Respiratory/Neurologic/Musculoskeletal

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action? 1. Cut the wires 2.Elevate the HOB 3. Notify HCP 4. Suction the mouth and oropharynx

Suction the mouth and oropharynx: Nurses priority needs to be attempting to clear the airway by suctioning via the oral or nasopharyngeal route.

A hospitalized client develops acute hemorrhagic stroke is transferred to the ICU. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer PRN stool softener daily 2. Administer scheduled enoxaparin injection 3. Implement seizure precautions 4. Keep client NP until swallow screen is performed 5. Perform frequent neuro assessments

1. Administer PRN stool softener daily 3. Implement seizure precautions 4. Keep client NP until swallow screen is performed 5. Perform frequent neuro assessments Anticoagulants are contraindicated in hemorrhagic strokes

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply. 1. Avoid the use of over the counter cough suppressant medicines 2. Oral antibiotics are not needed at home as you had IV therapy in the hospital 3. Pneumonia vaccination is not needed as you have lifelong immunity 4. Schedule a follow up with hCP and chest x-ray 5. Use a cool-mist humidifier in your bedroom at night 6. Use incentive spirometer at home

1. Avoid the use of over the counter cough suppressant medicine (unless prescribed by HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis) 4. Schedule follow up appointment with HCP and x-ray (Follow up is needed and x-ray may be needed) 5. Use a cool mist humidifier in your bedroom at night (Humidifiers keep mucus membranes moist, maintain effectiveness of muscociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions. 6. Use incentive spirometer at home (Deep breathing and coughing promote lung expansion, ventilation, oxygenation and airway clearance)

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the clients care plan to prevent a hip fracture? Select all that apply: 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises

1. Calcium supplements 4. Vitamin D supplements 5. Weight bearing exercises

A nurse is reviewing the lab results of a client admitted for an asthma exacerbation. Elevation of which cells indicate the clients asthma may be triggered by an allergic response? 1. Eosinophils 2. Lymphocytes 3. Neutrophils 4. reticulocytes

1. Eosinophils: These cells are seen in allergy.

The nurse is caring for a client after a motor vehicle accident. The clients injuries include 2 fractured ribs and concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? 1. Asymmetrical pupillary constriction 2. Brief LOC 3. HA 4. Loss of vision 5. Retrograde amnesia

2. Brief LOC 3. HA 5. Retrograde amnesia: Expected neuro changes with a concussion include brief LOC, retrograde amnesia, and HA.

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to broca aphasia? Select all that apply. 1. Client coughs and gasps when swallowing foods and liquids 2. Client is easily frustrated while attempting to speak 3. Client is unable to understand speech and is completely non verbal 4. Client misunderstands and inappropriately responds to verbal instruction 5. Clients speech is limited to short phrases that require effort

2. Client is easily frustrated while attempting to speak 5. Clients speech is limited to short phrases that require effort

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. 1. Diarrhea 2. Difficulty breathing 3. Difficulty swallowing 4. Muscle weakness 5. Resting tremor

2. Difficulty breathing 3. Difficulty swallowing 4. Muscle weakness: ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking and respiratory failure.

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which statement by the client indicate a correct understanding of teaching? Select all that apply. 1. I should continue strenuous exercise during flare-ups 2. I should include spine stretching activities such as swimming 3. I should quit smoking and perform breathing exercises 4. I should sleep on a soft mattress to decrease my morning stiffness 5. I will take the prescribed ibuprofen on an empty stomach

2. I should include spine stretching activities such as swimming 3. I should quit smoking and perform breathing exercises It is best to rest during flare ups, clients should sleep on their backs on a firm mattress. NSAID's should be taken with a meal or stomach

The nurse is teaching an overweight 54 year old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply. 1. Eating a high protein snack at bedtime 2. Limiting alcohol intake 3. Losing weight 4. Taking a mild sedative at bedtime 5. Taking modafinil at bedtime 6. Taking a nap during the day

2. Limiting alcohol intake (at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction) 3. Losing weight (Can reduce snoring, and sleep apnea associated airways obstruction) Avoid sedating medicines, and use continuous positive airway pressure devices at night

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first? 1. Client who reports nosebleed that has not resolved after holding pressure for 1 hour. 2. Client who reports sinus congestion with thick nasal drainage and severe facial pain. 3. Client with sore throat who reports difficulty in opening mouth and swallowing. 4. Client with seasonal allergies who reports new onset of unilateral ear pain and pressure

3. Client with sore throat who reports difficulty in opening mouth and swallowing: The nurse should immediately asses the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction.

The nurse receives report for 4 clients in the ED. Which client should be seen first? 1. 30 year old with spinal cord injury at L3 sustained motor vehicle accident who reports lower abdominal pain and difficulty urinating 2. 33 year old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65 year old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing HA and had emesis of 250ML 4. 70 year old with A-fib and a closed head injury waiting for brain imaging who reports a HA and had emesis of 200ML.

70 year old with A-fib and a closed head injury waiting for brain imaging who reports a HA and had emesis of 200ML: Constant HA, decreased mental status, and sudden onset emesis indicate increased intracranial pressure

The nurse auscultates the lung sounds of a client with SOB. Based on the sounds heard (coarse crackles Loud low pitched bubbling), which action would the nurse anticipate? 1. Administer albuterol via nebulizer 2. Administer furosemide IV push 3. Instruct the use of pursed lip breathing 4. Prepare for chest tube insertion

Administer furosemide IV push: Coarse crackles are present when fluid or mucus collects in the lower respiratory tract. Diuretics treat pulmonary edema

The nurse is caring for a client admitted with incomplete fractures of the right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time? 1. Administer prescribed IV morphine 2. Facilitate hourly client use of incentive spirometry 3. Instruct client on gently splinting injury during coughing 4. Notify health care provider immediately

Administer prescribed IV morphine: Rib fractures are often a result from blunt thoracic trauma. In the absence of significant internal injuries, interventions focus on pain management and pulmonary hygiene techniques (coughing, deep breathing, incentive spirometry. Pain control comes first.

The medical-surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and RR 30/min. What's the nurse's next action? 1. Administer dose of prescribed prn anti-anxiety medication 2. Call HCP who performed the surgery 3. Call the rapid response team 4. Place client in the left lateral recovery position

Call the rapid response team: RRT should be called for acute changes of HR<40 or >130 SBP <90 RR <8 or >28 O2 sat <90 despite oxygen UOP <50 ml in 4 hours Level of consciousness

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? 1. Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura 2. Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position 3. Client with myasthenia gravis who has a fever and increasing difficulty swallowing 4. Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream

Client with myasthenia gravis who has a fever and increasing difficulty swallowing: The clients infection and increasing difficulty swallowing indicate the need for immediate intervention

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the HCP immediately? 1. Distended abdomen and absent bowel sounds 2. Ecchymosis over the pelvic bone 3. Hgb of 11.5g/dl and HCT of 34% 4. Tenderness over the right heel

Distended abdomen and absent bowel sounds: In addition to pain, the nurse should assess for internal hemorrhage (abdominal distention, VS, H&H), paralytic ileus (bowel sounds), neurovascular deficits (extremity circulation, sensation, movement) and abdominal and GU injuries (hematuria, UOP<.5ml/kg/hr)

The RN on a orthopedic unit is orienting a new graduate nurse assigned to a client with a fractured hip and in bucks traction. The RN intervenes when the GN performs which action? 1. Elevates HOB to 45 degrees 2. Hold the weight while the client is repositioned up in the bed 3. Loosens velcro straps when the client reports the boot is too tight 4. Provides the client with a fracture pan for elimination needs

Elevates HOB to 45 degrees: The client should be in supine or semi-fowlers position (max 20-30 degrees). Elevating the HOB more than 30 degrees would promote sliding.

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. I am having problems extending my fingers since this morning 2. I cant take any of the pain medicine because it makes me feel sick 3. I have to scratch under the cast with nail file because of the itching 4. I noticed a warm spot on my cast and bad smell coming from it.

I am having problems extending my fingers since this morning: Volkman contracture occurs as a result of compartment syndrome associated with distal humerus fractures. This is an medical emergency.

The nurse reinforces the physical therapists teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1. I will hold the cane in my right hand 2. I will move my left leg forward after moving the cane 3. I will place the cane several inches in front of and to the side of my right foot 4. My cane should be equal distance from my waist to the floor

I will place the cane several inches in front of and to the side of my right foot: A cain measured from the waist would be too long to provide optimal support

The nurse moves a finger in a horizontal and vertical motion in front of the clients face while directing the client to follow the finger with the eyes. Which cranial nerve is the nurse assessing? Select all that apply. 1. II 2. III 3. IV 4. V 5. VI

III, IV, VI: Occulomotor (III), Trochlear (IV), and abducens (VI) are motor nerves of the eye that are tested by having the client track an object such as a finger through the fields of vision.

The nurse develops a care plan for a critically ill client with ARDS who is on a mechanical ventilator. What is the priority ND? 1. Imbalanced nutrition 2. Impaired gas exchange 3. Impaired tissue integrity 4. Risk for infection

Impaired gas exchange: ARDS involves damage to the alveolar capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar capillary changes and ventilation perfusion imbalance is an appropriate ND for a client with ARDS.

A client with stroke symptoms has a BP of 240/124. The nurse prepares the prescribed nicardipine IV infusion correctly to yield .1mg/ml. The nurse then administers the initial prescription to infuse 5mg/hr by setting the infusion pump at 50ml/hr. What is the nurses priority action at this time? 1. Assess hourly UOP 2. Increase pump setting to correct administration rate to 100ml/hr 3. Keep systolic BP above 170mmhg 4. Monitor for widening QT interval

Keep systolic BP above 170mmhg: Mild lowering is required usually to a systolic pressure that is not below 170 mmhg. It is important to now lower the BP too quickly or too slowly as this would extend the stroke.

The nurse is caring for a client in the immediate postop period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the HCP immediately? 1. Diminished gag reflex after endotracheal tube removal 2. Increased agitation level and pulling at linens 3.Left arm drift during bilateral arm extension 4. Responds to verbal commands with eyes closed

Left arm drift during bilateral arm extension: Following the removal of plaque the nurse must monitory for s/s of new or worsening neuro status as this surgery increases risk of stroke. FAST Facial drooping Arm weakness Speech difficulties Time

A client with pneumonia is transferred from the medical unit to the ICU due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the HCP? 1. Cough and mucus production 2. Refractory hypoxemia 3. Scattered rhonchi and crackles 4. Temp. 101 F

Refractory hypoxemia: It is the hallmark of ARDS. The lungs become stiff and noncompliant which makes ventilation and oxygenation less optimal and results in increased work of breathing, tachypnea, and alkalosis, atelectasis, and refractory hypoxemia.

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to reach the itch. Whats the best nurses priority? 1. Offer the client a straw to reach the itch 2. Perform a peripheral neurovascular check of casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

Review appropriate itch relief technique using the cool setting of a hair dryer: Attempting to reach an itch with any instrument or applying lotions or powders may cause skin break down and infection. Cool air from a hair dryer may alleviate the itch

The ED nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of bells palsy and unilateral facial droop and drooling 2. History of MS and reporting recent blurred visision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, Loss of consciousness, but glasgow coma scale is now 14

Temple region hit by ball, Loss of consciousness, but glasgow coma scale is now 14: This can be a sign of an epidural hematoma. Lucid interval is followed by a quick decline in mental function that can progress into coma and death.

The nurse assesses the several clients using GCS. Which scenario best demonstrates a correct application of this scale? 1. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as localization of pain. 2. The nurse asks the client what day it is and the client says, "banana". The nurse scores verbal response as confused. 3. The nurse speaks with the client and the client's eyes open. The nurse scores eye-opening as spontaneous. 4. The nurse walks in the room and the client states, "Hi honey, how are you?" The nurse scores a verbal response as oriented.

The nurse applies pressure to the nail bed, and the client tries to push the nurses hand away. The nurse scores motor response as localization of pain: