possible NCLEX questions

67)The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide (Lasix) and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1."I need to eat foods high in potassium." 2."I need to drink at least 2 to 3 L of fluid daily." 3."I need to eat small, frequent meals and snacks if nauseated." 4."I need to increase my intake of dietary items that are high in calcium."

4. Rational:The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption of calcium. Dietary restriction of calcium may be used as a component of therapy. The client should eat foods high in potassium, especially if the client is taking furosemide. Options 2 and 3 also are appropriate instructions for the client.

GERD: foods to avoid

> chocolate >perppermint >coffee >fried chicken >spicy foods

Ulcerative colitis diet

Answer: LOW fiber because it irritates the lining, avoid providing whole wheats, grains, nuts, fresh fruits, and veggies, corn, Lactose containg food sare poorly tolerated Client should avoid caffeine, pepper, and etoh

COPD

• If we over-ride the low O2 by giving high O2, we can stop the stimulus to breath • answer:Increase the oxygen to much then your decrease oxygen based respiratory affect

47)The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? 1.Dry skin 2.Thin, silky hair 3.Bulging eyeballs 4.Fine muscle tremors

1.

1)The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1.Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system. 4. Place a sterile dressing over the disconnection site.

2.

27)A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1.Hypoglycemia 2. Level of hoarseness 3.Respiratory distress 4.Edema at the surgical site

3.

128)Which condition on assessment of the client with Addison's disease should the nurse expect to note? 1. Edema 2.Obesity 3. Hirsutism 4.hypotension

4.

178)A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? 1.Take a deep breath. 2. Exhale immediately. 3. Breathe in and out quickly. 4. Perform the Valsalva maneuver.

4.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1,3,4,5

103)The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1.Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses

4.

17)The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Having intravenous equipment ready for insertion of an intravenous catheter

1,2,5,6

111)A nurse is caring for a client with a thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse should assess for which sign or symptom? 1.Bradycardia 2. Constipation 3. Hypertension 4. Low-grade temperature

3.A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which is an early indicator of this complication?

GERD- what is it

affect the lower esophageal sphincter

Latex allergies: what foods are you allergic to:

bananas

Gastric ucers

pain is irritated by food, 1-2 hrs after meal

Duodenal ulcer

pain is relieved b food, H, pylori 2-5 hours and cramplike pain

106)A nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1.Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal expected finding.

2.

13)A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? 1.Warm the client. 2.Maintain a patent airway. 3.Administer thyroid hormone. 4.Administer fluid replacement.

2.

66)The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1.A client with hypothyroidism 2.A client with Graves' disease who is having surgery 3.A client with diabetes mellitus scheduled for a diagnostic test 4.A client with diabetes mellitus scheduled for débridement of a foot ulcer

2.

75)The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need for further teaching? 1."I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty in breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider (HCP)."

2.

120)The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? 1."Do you have tremors in your hands?" 2."Are you experiencing pain in your joints?" 3."Do you notice swelling in your legs at night?" 4."Have you had problems with diarrhea lately?"

2. Rationale: Hyperparathyroidism is associated with oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and, sometimes, pathological fractures. Options 1 and 4 relate to assessment of hypoparathyroidism. Option 3 is unrelated to hyperparathyroidism.

105)A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? 1.Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

3.

138)A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse knows that which diet would most likely be prescribed for this client? 1.High fat intake 2. Low protein intake 3. Normal sodium intake 4. Low carbohydrate intake

3.

162)A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which is an early indicator of this complication? 1.Constipation 2.Bradycardia 3.Hyperreflexia 4.Low-grade temperature

3.

32)The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? 1.To treat thyroid storm 2. To prevent cardiac irritability 3. To treat hypocalcemic tetany 4. To stimulate release of parathyroid hormone

3.

33)A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? 1.Try to exercise before mealtimes. 2. Administer insulin after exercising. 3. Take a blood glucose test before exercising. 4. Exercise is best performed during peak times of insulin.

3.

63)The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign/symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? 1.Bradycardia 2. Flaccid paralysis 3. Tingling around the mouth 4. Absence of Chvostek's sign

3.

64)The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information? 1.The hoarseness is permanent. 2. It indicates nerve damage. 3. It is normal during this time and will subside. 4. It will worsen before it subsides, which may take 6 months.

3.

73)A nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction? 1. "I need to wear a Medic-Alert bracelet." 2. "I need to purchase a travel kit that contains cortisone." 3. "I will need to take daily medications until my symptoms decrease." 4. "I need an increased dose of glucocorticoid medication during stressful minor illnesses."

3.

116)A multidisciplinary health care team is developing a plan of care for a client with hyperparathyroidism. The nurse should include which priority intervention in the plan of care? 1.Restrict fluids to 1000 mL per day. 2.Describe the use of loperamide (Imodium). 3.Walk down the hall for 15 minutes three times a day. 4.Describe the administration of aluminum hydroxide gel.

3. Rational:Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted. Discussing the use of medications is not the priority with this client.

PE: initial nursing Action

> O2 >intubation >mechanical ventilation with positive expiatory pressure

TB: the first manifestation is a

>productive cough >dysnea >chills >night sweats >low grade fever

Chron's Disease

>question/answer: make sure to sit up not lay down

what is cholythisis

• Inflammation of the gallbladder • Right upper quadrant pain radiating to the right shoulder and scapula • Patient needs to decrease intake of fat

Managing sxs of SLE

• Sit whenever possible, avoid hot baths, schedule moderate to low impact exercises when not fatigued, maintain a balance diet • Avoid long periods of rest

160)A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Call the health care provider. 2. Replace the chest tube system. 3. Obtain a pulse oximetry reading. 4. Place the client in a Trendelenburg position.

1.

28)A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3.Lethargy 4. tremors 5. confusion 6. Bradycardia

1,2,4,5

34)The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1.Provide a warm environment for the client. 2.Instruct the client to consume a low-fat diet. 3.A thyroid-releasing inhibitor will be prescribed. 4.Encourage the client to consume a well-balanced diet. 5.Instruct the client that thyroid replacement therapy will be needed. 6.Instruct the client that episodes of chest pain are expected to occur.

1,2,4,5

131)During assessment of a client newly diagnosed with hypertension, the nurse recognizes that which is a common occurrence? 1.Be asymptomatic 2. Be short of breath 3. Have visual disturbances 4. Have frequent nosebleeds

1.

152)During physical examination of a client, which finding is characteristic of hypothyroidism? 1.Periorbital edema 2. Flushed warm skin 3. Hyperactive bowel sounds 4. Heart rate of 120 beats/min

1.

167)The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs should the nurse monitor for? Select all that apply. 1. Anorexia 2.Dizziness 3.Hypertension 4.Weight loss 5.Moon facies 6.truncal obesity

3,5,6

124)The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which client statement indicates an understanding of the nurse's instructions? 1."I expect to experience some tingling of my toes, fingers, and lips after surgery." 2. "I will definitely have to continue taking antithyroid medications after this surgery." 3. "I need to place my hands behind my neck when I have to cough or change positions." 4. "I need to turn my head and neck front, back, and laterally every hour for the first 12 hours after surgery."

3. Rationale: The client is taught that tension needs to be avoided on the suture line, otherwise hemorrhage may develop. One way of reducing incisional tension is to teach the client how to support the neck when coughing or being repositioned. Likewise, during the postoperative period the client should avoid any unnecessary movement of the neck. That is why sandbags and pillows frequently are used to support the head and neck. Any postoperative tingling in the fingers, toes, and lips probably is due to injury to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately. Removal of the thyroid does not mean that the client will be taking antithyroid medications postoperatively. Thyroid replacement medications are necessary.

103)A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? 1.Edema 2.Obesity 3.Hirsutism 4.Hypotension

4.

40)A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1.Apnea monitor 2. Oxygen flowmeter 3. Telemetry cardiac monitor 4. Oxygen saturation monitor

4.

How is Kaposi sarcoma confirmed

a positive punch biopsy of the cutaneous lesions (skin biopsy)

Teach pursed lip breathing

• Breathe out through the mouth • Close the mouth and breathe in via nose, purses the lip and breathes out slowly through the mouth w/o puffing cheeks

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option?

maintain bed rest

6.The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1.Do nothing, because this is an expected finding. 2. Check for an air leak because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Immediately clamp the chest tube and notify the health care provider.

1.

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? 1."Don't be concerned; this problem can be covered with clothing." 2."Usually these physical changes slowly improve following treatment." 3."This is permanent, but looks are deceiving and are not that important." 4."Try not to worry about it; there are other things to be concerned about."

2.

50)The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse should provide the client with which best instruction? 1.Eat meals at approximately the same time each day. 2. Adjust meal times depending on blood glucose levels. 3. Vary meal times if insulin is not administered at the same time every day. 4. Avoid being concerned about the time of meals so long as snacks are taken on time.

1.

182)A nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. 1.Sit upright in the bed or in a chair. 2. Inhale deeply and quickly as possible. 3. Hold the device in a downward position. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

1,4,5

16)The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? 1. Laryngeal stridor 2. Abdominal cramps 3. Difficulty in voiding 4. Mild to moderate incisional pain

1.

104)The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Place in Fowler's position for eating. 2. Encourage coughing with deep breathing. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client. 5. Place sequential compression boots on the client. 6. Encourage the intake of dark green, leafy vegetables.

2,3,4

23)The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1."I will need to limit the amount of protein in my diet." 2."I should eat foods that have a lot of potassium in them." 3."I am fortunate that I can eat all the salty foods I enjoy." 4."I am fortunate that I do not need to follow any special diet."

2.

48The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? 1.dry skin 2. bulging eyeballs 3. periorbital edema 4. coarse facial features

2.

55)The home care nurse is visiting a client newly diagnosed with diabetes mellitus. The client tells the nurse that he is planning to eat a dinner meal at a local restaurant this week. He asks the nurse if eating at a restaurant will affect diabetic control and if this is allowed. Which nursing response is most appropriate? 1."You are not allowed to eat in restaurants." 2. "You should order a half-portion meal and have fresh fruit for dessert." 3. "If you plan to eat in a restaurant, you need to skip the lunchtime meal." 4. "You should increase your daily dose of insulin by half on the day that you plan to eat in the restaurant."

2.

70)The nurse has provided home care measures to the client with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction? 1."I should always wear a Medic-Alert bracelet." 2. "I should perform my exercise at peak insulin time." 3. "I should always carry a quick-acting carbohydrate when I exercise." 4. "I should avoid exercising at times when a hypoglycemic reaction is likely to occur."

2.

93)A nurse is providing instructions to a client who is scheduled for cystoscopy and possible biopsy and will be receiving general anesthesia. Which instruction should the nurse provide to the client?1.The procedure will take about 4 hours. 2. Intravenous fluids may be started on the day of the procedure. 3. Preprocedure sedatives are never administered with general anesthesia. 4. A full liquid breakfast only may be allowed on the day of the procedure.

2.

2.The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3,4,5,6

26The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Wt loss 3. Feeling Cold 4. loss of body hair 5. persistent lethargy 6. Puffiness of the face

3,4,5,6

100)When reading the product literature for a medication, the nurse notes that the medication is nephrotoxic. The nurse plans care, knowing that this medication could cause damage to which structure of the kidney? 1.Pelvis 2. Calyx 3. Nephron 4. Renal artery

3.

147)A nurse is performing an assessment on a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate? 1.Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the health care provider (HCP) immediately. 4. Reassure the client that this is usually a temporary condition.

4.

150)The nurse determines the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1.Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal during inspiration and expiration.

4.

20)The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1."Cushing's disease results from an oversecretion of insulin." 2."Cushing's disease results from an undersecretion of corticotropic hormones." 3."Cushing's disease results from an undersecretion of mineralocorticoid hormones." 4."Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

4.

43)The nurse is caring for a client with a diagnosis of Addison's disease. The nurse is monitoring the client for signs of Addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? 1. agitation 2. diaphoresis 3. restlessness 4. severe abdominal pain

4.

49The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? 1."I will check my blood glucose level every day at 5:00 pm." 2. "I will check my blood glucose level 1 hour after each meal." 3. "I will check my blood glucose level 2 hours after each meal." 4. "I will check my blood glucose level before each meal and at bedtime."

4.

83)A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1.Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking-cessation program

4.

46)The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? 1."I should use tepid water for bathing." 2. "I need to keep my skin lubricated and cool." 3. "After bathing, I should pat my skin dry rather than rubbing it." 4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."

4. Rationale:The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.

Hypercalcemia **

A hospitalized clients serum calcium level is 7.9. The nurse is immediately concerned and takes action, knowing that this level could immediately lead to which complication- cardiac arrest (40's)

65)The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1.Fever and tachycardia 2. Pallor and tachycardia 3. Agitation and bradycardia 4. Restlessness and bradycardia

1.

TB: initial sx

> fatigue >lethargy >morning cough >low grade fever

Retinal Detachment

Answer: sense of curtain following across the field of vision

Unconscious pt and hearing

tell the family that the patient can possibly still hear

137)A nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? 1.Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

2.

14)The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1.Use nail polish to protect the nail beds from injury. 2. Stop smoking because it causes cutaneous vasospasm. 3. Wear gloves for all activities involving use of both hands. 4. Always wear warm clothing even in warm climates to prevent vasoconstriction.

2.

151)Which should the nurse do when caring for a client with chest tubes attached to a chest drainage system? 1.Empty the drainage collection chamber every shift. 2. Ensure the water level in the water seal chamber is at the 2-cm level. 3. Maintain the drainage collection device at the level of the client's chest. 4. Clamp the chest tube before moving the client from the bed to the chair.

2.

15:The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. diarrhea 2. Polyuria 3. polyphagia 4. Wt gain

2.

68)The nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instruction? 1."I should avoid bed rest." 2."I need to avoid doing any exercise at all." 3."I need to space activity throughout the day." 4."I should gauge my activity level by my energy level."

2. Rationale:The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to avoid bed rest and use energy levels as a guide to activity. The client also should be instructed to avoid high-impact activity or contact sports.

169)A nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to have which effect? 1.Dilate the major bronchi. 2. Increase surfactant production. 3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree.

3.

38)The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1.Tape the ET tube in place, and note the centimeter marking at the lip line. 2. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

3.

74)The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1.The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tubes are obstructed.

4. Rationale:Fluid in the water-seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 1, 2, and 3 are incorrect interpretations.

36)The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1.Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

2. Rationale:Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

68)Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? Chloride level of 98 mEq/L 2. Sodium level of 135 mEq/L 3. Potassium level of 6.8 mEq/L 4. Magnesium level of 1.6 mEq/L

3.

62)The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? 1.Maintain a supine position. 2. Monitor neck circumference every 4 hours. 3. Maintain a pressure dressing on the operative site. 4. Encourage deep breathing exercises and vigorous coughing exercises.

2. Rational:After thyroidectomy neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client should be placed in an upright position to facilitate air exchange. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

74)A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. 1.Hypernatremia 2. Signs of water deficit 3. High urine osmolality 4. Low serum osmolality 5. Hypotonicity of body fluids 6. Continued release of antidiuretic hormone

3,4,5,6

30)The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1.Provide a cool environment for the client. 2.Instruct the client to consume a high-fat diet. 3.Instruct the client about thyroid replacement therapy. 4.Encourage the client to consume fluids and high-fiber foods in the diet. 5.Inform the client that iodine preparations will be prescribed to treat the disorder. 6.Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

3,4,6

102)A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1.The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

4. Rationale:The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.