the nails.

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?

Nasal cannula

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

Overweight

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use?

Remove and discard the cap after one use and dry the client's hair with a towel.

The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply.

Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

Which of the following is a fat-soluble vitamin?

Vitamin E

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?

hypokalemia

A decrease in arterial blood pressure will result in the release of:

renin

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution the expected color and consistency.

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps?

How often the client brushes and flosses the teeth

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the clients oxygenation and alert the health care provider immediately

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take?

Place a drain sponge under the external bumper.

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?

She has motivation to participate in self-care.

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

The Recommended Dietary Allowance (RDA)

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?

The new nurse places the client in the left lateral recumbent position.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

Total parenteral nutrition

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

True

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

A woman consumes pasta, grains, and other carbohydrates for which purpose?

energy

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that:

hair should be washed as often as necessary.

The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?

older adults living on a fixed income

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply.

pregnant teenagers people with substance abuse problems older adults living on fixed incomes

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?

"Hold dentures over a plastic basin or towel when cleaning them."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

The nurse is educating a client on vitamin and mineral intake. Which statement by the client indicates a need for further teaching?

"Taking megadoses of vitamins will help me increase muscle mass quickly."

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.

> Use a tub/shower seat if balance problems are present. > Carefully monitor water temperature. > Provide the client a long-handled shower brush or attachment if experiencing limited mobility.

A client with dehydration will have an increase in:

Aldosterone

A kindergarten student is sent to the school nurse because they have been vigorously scratching their scalp for a few hours. What is the nurse's priority action?

Assess for possible pediculosis.

A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?

Contract the abdominal muscles.

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

4 to 6 hours

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle?

Implanted venous access catheter

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

Iodine

During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?

New foods should be introduced one at a time for a period of 2 to 3 days.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

A postmenopausal client wishes to increase the amount of vitamin D that she consumes to help keep her bones strong. Which food will the nurse recommend?

milk

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:

negative nitrogen balance.

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?

normal saline

The nurse working at a long-term care facility supervises while the unlicensed assistive personnel (UAP) bathes an older adult client. The nurse determines the UAP requires intervention when the UAP:

places a large quantity of soap on the washcloth.

A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?

"Can you share an example of what you ate yesterday?"

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?

"According to research, vegetarians have a higher incidence of obesity than others."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate?

Discontinue the IV and relocate it to another spot.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?

Drink liberal amounts of fluids.

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention

Which laboratory test is the best indicator of a client in need of TPN?

Serum albumin

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?

medications listed on the client's medication administration record (MAR)

What should the nurse consider when teaching a man with well-defined muscle mass about meal planning?

men have a higher needs for proteins

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:

there is a need to determine if the bottled water has fluoride.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

wheezing

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3000 Rationale: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

Which methods can be used to remove a client's soft contact lenses? Select all that apply.

Ask the client to remove them, if able.Use the pads of the index finger and thumb to gently pinch and remove the lens.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

Flow meter

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?

Psychological reasons for overeating should be explored, such as eating as a release for boredom.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which is the appropriate action for the nurse?

Remove the IV catheter and reinsert another in a different location.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse is caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instruction(s) is essential for the use of an incentive spirometer? Select all that apply.

Splint the abdomen with a pillow to decrease discomfort prior to use.Instruct the client to exhale normally and then place lips securely around the mouthpiece.Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. > Assist the client to an upright or semi-Fowler position.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Stay indoors as much as possible.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Take aspirin for headaches that develop.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?

Try eating foods that are attractive and at the proper temperature.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

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

Vitamin B12

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

Vitamin K

What assessments would a nurse make when auscultating the lungs?

air flow through the respiratory passages