Rasmussen - MDC III Exam 2

2. A nurse is providing discharge instructions to a client recently diagnosed with Tb. Which statement by the client indicates correct understanding of the teaching? SATA A. "I will follow up with my healthcare provider regularly." B. "My family does not require testing" C. "I need to strictly adhere to my medication schedule." D. " I will avoid alcoholic beverages while on this treatment plan". E. " I will visit the clinic every week for injections of medication"

A. "I will follow up with my healthcare provider regularly." B. "My family does not require testing" C. "I need to strictly adhere to my medication schedule." D. " I will avoid alcoholic beverages while on this treatment plan".

11. A nurse caring for a 60-year-old male client recently diagnosed with neck cancer. Which of the following assessment findings is not consistent with this diagnosis? A. Aphonia B. Difficulty swallowing C. Nausea D. Weight gain

A. Aphonia

25. In planning care for a client with chronic obstructive pulmonary disease (COPD), the nurse acknowledges what statement is true regarding nutritional needs? A. COPD can Increase metabolism, and the client should consume supplements additional calories and protein. B. COPD has no effect on calories and protein needs, meal tolerance, appetite, and weight. C. A client with COPD should decrease intake of calories and protein as dyspnea causes activity intolerance. D. COPD can cause an anabolic state, which creates conditions for building strengths and body mass.

A. COPD can Increase metabolism, and the client should consume supplements additional calories and protein.

28. The nurse is caring for a client who was recently diagnosed with asthma and is providing education on triggers of asthma. Which of the following can potentially trigger the disease process? (SATA) A. Cigarette smoking B. Animal dander (pets) c. Pollution. d. Exercise e. Dust.

A. Cigarette smoking B. Animal dander (pets) c. Pollution. d. Exercise e. Dust.

34. A client has been taking isoniazid for 3 weeks. What information gathered by the public health nurse needs to be reported to the healthcare provider immediately? A. Client is drinking 4-6 alcoholic beverages per day. B. Client was recently started on varenicline to quit smoking. C. Client has been taking isoniazid daily as prescribed. D. Client smokes 1.5 packs cigarette per day

A. Client is drinking 4-6 alcoholic beverages per day.

16. The nurse is providing discharge instruction for a client diagnosed with pneumonia. Which information is the nurse sure to include? A. Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds. B. Take all antibiotics as ordered, resumed at an all activity as before hospitalization. C. No restrictions regarding activities, diet, and rest because the client is fully recovered when discharge. D. Continue antibiotics only also no further sign of pneumonia is present avoid exposing immunosuppressant individuals.

A. Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds.

40. The nurse is caring for a postoperative client returning to the unit after surgical removal of cancer of the head. Which action(s) should the nurse take initially? (SATA) A. Ensure adequate gas exchange. B. Ambulation of the client postoperatively C. Assess the client's hemodynamics status D. Monitor for airway maintenance E. Educate the client on anesthesia effects

A. Ensure adequate gas exchange. C. Assess the client's hemodynamics status D. Monitor for airway maintenance E. Educate the client on anesthesia effects

22. A patient presented to the emergency room with difficulty breathing. Upon examination, the client has pus behind the tonsil and swelling on the right side of her neck. She is diagnosed with a peritonsillar abscess. Which of the following is a treatment priority for the patient? A. Maintain a patient airway B. oxygen therapy C. analgesics D. antibiotics

A. Maintain a patient airway

14. A homeless client is being discharged from a long-term therapy floor for tuberculosis (TB). What referral by the nurse is most appropriate? A. Outpatient public health visiting nurses for direct observation. B. Physical therapy for muscle strengthening to prevent home falls. C. Department of health for community infection control isolation D. Occupational therapy for employment placement and housing

A. Outpatient public health visiting nurses for direct observation.

33. A client arrives in the emergency department with epistaxis. What is the nurse's priority intervention? A. Position the client upright with the head forward. B. Monitor the color and the amount of blood. C. Apply an ice pack to the nose. D. Place the nasal packing.

A. Position the client upright with the head forward.

23. A nurse is caring for several older client in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activities should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Provide oral care every 4 hours. B. Encourage between-meal snacks C. Report any new onset of cough D. Monitor temperature every 4 hour

A. Provide oral care every 4 hours.

21. Which intervention promotes comfort in dyspnea management for a client with lung cancer? A. Provide supplemental oxygen via nasal cannula or mask B. Place the client in a supine position with a pillow under the knees and legs. C. Encourage exercise and independent ambulation around the room. D. Administer morphine only when the client request it (double check please)

A. Provide supplemental oxygen via nasal cannula or mask

44. Which of the following is a major diagnostic test for cystic fibrosis? A. Sweat chloride test B. Chest computed tomography test C. Arterial blood gas D. Chest x-ray

A. Sweat chloride test

32. A nurse is caring for a client with cystic fibrosis. Which of the following are assessment findings for a client with this disorder? (Select all that apply.) A. Thick sticky mucus. B. Steatorrhea. C. Decrease forced vital capacity (FVC) D. Recurrent respiratory infections. E Gastroesophageal reflux disease (GERD)

A. Thick sticky mucus. B. Steatorrhea. C. Decrease forced vital capacity (FVC) E Gastroesophageal reflux disease (GERD)

24. A client with chronic bronchitis often shows signs of hypoxia. Which of the following is the priority to monitor for in this client? A. oxygen saturation level. Large amounts of thick mucus B. Barrel chest C. nutritional status D. clubbing of fingers

A. oxygen saturation level. Large amounts of thick mucus

4. Which statement from a client with seasonal influenza requires additional teaching? A. " I'm contagious only when symptoms are present. B. "I can reduce my risk by implementing good hand hygiene." C. I should receive a new influenza vaccine every year" D. "I can be diagnosed on presentation of symptoms"

A. " I'm contagious only when symptoms are present.

27. A nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease. Which of the following would be a treatment priority for the client? A. Improve gas exchange. B. Blood pressure control. C. Prevention of infection. D. Increase activity level.

A. Improve gas exchange.

47. The nurse is providing education to a client who is prescribed a long-acting beta-agonist medication. Which statement by the client indicates the client understands the teaching? A. "I will take this medication when I start to experience an asthma attack." B. "I will take this medication every morning to help prevent an acute attack." C. "I will only take this medication when I am admitted to the hospital." D. "I will carry this medication with me at all times in case I need it"

B. "I will take this medication every morning to help prevent an acute attack."

43. The nurse is caring for a client who was recently diagnosed with cystic fibrosis. Which of the following is a treatment option for this disorder? A. pain management B. weight reduction C. Chest physiotherapy D. Tracheostomy

C. Chest physiotherapy

The nurse is teaching a client about post rhinoplasty care

I should try and avoid coughing, sneezing, and blocking my nose

42. A nurse is preparing to administer 250 mg of ceftriaxone IM stat. Available is ceftriaxone 1g/5 ml. how many ml should the nurse administer per dose? (Record the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Answer numerically only, do not label)

1.3

6. A nurse is preparing to administer dextromethorphan 30mg PO now. The amount available is dextromethorphan oral liquid 7.5 mg/5ml. How many ml should the nurse administer per dose? ( Record answer as a whole number)

20

A nurse is providing teaching to a client recently diagnoses with sleep apnea. Which of the following statements by the client indicates an understanding of the teaching. A. Sleep apnea only has an impact on my mental concentration." B. " I should contact the provider if my oxygen level is below 90%. C. " I should begin treatment only if my snoring impacts my partner." D. " I should contact the provider for a prescription for sleep medication."

B. " I should contact the provider if my oxygen level is below 90%.

17. A Patient with a recent diagnosis of sinus cancer states that he wants another course of antibiotics because he believes he has another sinus infection. What is the best nurse response? A. " Why are you doubting your doctor's diagnosis?" B. " Tell me more about your understanding of sinus cancer symptoms" C. " Let me bring you a brochure about sinus cancer" D. I will tell the physician to order an antibiotic"

B. " Tell me more about your understanding of sinus cancer symptoms"

45. A Nurse is caring for client with end stage emphysema. Which of the following would be an expected finding? A. pH 7.50 B. CO2 50mm Hg C. CO2 30 mm Hg D. HCO3 26 mEq/L

B. CO2 50mm Hg

50. The change of shift report has just been completed on the medical surgical unit. Which client will the oncoming nurse plan to assess first? A. client with chronic obstructive pulmonary disease (COPD) who is ready to discharge but is unable to afford prescribed medication. B. Client with cystic fibrosis (CF) who has an elevated temperature and a newly increased respiratory rate of 38 breaths/min. C. Hospice client with end-stage pulmonary fibrosis and an oxygen saturation level of 89% D. Client with lung cancer who needs an intravenous antibiotic administered before going to surgery

B. Client with cystic fibrosis (CF) who has an elevated temperature and a newly increased respiratory rate of 38 breaths/min.

38. A client presents with signs and symptoms that are often associated with lung cancer. Which clinical manifestations does the nurse expect to observe in this client? (SATA.) A. Hypothermia B. Hoarseness C. Peripheral edema D. Frank hemoptysis E. Chest tightness

B. Hoarseness D. Frank hemoptysis E. Chest tightness

12. The nurse is assessing a client who reports being struck in the face and head several times. During this assessment, the nurse observes pink-tinged drainage from the client's nares. What nursing.. data? (Select One) A. Test the drainage with a regent to check the pH B. Place a drop of drainage on filter paper and look for a yellow ring C. Ask the client to describe the appearance of the face before the injury D. Have the client gently blow their nose and observe for bloody mucus

B. Place a drop of drainage on filter paper and look for a yellow ring

37. Anxiety is common among clients who are diagnosed with chronic obstructive pulmonary disease. Which of the following interventions can assist in reducing a client's anxiety? (SATA.) A. Starting a vigorous exercise routine. B. Plan out periods of rest throughout the day. C. Professional counselling. D. Written plan for dealing with anxiety E. Relaxation techniques

B. Plan out periods of rest throughout the day. C. Professional counselling. D. Written plan for dealing with anxiety E. Relaxation techniques

13. The nurse knows which of the following tests is needed to confirm a tuberculosis diagnosis? A. Mantoux skin test B. Sputum culture C. Complete blood count D. Chest X-RAY

B. Sputum culture

7. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? SATA. A. Weight gain B. Wheezing C. Tachypnea D. Barrel chest E. Distended jugular vein

B. Wheezing C. Tachypnea D. Barrel chest E. Distended jugular vein

3. The nurse is teaching the client about post-rhinoplasty care. Which statement by the client indicates an understanding of the instructions? A. " I should remain supine if possible." B. " I should take over-the counter-nonsteroidal anti-inflammatory drug ( NSAIDs)." C. " I will have nasal packing and mustache dressing." D. " I will be able to breathe only from my nose"

C. " I will have nasal packing and mustache dressing."

39. A nurse is teaching a 78-year-old client about the importance of the pneumonia vaccination. Which statement by the client indicates an understanding of the teaching? A. "I 've already had pneumonia, so I only need one vaccination." B. "I only need pneumonia vaccination upon admission to a nursing home." C. "I need two different vaccinations to prevent pneumonia." D. "Only the flu vaccination is recommended at my age."

C. "I need two different vaccinations to prevent pneumonia."

36. The nurse is caring for a 60-year-old female client who presented to the emergency room status post motor vehicle accident. The client was an unrestrained passenger who hit the windshield and has multiple facial lacerations and dyspnea. Which is a priority nursing intervention for this client? A. Insert the intravenous catheter. B. Evaluate the pulse and blood pressure C. Assess and maintain the airways. D. Assess the client's breathing pattern

C. Assess and maintain the airways.

15. The nurse knows which of the following is the purpose of montelukast for a client with asthma? A. Constricts the smooth muscles of the airway and bronchioles. B. Acts as a rapid bronchodilator in severe asthmatic episodes. C. Blocks leukotriene receptors to decrease inflammation. D. Reduces the histamine effect of the triggering agents.

C. Blocks leukotriene receptors to decrease inflammation.

49. The nurse is performing medication teaching for a client with chronic airflow limitation. What is the correct sequence for administering inhaled medications? A. Bronchodilators should be taken 5-10 minutes after the steroid B. Bronchodilators and steroids are two different lasses of drugs, so the sequence irrelevant C. Bronchodilator should be taken at least 5 minutes before other inhaled drugs. D. Bronchodilator should be taken immediately after the steroid

C. Bronchodilator should be taken at least 5 minutes before other inhaled drugs.

30. A client who has chronic obstructive pulmonary disease (COPD) and asthma is receiving oxygen at 2 liters per minute. A family member tells a nurse. " My mother did not look good, so I turned her oxygen up to 7 liters". Which of these nursing actions is best? A. Notify the healthcare provider immediately about the family member. B. Thank the family member and continue to observe the client on this oxygen level. C. Decrease the oxygen to 2 liters per minute and assess the client. D. Elevate the head of the bed to make the client more comfortable.

C. Decrease the oxygen to 2 liters per minute and assess the client.

A nursing student is teaching a client about their new diagnosis of pulmonary fibrosis. The student would include which of the following in their teaching? A. A sputum culture may show the presence of mycobacterium B. This is incurable, autosomal recessive genetic disease that affects many organs. C. Inflammation of the mucous membranes in the airways can trigger an attack. D. Most clients have progressive disease with a life expectancy of less than5 years.

C. Inflammation of the mucous membranes in the airways can trigger an attack.

26. A nurse is providing education to a client recently diagnosed with pulmonary hypertension. What is the goal of drug therapy for this client? A. Increase the pulmonary vascular pressure to slow cor pulmonale. B. Increase the client's systemic blood pressure with vasoconstriction. C. Reduce the pulmonary pressure to slow cor pulmonale. D. Decrease the client's pain and make the client comfortable.

C. Reduce the pulmonary pressure to slow cor pulmonale.

41. A client has positive Mantoux skin test result. What explanation does the nurse give to the client? A. "There is active disease, and you need immediate treatment." B. "A repeat skin test is necessary because the test could give a false-positive result" C. "There is active disease, but you are not infectious to others" D. "You have been infected but this does not mean active disease is present."

D. "You have been infected but this does not mean active disease is present."

18. The nurse is assessing a client admitted with status asthmaticus. Initially , the nurse heard wheezes in the lungs, but now the lung sounds are inaudible. What is the priority intervention? A. Administration of long- acting bronchodilator. B. Measures to reduce anxiety C. Education to prevent future exacerbations D. Activation of rapid response team to secure an airway

D. Activation of rapid response team to secure an airway

29. A 47-year-old male client presented to the emergency room with complaints of nasal and facial pain and bloody discharge. He states the symptoms started approximately three months ago and have gotten progressively worse. He states that it feels like his nose is blocked up all the time. Based on these symptoms, which of the following diagnostic tests would the nurse expect the provider to order? A. Liver function test B. Complete blood count C. Tumor mapping D. Computer tomography (CT) scan of the face

D. Computer tomography (CT) scan of the face

8. A client with suspected TB is admitted to the hospital. A long with a private room, which of the following is appropriate related to isolation procedures? A. Respiratory isolation and contact isolation for sputum only B. Respiratory isolation with surgical masks until diagnosis is confirmed C. No respiratory isolation necessary until diagnosis is confirmed. D. Negative airflow room with a specially fitted respirator

D. Negative airflow room with a specially fitted respirator

46. Which of the following is a common problem associated with cystic fibrosis in adults? A. Hypertension B. Asthma C. Obesity D. Osteoporosis.

D. Osteoporosis.

19. A client was recently diagnosed with laryngeal cancer. When the nurse begins taking the client's history , the client asks," did you know that I have a throat cancer and may not survive?

D. Tell me more about your concerns.

20. The nurse is caring for a client 1 day after receiving radiation therapy for neck cancer. Which finding would the nurse expect after radiation therapy? A. Expressive aphasia B. Excessive saliva C. Mucus secretion D. Voice hoarseness

D. Voice hoarseness

Which statement by client shows understanding of radiation for neck cancer?

My voice initially be hoarse but should improve over time

A client with suspected TB is admitted to hospital. Isolation precautions?

Negative airflow room with specialty fitted respirator

50. Nurse caring for a client recently diagnosed with asthma. Which is not related?

Obesity

Which of the following is a problem with cystic fibrosis in adults?

Osteoporosis

Nurse caring for client underwent laryngectomy. Appropriate post operative care?

Pain management, alternative means of communication, diet modification, stress reduction

The nurse knows which of the following is the purpose of a fluticasone inhaler?

Reduces obstruction of airways by decreases inflammation

48. The nurse teaches a client with asthma to monitor for which problem while exercising? A. Wheezing from bronchospasm. B. Swelling in the feet and ankle C. Muscle fatigue D. Increased peak expiratory flow rates

a. Wheezing from bronchospasm.

10. An 84-year-old client is diagnosed with rhinosinusitis. The nurse questions which medication that she sees on the client's PRN medication list? a. Analgesic b. Nasal spray c. Antihistamine d. Antipyretic

c. Antihistamine

9. A nurse admits a client from the emergency department with new onset of dyspnea and productive cough with suspected pneumonia. The client has an oxygen saturation of 96% on 2L of O2 via nasal canula, and crackles in bilateral lung bases. Oral temperature 98.9 F, heart rate 103, respiratory rate 18. The provider enters the following orders, which will the nurse perform First? A. Collect blood sample for complete blood count B. Administer PO antipyretic for temperature over 101 degrees 101 degrees Fahrenheit C. Administer broad spectrum antibiotic D. Collect sputum sample for culture

d. Collect sputum sample for culture