SOC Quiz 5

The nurse has just administered the first dose of omalizumab (Xolair) 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 clinic nurse is providing instructions to a parents of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect the client to experience?

-A hyperinflanted chest noted on the chest X-ray -Decreased oxygen saturation with mild exercise

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 the list? Select all that apply.

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

The nurse is preparing for admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care?

-Place the infant in a private room. -Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side/adverse effects of the medication should the nurse monitor? Select all that apply.

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

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 instructions?

1"I must take the medication exactly as prescribed."

The mother of a hospitalized 2-year-old child with viral laryngotracheobroncitis (croup) asks the nurse who the health care provider did not prescribe antibiotics. Which response should the nurse make?

"Antibiotic are not indicated unless a bacterial infection is present."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for 1.5 weeks. The nurse determines that the client has understood the information if the client makes which statement?

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

The nurse teaches a client about the effects of diphenhydramine (Benadryl), 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 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 community health nurse is conducting an education session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis?

A cough with expectoration of mucoid sputum

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the side and adverse effects 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 has been started on long-term therapy with rifampin (Rifadin). 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 has begun therapy with theophylline (Theo-24). The nurse should plan to teach the client to limit the intake of which items while taking this medication?

Coffee, cola, and chocolate

A 10-year-old child with asthma is treated for an acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing

Terbutaline is prescribed for a client with bronchitis. The nurse understands that this medication should be used with caution if which medical condition is present in the client?

Diabetes mellitus

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

Difficulty in discriminating the color red from green

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the 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 mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side.

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

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct cool mist over the face

A client with tuberculosis is being started on antituberculosis 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 (Accolate) 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 tests

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

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a room with another child with RSV

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 with 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 item 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 if 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 1½ 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?

Peripheral 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

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10mm. The nurse should interpret these results as which finding?

Positive

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of the pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

Report yellow eyes or skin immediately.

The nurse is preparing to administer a dose of naloxone hydrochloride intravenously to a client with an intravenous 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 (Serevent Diskus), two puffs, and beclomethasone dipropionate (Qvar), two 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

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 on the side of the bed and leaning on an over-bed 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 most appropriate?

Stop the procedure and reoxygenate the client

A client has a prescription to take guaifenesin (Mucinex). 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 emergency department nurse is caring for a child diagnosed with epiglottis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out.

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 which initial action?

Ventilate the client manually

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 anticipate to be prescribed?

Venturi mask