RN218 2
Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy
Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy
1. A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%
b. 21%
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: The reddened area is firm. What action by the nurse is best? a. Assess the client for possible items to which he or she is allergic. b. Call the primary health care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.
c. Immediately place the client on Airborne Precautions.
A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.
c. Provide oral care every 4 hours.
The emergency department nurse is participating in a bioterrorism drill in which several "clients" are suspected to have inhalation anthrax. Which "clients" would the nurse see as the priorities? (Select all that apply.) a. Widened mediastinum on chest x-ray b. Dry cough c. Stridor d. Oxygen saturation of 91% e. Diaphoresis f. Oral temperature of 99.9° F (37.7° C)
c. Stridor d. Oxygen saturation of 91% e. Diaphoresis
A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing
c. Tying a square knot at the back of the neck
A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? a. "I need to take extra vitamin C while on isoniazid." b. "I should take this medicine with milk or juice." c."I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."
c."I will take this medication on an empty stomach."
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? a. Administration of oxygen via facemask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin
d. Administration of intravenous insulin
The nurse reviews the function of thyroid gland hormones. What is the primary function of calcitonin? a. Sodium and potassium balance b. Magnesium balance c. Norepinephrine balance d. Calcium and phosphorus balance
d. Calcium and phosphorus balance
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."
d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."
After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."
d. "I should look into swimming or water aerobics to get my exercise."
After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? a. "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."
d. "I will take this medicine immediately before I eat."
A nurse collaborates with assistive personnel (AP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when teaching the AP about this activity? a. "Note the time of the client's first void and collect urine for 24 hours." b. "Add the preservative to the container at the end of the test." c. "Start the collection by saving the first urine of the morning." d. "It is okay if one urine sample during the 24 hours is not collected."
d. "It is okay if one urine sample during the 24 hours is not collected."
A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury? a. "Examine your feet using a mirror every day." b. "Rotate your insulin injection sites every week." c. "Check your blood glucose level before each meal." d. "Use a bath thermometer to test the water temperature."
d. "Use a bath thermometer to test the water temperature."
he nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? a. Diabetic ketoacidosis (DKA) b. Severe hypoglycemia c. Chronic kidney disease (CKD) d. Hyperglycemic-hyperosmolar state (HHS)
d. Hyperglycemic-hyperosmolar state (HHS)
A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.
d. Instruct the client to rotate sites for insulin injection.
he nurse assesses a client who is scheduled to have a laboratory test to determine if the client's adrenal glands are hypoactive. What type of testing would the client likely have? a. Catecholamine testing b. Suppression testing c. Bone marrow testing d. Provocative testing
d. Provocative testing
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? a. Serum chloride level of 98 mEq/L (98 mmol/L) b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) c. Serum sodium level of 132 mEq (132 mmol/L) d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately.
d. Stay with the client and have someone else call the primary health care provider immediately.
A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir. b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.
d. Teach the client to sneeze in the upper sleeve.
A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting nurses for directly observed therapy
d. Visiting nurses for directly observed therapy
Chapter 28: Concepts of Care for Patients With Infectious Respiratory Problems
Chapter 28: Concepts of Care for Patients With Infectious Respiratory Problems
Chapter 56: Assessment of the Endocrine System
Chapter 56: Assessment of the Endocrine System
Chapter 59: Concepts of Care for Patients With Diabetes Mellitus
Chapter 59: Concepts of Care for Patients With Diabetes Mellitus
The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? a. 8:00 a.m. (0800) b. 4:00 p.m. (1600) c. 8:00 p.m. (2000) d. 11:00 p.m. (2300)
b. 4:00 p.m. (1600)
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.
b. The client has joined a book club that meets at the library.
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? a. pH 7.38; HCO3 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28; HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48; HCO3 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg
b. pH 7.28; HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg
The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug once a day before breakfast." b. "Take the drug every evening before bedtime." c. "Give your drug injection the same day every week.". d. "Take the drug with dinner at the same time each day."
c. "Give your drug injection the same day every week.".
The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health condition? a. Hypotension b. Hyperthyroidism c. Abdominal obesity d. Hypoglycemia
c. Abdominal obesity
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond? a. "I can give your injections to you while you are here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "Your disease will not be managed properly if you refuse to administer the shots." d. "Tell me what it is about the injections that are concerning you."
d. "Tell me what it is about the injections that are concerning you."
A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 L a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake to 80 g a day." d. "Walk at a moderate pace for 1 mile daily."
d. "Walk at a moderate pace for 1 mile daily."
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"
d. "What is your occupation?"
A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect? a. 5.0% b. 5.7% c. 6.2% d. 7.4%
d. 7.4%
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 19-year-old Caucasian b. A 22-year-old African American c. A 44-year-old Asian American d. A 58-year-old American Indian
d. A 58-year-old American Indian
A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take? a. "Have you gained unexpected weight this week?" b. "Has your urinary output declined recently?" c. "Have you had fever and achiness this week?" d. "Have you had abdominal pain recently?"
a. "Have you gained unexpected weight this week?"
The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug with each meal." b. "Take the drug every evening before bedtime." c. "Take the drug on an empty stomach in the morning." d. "Decide on the best day of the week to take the drug."
a. "Be sure to take the drug with each meal."
A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"
a. "Breathing so quickly can be dehydrating."
A nurse teaches a client with diabetes mellitus about foot care. Which statements would the nurse include in this client's teaching? (Select all that apply.) a. "Do not walk around barefoot." b. "Soak your feet in a tub each evening." c. "Trim toenails straight across with a nail clipper." d. "Treat any blisters or sores with Epsom salts." e. "Wash your feet every other day."
a. "Do not walk around barefoot." c. "Trim toenails straight across with a nail clipper."
After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."
a. "If I develop an infection, I should stop taking my corticosteroid."
A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why she has to have it. How would the nurse respond? a. "It measures your average blood glucose level for the past 3 months." b. "It determines what type of anemia you may have." c. "It measures the amount of liver glycogen you have." d. "It determines you have some type of leukemia or other blood cancer."
a. "It measures your average blood glucose level for the past 3 months."
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 L a day." c, "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."
a. "Maintain tight glycemic control and prevent hyperglycemia."
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d"Changing injection sites from the thigh to the arm will change absorption rates."
a. "The lower abdomen is the best location because it is closest to the pancreas."
A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."
a. "Your risk of diabetes is higher than the general population, but it may not occur."
A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. A 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension
a. A 22-year-old client with asthma c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension
A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for diabetes? (Select all that apply.) a. A 56-year-old African-American male b. A 22-year-old female with a 30-lb (13.6 kg) weight gain during pregnancy c. A 60-year-old male with a history of liver trauma d. A 48-year-old female with a sedentary lifestyle e. A 50-year-old male with a body mass index greater than 25 kg/m2 f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)
a. A 56-year-old African-American male d. A 48-year-old female with a sedentary lifestyle e. A 50-year-old male with a body mass index greater than 25 kg/m2 f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)
A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity
a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity
A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next? a. Administer another half-cup (120 mL) of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.
a. Administer another half-cup (120 mL) of orange juice.
A nurse admits a client from the emergency department. Client data are listed below: HISTORY °70 years of age ° History of diabetes ° On insulin twice a day ° Reports new onset dyspnea and productive cough PHYSICAL ASSESSMENT °Crackles and rhonchi heard throughout the lungs ° Dullness to percussion LLL ° Afebrile ° Oriented to person only LABORATORY VALUES °WBC5,200/mm3(5.2 x109/L) ° PaO2 on room air 85 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 L per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.
a. Administer oxygen at 4 L per nasal cannula.
The emergency department (ED) manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission. b. Blood cultures obtained within 20 minutes. c. Chest x-ray obtained within 30 minutes. d. Pulse oximetry obtained on all clients.
a. Antibiotics started before admission.
A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed.
a. Apply water-soluble ointment to nares and lips.
A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time
a. Applying suction while inserting the catheter
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring that the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash c. Reminding the client to cough and deep breathe often d. Suctioning excess secretions through the tracheostomy e. Holding the new tracheostomy tube while the RN changes the ties
a. Applying water-soluble lip balm to the client's lips d. Suctioning excess secretions through the tracheostomy
A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse that the precautions are meant to keep other clients safe. c. Show the spouse how to follow the Isolation Precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.
a. Ask the spouse to explain the fear of visiting in further detail.
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client's lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals.
a. Assess the client's lung sounds.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
a. Assess the client's oxygen saturation.
A client has been diagnosed with an empyema. What interventions would the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours
a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion
a. Cognition b. Dexterity d. Range of motion e. Vision f. Upper arm range of motion
A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.
a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.
a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.
A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension
a. Deep and fast respirations c. Tachycardia e. Orthostatic hypotension
A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity
a. Educating the client on adherence to the treatment regimen
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone—increased bone formation b. Excessive melanocyte-stimulating hormone—darkening of the skin c. Excessive parathyroid hormone—synthesis and release of corticosteroids d. Excessive antidiuretic hormone—increased urinary output e. Excessive adrenocorticotropic hormone—increased bone resorption
a. Excessive thyroid-stimulating hormone—increased bone formation b. Excessive melanocyte-stimulating hormone—darkening of the skin
The nurse is learning about endemic pulmonary diseases. Which diseases are matched with correct information? (Select all that apply.) a. Hanta virus: found in urine, droppings, and saliva of infected rodents. b. Aspergillosis: requires a prolonged course of antibiotics. c. Histoplasmosis: sources include soil containing bird and bat droppings. d. Blastomycosis: requires strict adherence to multi-antibiotic regimen. e. Cryptococcosis: has been eradicated due to strategic deforestation. f. Coccidioidomycosis: found in the southwest and far west of the United States.
a. Hanta virus: found in urine, droppings, and saliva of infected rodents. c. Histoplasmosis: sources include soil containing bird and bat droppings. f. Coccidioidomycosis: found in the southwest and far west of the United States.
A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding would indicate that the medication is effective? a. Heart rate of 92 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg
a. Heart rate of 92 beats/min
A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.) a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms. d. Most hormones are stored in the target tissues for use later. e. Most hormones cause target tissues to change activities by changing gene activity.
a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms.
The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension
a. Increased rate and depth of respiration
When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) a. Lethargy b. Diarrhea c. Low body temperature d. Tachycardia e. Slowed speech f. Weight gain
a. Lethargy c. Low body temperature e. Slowed speech f. Weight gain
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home. f. No alcohol-based hand sanitizers are present.
a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage.
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones would the nurse expect to be decreased as a result? (Select all that apply.) a. Thyroid-stimulating hormone b. Vasopressin c. Follicle-stimulating hormone d. Calcitonin e. Growth hormone
a. Thyroid-stimulating hormone c. Follicle-stimulating hormone e. Growth hormone
A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. What drugs would the nurse anticipate administering? (Select all that apply.) a. Vancomycin b. Ciprofloxacin c. Doxycycline d. Ethambutol e. Sulfamethoxazole-trimethoprim (SMX-TMP)
a. Vancomycin b. Ciprofloxacin c. Doxycycline
A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."
b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."
b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections? a. "Wash your hands after completing each test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip with a cotton ball." d. "Use gloves when monitoring your blood glucose."
b. "Do not share your monitoring equipment."
A nurse assesses a female client who presents with hirsutism. Which question would the nurse ask when assessing this client? a. "How do you plan to pay for your treatments?" b. "How do you feel about yourself?" c. "What medications are you prescribed?" d. "What are you doing to prevent this from happening?"
b. "How do you feel about yourself?"
A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."
b. "Monitor your blood glucose levels at least every 4 hours while sick."
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."
b. "Older people often have vague symptoms, so an x-ray is essential."
A nurse teaches an older woman who has a decreased production of estrogen. Which statement would the nurse include in this client's teaching to decrease injury? a. "Drink at least 2 quarts (2 L) of fluids each day." b. "Walk around the neighborhood for daily exercise." c. "Bathe your perineal area twice a day." d. "You should check your blood glucose before meals."
b. "Walk around the neighborhood for daily exercise."
A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."
b. "Your brain needs a constant supply of glucose because it cannot store it."
A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/μL (5.2 1012/L) c. White blood cell (WBC) count: 12,500/mm3 (12.5 109/L)
b. Alanine aminotransferase (ALT): 180 U/L
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.
b. Determine if the client can switch to a nasal cannula during the meal.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.
b. Ensure that informed consent is on the chart.
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL (4.2 mmol/L) Postprandial blood glucose: 200 mg/dL (11.1 mmol/L) Hemoglobin A1C level: 5.5% How would the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance
b. Good control of blood glucose
A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: VITAL SIGNS & ASSESSMENT Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter LABORATORY RESULTS Serum potassium: 2.6 mEq/L (2.6 mmol/L) MEDICATIONS Potassium chloride 40 mEq/L (40 mmol/L) IV bolus STAT Increase IV fluid to 100 mL/hr What action would the nurse take? a. Administer the potassium and then consult with the primary health care provider about the fluid prescription. b. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate for the client. d. Increase the intravenous flow rate before administering the potassium to the client.
b. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription.
A nurse is caring for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition? a. Decreased blood pressure b. Increased pulse c. Decreased respiratory rate d. Increased urine output
b. Increased pulse
A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that oral antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.
b. Inform the client that oral antibiotics will be needed for 60 days.
The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.
b. Inquire as to recent travel outside the United States.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days
b. Intact skin behind the ears
A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3 (72 109/L)
b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.
b. Measure and compare cuff pressures.
A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine
b. Presence of protein in the urine
A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories
b. Proteins
Which teaching point is most important for the client with a peritonsillar abscess? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Let us know if you want liquid medications. d. Wash hands frequently.
b. Take all antibiotics as directed.
fter teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% of my total calorie intake." c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of water is not restricted by my treatment plan or medication regimen."
c. "I should decrease my intake of protein and eliminate carbohydrates from my diet."
A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule a computed tomography scan this week."
c. "Try warm, moist heat packs on your face."
The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition? a. Sodium b. Magnesium c. Aldosterone d. Renin
c. Aldosterone
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best? a. Teach the client about possible drowsiness. b. Instruct the client to drink plenty of water. c. Consult with the PHCP about the medication. d. Encourage the client to take the medication with food.
c. Consult with the PHCP about the medication.
The nurse assesses an older client. What age-related physiologic changes would the nurse expect? a. Heat intolerance b. Rheumatoid arthritis c. Dehydration d. Increased appetite
c. Dehydration
The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? a. Assess the client's blood glucose level. b. Monitor the client's urinary output every hour. c. Establish intravenous access to provide fluids. d. Give regular insulin per agency policy.
c. Establish intravenous access to provide fluids.
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the primary health care provider.
c. Examine the client's feet for signs of injury.
The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.
c. Immediately increase the flow rate.
