UNRS 107 Quiz2_Prep_Rationale - ATI Quiz #2 Prep

70. A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose?

4 mL

74. A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? A. Bag valve mask device B. Defibrillator machine C. Chest tube equipment D. IV infusion pump

A. Bag valve mask device Rationale: A bag valve mask device is required next to the bedside for a client who has received a competitive neuromuscular blocking agent to provide ventilatory support in case the client develops respiratory arrest. Competitive neuromuscular blocking agents relax skeletal muscles and can cause temporary paralysis of the diaphragm.

71. A nurse is caring for a client who was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer? A. Ciprofloxacin B. Fluconazole C. Tobramycin D. Vancomycin

A. Ciprofloxacin Rationale: Ciprofloxacin, a fluoroquinolone, is the antibiotic of choice to treat and prevent systemic infection with Bacillus anthracis.

62. A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal.

A. Continue to monitor the client. Rationale: The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.

31. A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take? A. Infuse the medication with an IV pump. B. Cover the IV container with dark paper. C. Administer a test dose first. D. Infuse the medication at 35 mg/min.

A. Infuse the medication with an IV pump. Rationale: Theophylline should be administered slowly on an infusion pump. Rapid administration may cause hypotension and death.

35. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make? A. "We can teach you some relaxation techniques to minimize your pain." B. "Keep wire cutters with you at all times." C. "Use a water pick device to keep your teeth clean." D. "Consume a high-protein, liquid diet."

B. "Keep wire cutters with you at all times." Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to include is to tell the client to keep wire cutters available at all times. When the jaw is wired shut, the client is likely to aspirate if vomiting occurs. The client should use the wire cutters to clip the wires to keep the mouth clear of emesis, and should notify the provider so the jaw can be re-wired.

82. A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? A. Raise the affected extremity above the level of the heart. B. Immobilize the affected extremity with a splint. C. Apply ice to the bite area. D. Apply a tourniquet to the affected extremity.

B. Immobilize the affected extremity with a splint. Rationale: Immobilizing the client's affected extremity with a splint will limit the spread of the venom in the circulatory system.

33. A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently. B. Encourage coughing and deep breathing. C. Encourage the client to increase fluid intake. D. Encourage regular use of the incentive spirometer.

C. Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

27. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature

C. Increased heart rate Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

59. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.

C. Preoxygenate the client with 100% oxygen for up to 3 min. Rationale: To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

23. A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? A. Blurred vision B. Palpitations C. Constipation D. Depression

D. Depression Rationale: Montelukast can cause neuropsychiatric effects such as depression, behavior changes, hallucinations, and suicide ideation. The nurse should instruct the client to report such adverse effects. A change in medication might be prescribed.

68. A nurse is preparing to administer diphenhydramine 30 mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/1 mL. How many mL should the nurse administer?

0.6 mL

50. A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL

26. A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be required while on this medication regimen? A. Liver function tests B. Gallbladder studies C. Thyroid function studies D. Blood glucose levels

A. Liver function tests Rationale: Pyrazinamide and rifampin can both cause hepatotoxicity, thus the provider will monitor liver function regularly.

25. A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.) A. Inhale deeply and then exhale completely. B. Place her lips firmly around the mouthpiece. C. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. D. Hold her breath for 10 seconds. E. Exhale slowly through pursed lips. F. Wait 60 seconds between each puff.

A. Inhale deeply and then exhale completely. B. Place her lips firmly around the mouthpiece. C. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. D. Hold her breath for 10 seconds. E. Exhale slowly through pursed lips. F. Wait 60 seconds between each puff.

20. A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "Placing your child on her back when sleeping will decrease the risk of SIDS." B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." C. "SIDS rates have been rising over the last 10 years." D. "Sleep apnea is the main cause of SIDS."

A. "Placing your child on her back when sleeping will decrease the risk of SIDS." Rationale: The nurse should instruct the mother to position in the infant on her back during sleep to prevent SIDS. The incidence of SIDS has declined since the Back to Sleep campaign started in the 1990s.

36. A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Adjust the suction. B. Apply suction while rotating the catheter. C. Don sterile gloves. D. Check the function of the suction catheter. E. Insert the catheter without suction. F. Hyperoxygenate the client.

A. Adjust the suction. C. Don sterile gloves. D. Check the function of the suction catheter. F. Hyperoxygenate the client. E. Insert the catheter without suction. B. Apply suction while rotating the catheter. Assess for secretion clearance.

11. A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases. B. Urinary output. C. Chest tube drainage. D. Pain level.

A. Arterial blood gases Rationale: According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.

42. A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the client eats. C. Secure the oxygen tubing to the bed sheet near the client's head. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

A. Attach a humidifier bottle to the base of the flow meter. Rationale: Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

64. A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) A. Elevate the head of the bed to at least 30&deg. B. Verify the prescribed ventilator settings daily. C. Apply restraints if the client becomes agitated. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily.

A. Elevate the head of the bed to at least 30&deg. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily. Rationale: Elevate the head of the bed to at least 30° is correct because a client who is intubated is at risk for aspiration and ventilator-associated pneumonia. To minimize these risks, the nurse should maintain the head of the bed at 30° or higher. Verify the prescribed ventilator settings daily is incorrect because the nurse should perform and document ventilator checks at least every 8 hr to ensure the ventilator settings are as prescribed. Apply restraints if the client becomes agitated is incorrect because a client who becomes agitated or restless might be experiencing air hunger. The nurse should assess the flow settings. If the client continues to be restless or agitated, a chemical restraint, such as midazolam, may be administered. Physical restraints are a last resort and only applied to prevent accidental dislodgment of the endotracheal tube. Administer pantoprazole as prescribed is correct because stress ulcers occur in many patients receiving mechanical ventilation. Antacids, histamine blockers, or proton-pump inhibitors are often prescribed as soon as a client is intubated. Reposition the endotracheal tube to the opposite side of the mouth daily is correct because the nurse should assess the area around the endotracheal tube frequently for color, tenderness, skin irritation, and drainage. The nurse should perform oral care every 2 hr. To prevent skin breakdown, the oral endotracheal tube should be moved to the opposite side of the mouth once daily.

A school nurse receives a call that some children and teachers report being exposed to an undetermined noxious gas odor presenting in the classrooms and are experiencing dizziness. Which of the following actions should the nurse take? A. Have students evacuated from the school and establish a triage area in the school parking lot. B. Move individuals who are reporting symptoms to one of the affected classrooms and create a triage area inside the room. C. Arrange for client transportation to the nearest emergency department and tell the group triage will occur there. D. Transport all children and school personnel to the nearest medical facility using school buses.

A. Have students evacuated from the school and establish a triage area in the school parking lot.' Rationale: Following the principle of mitigation, the nurse should facilitate evacuation out of the building to prevent exposure to the harmful gas and set up the triage site at a nearby location.

45. A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds

A. Loud, scratchy sounds Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

5. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration. B. Ensure adequate nutrition. C. Promote oral hygiene. D. Relieve the client's pain.

A. Prevent aspiration. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and wire cutters should be kept at the bedside in case of vomiting

79. A nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax. Which of the following is appropriate to include in the plan of care? A. Provide respiratory support. B. Place the client in droplet isolation. C. Administer antihypertensive medications. D. Monitor ascites.

A. Provide respiratory support. Rationale: As the infection from an inhaled form of anthrax progresses, the client develops increasingly serious respiratory symptoms including severe respiratory distress, stridor, cyanosis, hypotension, and shock. The nurse should plan to provide respiratory support in the form of mechanical ventilation.

19. As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure? A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test. D. Expect minor discomfort after the procedure.

A. Remove all metal necklaces. Rationale: Metal objects block visualization of body structures and tissues, thus the client must remove them.

28. A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi-Fowler's position.

A. Repeat auscultation after asking the client to breathe deeply and cough. Rationale: Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

21. A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation B. Constipation C. Hypertension D. Bradycardia.

A. Sedation Rationale: Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.

58. A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhaler for 3 to 5 seconds. B. Rinse the mouth with mouthwash after inhaling the medication. C. Wait 2 min between inhalations. D. Press down twice on the MDI canister.

A. Shake the inhaler for 3 to 5 seconds. Rationale: After fully inserting the canister into the inhaler, the client should shake it vigorously for 3 to 5 seconds to make sure he mixes the medication thoroughly.

44. A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat

A. Stridor Rationale: Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately.

3. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes. B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning.

A. Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

2. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 in) above the naris. D. Instruct the client to stay in the same position for 2 min.

A. Tell the client to blow her nose gently before the instillation. Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

81. A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant? A. Trendelenburg B. Sitting on a nurse's lap leaning forward C. Supine D. Sitting on a nurse's lap leaning backward

A. Trendelenburg Rationale: Infants who have cystic fibrosis are placed in various positions to allow gravity to facilitate the removal of tenacious secretions. The nurse should identify the Trendelenburg position (head lower than body) as being contraindicated for the infant because infants do not have autonomic regulation of blood flow to the head. This position is also contraindicated for children who have head injuries.

78. A nurse is caring for a client who is postoperative following an intermaxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside? A. Wire cutters B. NG tube C. Urinary catheter tray D. IV infusion pump

A. Wire cutters Rationale: Establishment and maintenance of a patent airway is a primary goal of nursing management for a client who has facial injuries. Following intermaxillary fixation, the client's jaws will be wired shut for 6 to 10 weeks postoperatively, placing him at increased risk for aspiration in the case that he vomits. Keeping wire cutters at the bedside provides a means of opening the airway by cutting the wires should this occur. In the case that the wires are cut, the client will need to return to the operating room to have his jaws rewired.

76. A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? A. "Check your heart rate before each dose." B. "Inspect your mouth for lesions daily." C. "Use this medication to relieve an acute attack." D. "Skip the morning dose if you do not have any symptoms."

B. "Inspect your mouth for lesions daily." Rationale: The nurse should instruct the client to inspect her mouth daily. Fluticasone is a corticosteroid, which reduces the client's immunity and increases the risk for infection, such as Candida albicans.

77. A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? A. "Eat 3 large meals each day." B. "Limit water intake with meals." C. "Reduce protein intake." D. "Use a bronchodilator 1 hour before eating."

B. "Limit water intake with meals." Rationale: The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.

69. A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? A. "The spacer increases the amount of medication delivered to the oropharynx." B. "The spacer increases the amount of medication delivered to the lungs." C. "Inhale rapidly using the spacer with the MDI." D. "Cover exhalation slots of the spacer with lips when inhaling."

B. "The spacer increases the amount of medication delivered to the lungs." Rationale: The client uses a spacer to increase the amount of medication that reaches the lungs.

10. A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication? A. Give the medication in the morning daily. B. Administer the medication 2 hr before exercise. C. Give the medication at the onset of wheezing. D. Administer the granules mixed with 20 oz of water.

B. Administer the medication 2 hr before exercise. Rationale: Montelukast should be given daily during the evening, except when being used for exercise-induced bronchospasm. It should then be given 2 hr before exercise, and not given again for 24 hr.

65. A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching? A. Apply suction when inserting the catheter. B. Apply suction for less than 10 seconds. C. Set the suction pressure to 110 mm Hg. D. Allow the child to rest for 10 to 15 seconds after each suctioning attempt.

B. Apply suction for less than 10 seconds. Rationale: Prolonged suctioning can cause damage to tissues and induce hypoxia. Hypoxia can interfere with stages of respiration, cellular absorption, and blood transport.

39. A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A. Instruct the woman to call 911. B. Ask the partner if he can speak. C. Use the jaw-thrust maneuver. D. Perform chest compressions.

B. Ask the partner if he can speak. Rationale: Before intervening, the nurse should determine if the partner's airway is blocked. Therefore, the nurse should ask the partner if he can speak. If he can speak, breathe, or cough, air is moving through his airway.

56. A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? A. Instructing how to measure oxygen saturation B. Instructing how to use kitchen tools to prepare a meal C. Instruction how to plan a diet based on individual caloric needs D. Instructing how to perform pursed-lip breathing

B. Instructing how to use kitchen tools to prepare a meal Rationale: As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping.

34. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Verify the oxygen flow rate every other day. B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. E. Apply petroleum ointment to nares if they become dry and irritated.

B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. Rationale: Verify the oxygen flow rate every other day is incorrect. The rate of oxygen flow should be checked daily.Check the cannula position on a regular basis is correct. The position of the nasal cannula should be verified every 8 hours or more often if needed.Check the tops of the ears for skin breakdown is correct. The tops of the ears, the nares and the nasal mucous membranes should be assessed regularly for skin breakdown.Post "no smoking" signs in a prominent location in the home is correct. The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries.Apply petroleum ointment to nares if they become dry and irritated is incorrect. Protecting the nares is important, but the client should use a water-based lubricant or saline nasal spray to reduce dryness and irritation. Oxygen has a high combustion potential, and petroleum products are combustible.

57. A nurse is preparing to provide tracheostomy care for a client who has a nondisposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.) A. Sterile cotton balls B. Clean gloves C. Sterile water D. Sterile cotton-tipped applicators E. Sterile basin

B. Clean gloves D. Sterile cotton-tipped applicators E. Sterile basin Rationale: Sterile cotton balls is incorrect.. The nurse should avoid using sterile cotton balls when providing tracheostomy care as cotton lint can be aspirated by the client. Clean gloves is correct. The nurse will use clean gloves to remove the soiled tracheostomy dressing. Sterile water is incorrect. The nurse will need sterile normal saline to clean the inner cannula and the clients incision site. Sterile cotton-tipped applicators is correct. The nurse will need to use the sterile cotton-tipped applicators to cleanse the tracheostomy site. Sterile basin is correct.. The nurse will need a sterile basin to soak the nondisposable inner cannula in.

16. A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber. B. Continuous bubbling in the water-seal chamber. C. Bloody drainage in the collection chamber. D. Fluid-level fluctuations in the water-seal chamber.

B. Continuous bubbling in the water-seal chamber Rationale: Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.

4. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Administer vitamin K. B. Dry the skin. C. Administer eye prophylaxis. D. Place an identification bracelet.

B. Dry the skin. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother's abdomen, and a cap applied to the newborn's head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow's hierarchy of needs, this is the most important nursing action after securing the airway.

80. A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? A. Vigorously rub the skin following a decontamination shower. B. Initiate seizure precautions. C. Provide respiratory support with a plastic oral airway. D. Prepare to administer amyl nitrate.

B. Initiate seizure precautions. Rationale: Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen.

55. A nurse is planning care for a client who has terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day. B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. C. Instruct the client to stop taking the morphine if itching develops. D. Instruct the client to keep room lights dim during waking hours.

B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. Rationale: Morphine acts on the medulla to suppress cough. The nurse should teach the client to actively cough to prevent a buildup of secretions in the airway.

29. A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? A. Clamp the tube when the client is ambulating. B. Keep the collection device below the level of the client's chest. C. Coil the tubes carefully to prevent kinking. D. Lay the client flat to avoid leaks in the tubing.

B. Keep the collection device below the level of the client's chest. Rationale: The nurse should keep the drainage system lower than the client's chest to facilitate drainage from the chest cavity.

13. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse should take? A. Observe the client before taking further action. B. Perform the Heimlich maneuver. C. Assist the client to the floor and begin mouth-to-mouth resuscitation. D. Slap the client on the back several times.

B. Perform the Heimlich maneuver. Rationale: The client cannot talk, coughs only once, and is demonstrating the universal choking sign: grasping at the throat with the hands. Choking requires immediate intervention. The Heimlich maneuver is the most effective method for clearing the obstruction in the airway of a choking person

51. A nurse assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which of the following actions should the nurse take? A. Locate the child's parents to obtain consent for treatment. B. Place a yellow triage tag on the child. C. Notify the emergency department of the child's imminent arrival. D. Perform a complete head-to-toe assessment.

B. Place a yellow triage tag on the child. Rationale: The child's Condition indicates the need for treatment within 30 min to 2 hr. Therefore, the nurse should triage the child with a yellow tag.

17. A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take? A. Obtain a throat culture. B. Place the child in an upright position. C. Transport the child to radiology for a throat x-ray. D. Visualize the epiglottis with a tongue depressor.

B. Place the child in an upright position. Rationale: Placing the child in an upright position will assist in maintaining a patent airway.

49. A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect? A. Dullness B. Resonance C. Tympany D. Flatness

B. Resonance Rationale: Resonance characterizes chronic bronchitis. It is a loud, low-pitched sound of long duration.

6. A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance. B. Suppress respiratory effort. C. Induce sedation. D. Decrease respiratory secretions.

B. Suppress respiratory effort Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor lung compliance.

60. A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply.) A. The medication will stimulate flow of mucus. B. The medication will prevent wheezing. C. The medication will open the airways. D. The medication will reduce inflammation. E. The medication will decrease coughing episodes.

B. The medication will prevent wheezing. C. The medication will open the airways. E. The medication will decrease coughing episodes. Rationale: The medication will stimulate flow of mucus is incorrect. Expectorants, such as guaifenesin, stimulate the flow of mucous to produce a productive cough. Asthma is characterized by bronchoconstriction, airway edema, and increased mucus production. Albuterol relaxes the airways, allowing for expectoration of mucus. The medication will prevent wheezing is correct. Albuterol is used to prevent or treat wheezing. The medication will open the airways is correct.Albuterol promotes bronchodilation. The primary purpose is to provide rapid relief of bronchoconstriction, thus opening the airway and improving oxygenation. The medication will reduce inflammation is incorrect. Albuterol does not reduce inflammation. Glucocorticoid medications reduce inflammation. The medication will decrease coughing episodes is correct. Coughing is often an early indicator of bronchospasm. Albuterol provides a rapid response to relax smooth muscle and reduce bronchoconstriction, which will decrease coughing.

22. A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduces inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions

D. Stimulates secretions Rationale: Expectorants act by increasing secretions to improve a cough's productivity.

47. A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." B. "Use the incentive spirometer every 4 hr after the tube is removed." C. "Avoid speaking for long periods." D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed."

C. "Avoid speaking for long periods." Rationale: The client should avoid speaking for long periods to promote gas exchange.

46. A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."

C. "I will follow a daily diet high in calories and protein." Rationale: Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.

63. A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? A. Percuss each lung segment for 15 min. B. Perform CPT immediately after the child eats. C. Administer albuterol prior to CPT. D. Perform vibration during the client's inspirations.

C. Administer albuterol prior to CPT. Rationale: Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

15. A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects? A. Osteoarthritis. B. Basal cell carcinoma. C. Asthma. D. Hypothyroidism.

C. Asthma Rationale: The ozone exerts its primary adverse effects on the respiratory system, reducing lung function and increasing the risk of respiratory infection. Clients who have respiratory disorders, such as asthma and COPD, are especially vulnerable.

8. A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection. B. Pulmonary edema. C. Atelectasis. D. Delayed gastric emptying.

C. Atelectasis Rationale: Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

7. A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? A. Consume a high-protein diet. B. Administer the medication with food. C. Avoid caffeine while taking this medication. D. Increase fluids to 1L/per day.

C. Avoid caffeine while taking this medication. Rationale: The nurse should instruct the client that caffeine should be avoided while taking theophylline, as it can increase central nervous system stimulation.

73. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? A. Position the head of the client's bed in the flat position. B. Turn the client every 4 hr. C. Brush the client's teeth with a suction toothbrush every 12 hr. D. Provide humidity by maintaining moisture within the ventilator tubing.

C. Brush the client's teeth with a suction toothbrush every 12 hr. Rationale: The nurse should brush the client's teeth every 12 hr and rinse the client's mouth with an antimicrobial rinse to reduce the growth of bacteria.

38. A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective? A. Increased respiratory rate B. Stable oxygen saturation C. Clear breath sounds D. Brisk capillary refill.

C. Clear breath sounds Rationale: Clear breath sounds indicate that there are no remaining secretions obstructing or potentially obstructing the client's airway.

14. A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective? A. Barking cough. B. Improved hydration. C. Decreased stridor. D. Decreased temperature.

C. Decreased stridor Rationale: Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.

52. A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take? A. Start CPR. B. Place a red tag on the client's upper body and obtain immediate help from other personnel. C. Place a black tag on the client's upper body and attempt to help the next client in need. D. Reposition the client's upper airway a second time before assessing his respirations.

C. Place a black tag on the client's upper body and attempt to help the next client in need. Rationale: When assessing an apneic adult casualty in a disaster situation, a nurse should attempt to reposition the upper airway on time. If the client still does not breathe, a black tag should be placed on the upper body and the nurse should move on to the next client in need.

72. A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with an emesis basin. B. Notify housekeeping. C. Prevent the client from aspirating. D. Administer an antiemetic to the client.

C. Prevent the client from aspirating. Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines the priority action is to prevent the client from aspiration by turning the client to his side and suctioning his airway.

41. A nurse is providing teaching to a parent of a child who has acute group A ß-hemolytic streptococci. Which of the following information should the nurse include in the teaching? A. Avoid the use of warm compresses around the head or neck. B. Intramuscular injections will be required monthly. C. Replace the child's toothbrush after 24 hr on antibiotics. D. Keep the child home from school for at least 1 week.

C. Replace the child's toothbrush after 24 hr on antibiotics. Rationale: The child's toothbrush should be replaced after 24 hr on antibiotics to prevent the spread of infection or re-infection.

30. A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis Rationale: With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.

24. A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? A. Sedation B. Increased appetite C. White coating in the mouth D. Dry oral mucous membranes

C. White coating in the mouth Rationale: Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

66. A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching? A. "Take cromolyn sodium at the first sign of breathing difficulty." B. "You should stop playing basketball, but you can swim instead." C. "Use the peak expiratory flow meter once per week." D. "Avoid triggers that cause an attack."

D. "Avoid triggers that cause an attack." Rationale: The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollen, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers.

75. A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include? A. "Take isoniazid with an antacid." B. "Provide a sputum specimen every 2 weeks to the clinic for testing." C. "Expect your sputum cultures to be negative after 6 months of therapy." D. "Drink at least 8 ounces of water when you take the pyrazinamide tablet."

D. "Drink at least 8 ounces of water when you take the pyrazinamide tablet." Rationale: A client who has tuberculosis usually takes pyrazinamide for the first 2 months of therapy and can shorten the entire course of therapy to 6 months. The nurse should instruct the client to drink at least 240 mL (8 oz) of fluid when taking the medication and to protect himself from the sun with cotton clothing and sunscreen.

48. A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching? A. "We'll continue to encourage him to drink lots of fluids." B. "We'll take his temperature every 4 hours." C. "We'll give him Tylenol for the pain." D. "We'll discard his toothbrush and buy another."

D. "We'll discard his toothbrush and buy another." Rationale: Children who have positive throat cultures for streptococcal infection should replace their toothbrush after they have been taking antibiotics for 24 hr. Using a contaminated toothbrush can re-introduce the bacteria and spread it to others if others handle the toothbrush.

53. A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. A client who has pertussis C. A client who has streptococcal pharyngitis D. A client who has measles

D. A client who has measles Rationale: A client who has measles requires airborne precautions as well as a negative pressure room.

54. A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? A. Beclomethasone B. Salmeterol C. Formoterol D. Albuterol

D. Albuterol Rationale: Albuterol is an inhaled short-acting beta2 agonist (beta2-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.

67. A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first? A. Fluticasone B. Budesonide C. Montelukast D. Albuterol

D. Albuterol Rationale: Albuterol is considered a "rescue" medication due to its rapid onset of action. Asthma is a chronic inflammatory disorder of the airways. Asthmatic episodes are associated with airflow limitation or reversible obstruction. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma by promoting bronchodilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or as a parenteral preparation. The inhaled medication has a more rapid onset of action than the oral form and also reduces the risk for the adverse effects of irritability, tremor, nervousness, and insomnia.

9. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible. B. Administering oxygen via nasal cannula at 2 L/min. C. Helping the client select a low-salt diet. D. Encouraging the client to drink 2 to 3 L of water daily.

D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

40. A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding. B. Insert an orogastric tube for decompression of the stomach. C. Place the newborn in Trendelenburg position. D. Maintain oxygen saturations between 93% to 95%.

D. Maintain oxygen saturations between 93% to 95%. Rationale: Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

32. A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take? A. Initiate airborne precautions. B. Obtain a throat culture. C. Use a tongue depressor to observe the epiglottis. D. Monitor oxygen saturation.

D. Monitor oxygen saturation. Rationale: The nurse should monitor the child's oxygen saturation levels to check for indications of respiratory distress or a decline child's condition.

61. A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side. B. Administer a 500 mL bolus of 5% dextrose in water prior to induction. C. Inform the client the anesthetic effect will last for approximately 6 hr. D. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.

D. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. Rationale: The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

37. A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.

D. Place in a prone position. Rationale: Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.

12. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.

D. The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.

83. A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use? A. Postural drainage B. Nebulization C. Percussion D. Vibration

D. Vibration Rationale: Vibration after percussion, or alternately with percussion, increases the velocity and turbulence of the air the client exhales, while loosening secretions and triggering coughing.

43. A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D. Wheezes Rationale: Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

1. A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire. D. Rescue the clients.

The correct order for responding to a fire emergency is typically referred to as "RACE," which stands for: R. Rescue the clients. A. Activate the fire alarm (pull the fire alarm). C. Confine the fire. E. Extinguish the fire.