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A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

"Crushing the medication might cause you to have a stomachache or indigestion."

A nurse is reviewing information about the Health insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse is orienting a newly licensed nurse on the purpose of administering atracurium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"This medication is given to facilitate ventilation"

A nurse at an extended-care facility is Instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first.

A nurse is caring for a client who is using a patient-controlled analgesia (CA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed."

NGN- Patient presents with a pulmonary embolism. Which finding Is expected in this condition?

-Low PaO2 -Dyspnea -Tachycardia -Feeling of impending doom

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

-Provide oral care daily with chlorhexidine (0.12%) solution -Provide a "sedation holiday" daily -Elevate the head of the bed to at least 30 degrees -Give prescribed pantoprazole (Protonix).

NGN- A nurse is caring for a client who is scheduled for surgery. A nurse is providing preoperative teaching to a client about pain management using a patient-controlled analgesia (PCA) system. Which of the following 3 statements should the nurse include?

-There is minimal risk of an overdose of pain medication while using the PCA pump." -"Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable. -"Using the PCA regularly will provide a consistent level of pain relief."

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor- vehicle crash. Identify the sequence of actions the nurse should take.

1) Open the airway using a jaw-thrust maneuver. 2) Determine the effectiveness of ventilator efforts. 3) Establish IV access. 4) Perform a Glasgow Coma Scale assessment. 5) Remove clothing for a thorough assessment.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy.

A nurse in an emergency department is assessing a client who is having a pneumothorax. Which of the following manifestations should the nurse expect?

Anxiety and dyspnea, Nausea and epigastric distress, Chest pain unrelieved by nitrates, Pallor and diaphoresis

A nurse is preparing to perform hand hygiene. Which of the following actlons should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the client's airway.

A nurse is caring for a client who is receiving a continuous I infusion of heparin. Which of the following actions should the nurse take?

Check the activated partial thromboplastin time (aPTT) every 4 hr.

Respiratory effort usually exhibited by the patient with cerebral brain damage is called

Cheyne-Stokes

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. When documenting this assessment finding, which term is the most appropriate for the nurse to use?

Cheyne-Stokes

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations

SATA- A 58 yr old patient who has been in the ICU for 6 days has disturbed sensory perception from sleep deprivation. Which actions should the nurse include in the plan of care?

Cluster nursing activities, Providing uninterrupted rest periods will minimize sleep-cycle disruption

A nurse is caring for a client who has a new chest tube in place to closed-chest water-seal drainage and suction. The nurse should observe the client for which of the following indications of a problem in the drainage system?

Continuous bubbling in the water-seal chamber

Which of the following upper respiratory drugs cause local vasoconstriction?

Decongestants

When evaluating a 62 yr old patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse prioritize to do next?

Discontinue the catheter and culture the tip.

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Eat foods that contain plenty of potassium.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Flush the NG feeding tube with 30 mL of water immediately following medication administration.

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Hemodynamic status

A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood?

Hemoglobin

A nurse who is caring for a client who just developed PE. Which of the following medications should the nurse anticipate administering?

Heparin

NGN- The nurse is caring for a client who is intubated and mechanically ventilated. Identify the expected alarm for the following events. Only one correct answer per row

High-Pressure Alarm- Kink in tubing, Secretions Low-Pressure Alarm- Endotracheal tube cuff leak, Unplanned extubation Apnea- RR is 0

A recently admitted 36 yr old patient who has sustained multiple traumas develops a low CVP pressure. Which of the following interpretations will alert the nurse of this change?

Hypovolemia

After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take?

Increase the IV fluid infusion per protocol.

NGN- The nurse and the surgical unit is caring for client who has a chest tube attached to a stationary closed chest drainage system. See nurses' notes and vital signs to select nursing actions.

Indicated= Request order for a stat chest x-ray, Contact the client's surgeon/ Contraindicated= Increase the amount of suction in the suction control, Prepare to replace chest tube collection device, Clamp the chest tube

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side

Left Pedal

An intubated client's oxygen saturation has dropped to 86%. What action by the nurse takes priority?

Listen to the client's lung sounds.

The nurse performing a respiratory assessment on her client and hears rhonchi in bilateral lobes. Which is the best description for this adventitious sound?

Low pitched, continuous, snoring or rattling.

Breathing is controlled by what part of the CNS?

Medulla Oblongata

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side

NGN- Client is intubated on mechanical ventilation in the intensive care unit. What Interventions can the nurse perform to reduce the risk of ventilator-associated pneumonia VAP?

Oral care with chlorhexidine, Suction as needed, Keep HOB elevated, Ambulate the patient daily

A nurse is reviewing the laboratory data on a client who has a new pulmonary embolism. Which of the following data should the nurse report?

Platelets 74,000

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. What is the most likely indication of this finding?

Pneumothorax

What action by a new intensive care unit staff nurse would indicate chat the nurse educator's teaching about arterial pressure monitoring has been effective?

Positions the zero-reference stopcock line level with the phlebostatic axis.

A nurse is caring for a client who develops ARDS. The nurse is aware that the disease is characterized by?

Progressive loss of lung compliance and increasing hypoxia

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose

Protamine sulfate

A nurse is teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations?

Pulmonary artery

Which of the following is a hallmark characteristic of acute respiratory distress syndrome (ARDS)?

Refractory Hypoxemia

The patient is admitted with pneumothorax. The ABG shows Ph 7.20. What should the nurse know about the PaC02 50? What does this indicate?

Respiratory Acidosis

The client's respiratory assessment reveals loud, low pitch snoring sounds during inspiration and expiration. Which term best represents these sounds?

Rhonci

A patient whose heart monitor shows systole. The patient is apneic, and has no palpable pulses. What action should the nurse take next?

Start cardiopulmonary resuscitation (CPR)

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?

Stopping the transfusion

Which of the following allows the alveoli sac to stay open and allows for the exchange of gases?

Surfactant

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time.

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Tell the client to blow her nose gently before the installation.

The nurse assesses a client with dyspnes, decreased breath sounds, tracheal deviation, and pulse oximetry reading of 86%. What is the nurse's interpretation of these findings?

Tension pneumothorax

The nursing student is asked to demonstrate the Allen test on a fellow student. which of the following best describes the Allen test?

Test used to determine patency of the radial and ulnar arteries

A client has the following arterial blood gas values pH 7.52, Pa02 42 mm Hg, PaCO2 28 mm Hg. HCO3 24 mEq/L Based upon the client's Pa02, which of the following conclusions would be accurate?:

The client is severely hypoxic.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?

The client's self-report of pain severity

Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

The right-hand feels cooler than the left hand

What is the best initial action by the nurse to verify the correct placement of an oral endotracheal tube (ET) after insertion?

Use an end-tidal CO2 monitor.

Analyze the following ABG pH: 7.31, PaCO2: 26 mm Hg, HCO3: 13 mm Hg:

metabolic acidosis partially compensated

A nurse is caring for a client whose arterial blood gas results show a pH of 7.23; PaCO2 of 61 and HCO3 of 25 mEq/L. The nurse should identify that the client is experiencing:

respiratory acidosis, uncompromised

Which of the following statements is an example of the effect of aging, illness, or trauma on self-concept?

society devalues, aging and chronic illness