Saunders Assessment

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instruction?

"I must take the medication exactly as prescribed."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

"I should not be contagious after 2 to 3 weeks of medication therapy."

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement?

"I will take the medication on an empty stomach."

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?

"My lips and tongue are swollen."

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

10 seconds

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? SATA 1.) A low arterial PCo2 level 2.) A hyper-inflated chest noted on the chest x-ray 3.) Decreased oxygen saturation with mild exercise 4.) A widened diaphragm noted on the chest x-ray 5.) Pulmonary function tests that demonstrate increased vital capacity

A hyper-inflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

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? SATA 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 in 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 out used tissues in plastic bags. 6.) When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy in initiated. Respiratory isolation is not necessary because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and out used tissues in plastic bags.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? SATA 1.) Administering oxygen 2.) Inserting a Foley catheter 3.) Administering furosemide 4.) Administering morphine sulfate intravenously 5.) Transporting the client to the coronary care unit 6.) Placing the client in a low Fowler's side-lying postition

Administering oxygen Inserting a Foley catheter Administering furosemide Administering morphine sulfate intravenously

A client has begun therapy wit theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication?

Coffee, cola, and chocolate

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse affects of this medication and should tell the client that which undesirable effect is associated with this medication?

Bronchospasm

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

Bronchospasm

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication?

Cardiogenic shock

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication?

Causes orange discoloration of sweat, tears, urine, and feces

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

Crackles

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

Diabetes mellitus

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

Difficulty in discriminating the color red from green

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates he presence of a pneumothorax in this client?

Diminished breath sounds

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

Dyspnea

The coronary health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? SATA 1.) Dyspnea 2.) Headache 3.) Night sweats 4.) A bloody, productive cough 5.) A cough with the expectoration of mucoid sputum

Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum

A client with tuberculosis is being started on anti-tuberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed?

Liver enzyme levels

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function test

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

Mask

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medcation would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

Metformin

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially on inspiration.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Percussion and vibration

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Periphereal neuritis

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

Prepare for transcutaneous pacing

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon monoxide elimination

A client is to begin a 6-month course of therapy with isoniazid. The nurse should provide which information to the client about the medication?

Report yellow eyes or skin immediately

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?

Resuscitation equipment

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

Right pneumothorax

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

Salmeterol first and then the beclomethasone

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath

Rifabutin is prescribed for a client with active mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? SATA 1.) Signs of hepatitis 2.) Flulike syndrome 3.) Low neutrophil count 4.) Vitamin B6 deficiency 5.) Ocular pain or blurred vision 6.) Tingling and numbness of the fingers

Signs of hepatitis Flulike syndrome Low neutrophil count Ocular pain or blurred vision

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

Sputum culture

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

Stop the procedure and re-oxygenate the client.

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action?

Take the tablet with a full glass of water

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

Ventilate the client manually

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?

Ventricular dysrhythmias

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

Venturi mask