adult health II exam III

a nurse is providing discharge teaching to a client who has a temporary tracheostomy. which of the following statements by the client indicates an understanding of the teaching? a. I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." b. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." c. "I should remove the old twill ties after the new ties are in place." d. "I should apply suction while inserting the catheter into my tracheostomy tube."

"I should remove the old twill ties after the new ties are in place." As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

a charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A.) "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B.) "I will notify the provider if there is continuous bubbling in the water seal chamber." C.) "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." D.) "I will notify the provider if there are several small, dark-red blood clots in the tubing."

"I will notify the provider if there is continuous bubbling in the water seal chamber." rationale:Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

a nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? A.) A client who is 48 hr postoperative following a total hip arthroplasty B.) A client who is 8 hr postoperative following an open surgical appendectomy C.) A client who is 2 hr postoperative following an open reduction external fixation of the right radius D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A.) A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery.

a nurse developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? A.) Airborne B.) Neutropenic C.) Contact D.) Droplet

A.) Airborne

a nurse in an ED is caring for a client who's experiencing a pulmonary embolism. which of the following actions should the nurse take first? A.) Apply supplemental oxygen. B.) Increase the rate of IV fluids. C.) Administer pain medication. D.) Initiate cardiac monitorin

A.) Apply supplemental oxygen. ABC question

a nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments if the priority? A.) presence of gag reflex B.) pain level rating using 0 to 10 scale C.) hydration status D.) appearance of the IV insertion site

A.) presence of gag reflex

a nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on 4 clients. for which of the following clients should the nurse clarify the provider's prescription? A.) pt w/ epistaxis B.) pt w/ amyotrophic lateral sclerosis C.) pt w/ pneumonia D.) pt w/ emphysema

A.) pt w/ epistaxis

a charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. which of the following statements by a staff nurse indicates an understanding of the teaching? A.) "I will use clean technique when suctioning a client's endotracheal tube." B.) "I will use a rotating motion when removing the suction catheter." C.) "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D.) "I will suction a client's endotracheal tube every 2 hours."

B.) "I will use a rotating motion when removing the suction catheter."

a nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. which of the following findings is the priority for the nurse to report to the provider? A.) Bleeding at the surgical site B.) Decreased oxygen saturation C.) Urinary retention D.) Increased pain level

B.) Decreased oxygen saturation

a nurse is assessing a client who has emphysema. which of the following findings should the nurse report to the provider? A.) Rhonchi on inspiration B.) Elevated temperature C.) Barrel-shaped chest D.) Diminished breath sounds

B.) Elevated temperature

a nurse is caring for a client who's in respiratory distress. which of the following low-flow delivery devices should the nurse use to provide the client w/ highest level of oxygen? A.) Nasal cannula B.) Nonrebreather mask C.) Simple face mask D.) Partial rebreather mask

B.) Nonrebreather mask

a nurse in a provider's office is assessing a client who has COPD. which of the following findings is the priority for the nurse to report to the provider? A.) Increased anterior-posterior chest diameter B.) Productive cough with green sputum C.) Clubbing of the fingers D.) Pursed-lip breathing with exertion

B.) Productive cough with green sputum

a nurse is caring for a client who's in acute respiratory failure and is receiving mechanical ventilation. which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A.) BP B.) Cap refill C.) ABGs D.) HR

C) ABGs

a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A.) Excess secretions B.) Kinks in the tubing C.) Artificial airway cuff leak D.) Biting on the endotracheal tube

C.) Artificial airway cuff leak

a nurse is caring for a client who has a chest tube following a lobectomy. which of the following items should the nurse keep easily accessible for the client? A.) Extra drainage system B.) Suture removal kit C.) Container of sterile water D.) Non adherent pads

C.) Container of sterile water

a nurse is caring for a client who's 1 hr postoperative following a thoracentesis. which of the following is the priority assessment finding?A.) Pallor B.) Insertion site pain C.) Persistent cough D.) Temperature 37.3° C (99.1° F)

C.) Persistent cough

a nurse is creating a plan of care for a client who has COPD. which of the following interventions should the nurse include? A.) Schedule respiratory treatments following meals. B.) Have the client sit up in a chair for 2-hr periods three times per day. C.) Provide a diet that is high in calories and protein. D.) Combine activities to allow for longer rest periods between activities.

C.) Provide a diet that is high in calories and protein.

a nurse is assessing a client who has bacterial pneumonia. which of the following manifestations should the nurse expect? A.) decreased fremitus B.) SaO2 95% on room air C.) temperature 38.8° C (101.8° F) D.) bradypnea

C.) temperature 38.8° C (101.8° F)

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following information should the nurse include in the teaching? A) "Avoid lifting both arms above your head when dressing." B) "Use your cell phone on the same ear as the pacemaker site is located." C) "Avoid travel by airplane." D) "Hiccups are an expected outcome of having a pacemaker."

CORRECT -> A) "Avoid lifting both arms above your head when dressing." The nurse should reinforce that the client should avoid lifting her arm or shoulder on the side of the pacemaker because dislodgement of the pacer leads can occur. INCORRECT -> B) "Use your cell phone on the same ear as the pacemaker site is located." The nurse should reinforce that the client should use her cell phone on the opposite ear to prevent interference with the pacemaker function. INCORRECT -> C) "Avoid travel by airplane." The nurse should reinforce to the client that there is no travel restriction when the client has a pacemaker. Airport security screening equipment will not harm the function of the pacemaker. INCORRECT -> D) "Hiccups are an expected outcome of having a pacemaker." The nurse should reinforce that the client should report experiencing hiccups because this is a complication that can indicate a lead wire is displaced and is stimulating the diaphragm.

A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A) A weight gain of 1 kg (2.2lbs) in 1 day B) Pitting edema +1 C) Client reports a nocturnal cough D) B-Type Natriuretic Peptide (BNP) level of 100pg/mL

CORRECT -> A) A weight gain of 1 kg (2.2lbs) in 1 day A weight gain of 1 kg in 1 day alerts the nurse that the client might be retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening. INCORRECT -> B) Pitting edema +1 Pitting edema, a visible finger indentation after application of pressure, alerts the nurse that the client has retained fluid and demonstrates that there is fluid in the client's tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 is an indication that the client has developed fluid volume overload and the heart failure is worsening. INCORRECT -> C) Client reports a nocturnal cough The client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. INCORRECT -> D) B-Type Natriuretic Peptide (BNP) level of 100pg/mL Serum BNP levels increase as a result of the ventricular hypertrophy that occurs in heart failure. A BNP level above 100pg/mL is indicative of heart failure. Levels continue to increase with the severity of heart failure.

A nurse is assisting in the care of a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A) Administer antihypertensive medication for blood pressure B) Monitor that urinary output is 20 ml/hr C) Withhold pain medication to prepare for surgery D) Take vital signs every 2 hr

CORRECT -> A) Administer antihypertensive medication for blood pressure. The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall. INCORRECT -> B) Monitor that urinary output is 20 ml/hr. The nurse should monitor that the client has adequate kidney profusion determined by urinary output of at least 30 ml/hr. Oliguria can indicate a rupture of the aneurysm. INCORRECT -> C) Withhold pain medication to prepare for surgery. The nurse should administer pain medication because pain occurs due to pressure from the aneurysm on the lumbar nerves. Pain can also cause hypertension. INCORRECT -> D) Take vital signs every 2 hr. The nurse should take the client's vital signs at least every 15 min in order to monitor for a sudden drop in blood pressure, which can indicate a rupture of the aneurysm.

A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate? A) Potassium 2.8 mEq/L B) Digoxin level 0.7 ng/mL C) Hemoglobin 11.5 g/dL D) Calcium 8.0 mg

CORRECT -> A) Potassium 2.8 mEq/L Manifestations of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias. INCORRECT -> B) Digoxin level 0.7 ng/mL The client has a digoxin level within the therapeutic range of 0.5 to 0.8 ng/mL. INCORRECT -> C) Hemoglobin 11.5 g/dL The manifestations of mild anemia include headache, palpitations, and shortness of breath with exertion. INCORRECT -> D) Calcium 8.0 mg Manifestations of hypocalcemia include numbness and tingling of the hands and feet, abdominal cramping, and tetany. Severe hypocalcemia can cause hypotension and ECG changes.

A nurse is assisting in collecting data from a client who has a history of unstable angina. Which of the following findings should the nurse expect? A) The client reports chest pain when at rest B) Nitroglycerin relieves chest pain C) Physical exertion does not precipitate chest pain D) Chest pain lasts less than 5 min

CORRECT -> A) The client reports chest pain when at rest The client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetals) angina, caused by an artery spasm. INCORRECT -> B) Nitroglycerin relieves chest pain The client who has unstable angina will have minimal if any, relief of chest pain from nitroglycerin. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction. INCORRECT -> C) Physical exertion does not precipitate chest pain The client who has unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction. INCORRECT -> D) Chest pain lasts less than 5 min. The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.

a nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. which of the following client statements indicates an understanding of the teaching? A.) "I will monitor my heart rate every day while taking this medication." B.) "I will make sure I have this medication with me at all times." C.) "I will need to carefully rinse my mouth after I take this medication." D.) "I will take this medication every night even if I don't have symptoms."

D.) "I will take this medication every night even if I don't have symptoms." Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

a nurse is caring for a client who has pulmonary embolism. which of the following interventions is the nurse's priority? A.) Provide a quiet environment B.) Encourage use of incentive spirometer every 1-2 hrs C.) Obtain blood sample for electrolyte study D.) Administer heparin via continuous IV infusion

D.) Administer heparin via continuous IV infusion

a nurse is assessing a client who has acute respiratory distress syndrome (ARDS). which of the following findings should the nurse report to the provider? A.) Decreased bowel sounds B.) Oxygen saturation 92% C.) CO2 24 mEq/L D.) Intercostal retractions

D.) Intercostal retractions

a nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A.) Collapsed neck veins on the affected side B.) Collapsed neck veins on the unaffected side C.) Tracheal deviation to the affected side D.) Tracheal deviation to the unaffected side

D.) Tracheal deviation to the unaffected side

a nurse is caring for a client who's postoperative and has an RR of 9/min secondary to general anesthesia effects na incisional pain. which of the following ABG values indicates the client is experiencing respiratory acidosis? A.) pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B.) pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C.) pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D.) pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

D.) pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

a nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? A.) Lateral position with a pillow at the back and over the chest to support the arm B.) High-Fowler's position with the arms supported on the overbed table C.) Semi-Fowler's position with pillows supporting both arms D.) Supine position with the head of the bed elevated to 15°

High-Fowler's position with the arms supported on the overbed table

A nurse is providing a preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is appropriate? a. after the surgeon removes the lung, you will not need to cough b. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough c. don't worry, you will have a pump that delivers pain medication as you need it, so you will have very little pain d. I will show you how to splint your incision while coughing.

I will show you how to splint your incision while coughing

A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta-blocker. Which of the following client statements indicates an understanding of the teaching? A) "I should eat foods high in saturated fat." B) "Before taking my medication, I will check my blood pressure and radial pulse rate." C) "I will exercise once a week for an hour at the health club." D) "I will stop taking my medication when my blood pressure is within a normal range."

INCORRECT -> A) "I should eat foods high in saturated fat." The client should consume foods low in saturated fat to decrease further atherosclerotic plaque development in the arteries. CORRECT -> B) "Before taking my medication, I will check my blood pressure and radial pulse rate." A beta-blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration. INCORRECT -> C) "I will exercise once a week for an hour at the health club." The client should exercise at least three to five times a week for a minimum of 30 min each. INCORRECT -> D) "I will stop taking my medication when my blood pressure is within a normal range." The client should not discontinue the prescribed medication because adherence to a medical regimen when taking medication will help to prevent complications following myocardial infarction.

A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect? A) Bradycardia B) Relief of chest pain with deep inspiration C) Dyspnea with hiccups D) Chest pain that increases when sitting upright

INCORRECT -> A) Bradycardia The client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. INCORRECT -> B) Relief of chest pain with deep inspiration Chest pain associated with pericarditis will increase with deep inspiration due to increased pressure on the pericardial sac. CORRECT -> C) Dyspnea The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade. INCORRECT -> D) Chest pain that increases when sitting upright Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.

A nurse is checking for cardiac tamponade on a client who has pericarditis. Which of the following actions should the nurse take? A) Check for hypertension B) Auscultate for loud, bounding heart sounds C) Auscultate blood pressure for pulsus paradoxus D) Check for a pulse deficit

INCORRECT -> A) Check for hypertension. The client who has cardiac tamponade will have hypotension because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. INCORRECT -> B) Auscultate for loud, bounding heart sounds. The client who has cardiac tamponade will have muffled heart sounds on auscultation because of the fluid compressing the atria and ventricles. CORRECT -> C) Auscultate blood pressure for pulsus paradoxus. The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. INCORRECT -> D) Check for a pulse deficit. The nurse will not detect cardiac tamponade by checking for a pulse deficit. This is performed by checking the apical and radial pulses simultaneously to determine if the rate is the same. If the rate is different, the findings indicate cardiac dysrhythmia.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A) Decreased capillary refill B) Dyspnea C) Dizziness D) Dependent edema

INCORRECT -> A) Decreased capillary refill Decreased capillary refill occurs in clients who have decreased cardiac output resulting from left-sided heart failure. INCORRECT -> B) Dyspnea When the left side of the heart fails, blood return from the lungs via the pulmonary vein is slowed, causing fluid buildup in the lungs that results in shortness of breath. INCORRECT -> C) Dizziness Dizziness occurs in clients who have decreased cardiac output resulting from left-sided heart failure. CORRECT -> D) Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.

A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24hr? A) Infective endocarditis B) Pericarditis C) Ventricular dysrhythmias D) Pulmonary emboli

INCORRECT -> A) Infective endocarditis Infective endocarditis occurs when bacteria invades the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. INCORRECT -> B) Pericarditis Pericarditis can occur 1 to 12 weeks following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. CORRECT -> C) Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. INCORRECT -> D) Pulmonary emboli Pulmonary emboli occur if the client develops heart failure following myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or deep-vein thrombosis.

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A) Midsternal chest pain B) Thrill C) Pitting edema in lower extremities D) Lower back discomfort

INCORRECT -> A) Midsternal chest pain A client who has an abdominal aortic aneurysm will have back and abdominal pain. Midsternal chest pain is a manifestation of myocardial infarction. INCORRECT -> B) Thrill The nurse should auscultate for a bruit heard over the location of the mass. INCORRECT -> C) Pitting edema in lower extremities Pitting edema is a manifestation of heart failure. This is not a finding with an abdominal aortic aneurysm. CORRECT -> D) Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicates that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.

A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the client's lower extremities should the nurse expect? A) Pitting edema B) Areas of reddish-brown pigmentation C) Cool, pale skin with minimal body hair D) Sunburned appearance with desquamation

INCORRECT -> A) Pitting edema The client who has venous insufficiency can display pitting edema because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. This also can be a manifestation of congestive heart failure due to coronary artery disease. INCORRECT -> B) Areas of reddish-brown pigmentation The client who has venous insufficiency can display areas of reddish-brown pigmentation because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. CORRECT -> C) Cool, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses. INCORRECT -> D) Sunburned appearance with desquamation Desquamation, which is the loss of bits of outer skin by peeling or shedding, is associated with sunburn, Kawasaki's disease, and various other skin lesions.

A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take? A) Place the client in low-Fowler's position B) Assist the client to use the incentive spirometer every 4hr C) Weigh the client every other day D) Enforce fluid restrictions

INCORRECT -> A) Place the client in low-Fowler's position The nurse should place the client in high-Fowler's position to decrease dyspnea and improve impaired oxygenation from fluid retention in the lungs. INCORRECT -> B) Assist the client to use the incentive spirometer every 4hr The nurse should assist the client to use the incentive spirometer every 2hr to promote coughing and improve impaired oxygenation. INCORRECT -> C) Weigh the client every other day The nurse should weigh the client every day to determine the amount of fluid retention and if there is a need for a diuretic to decrease fluid overload in the lungs and lower extremities. CORRECT -> D) Enforce fluid restrictions The nurse should enforce fluid restrictions to help reduce fluid retention in the lungs and lower extremities.

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take? A) Weigh the client weekly B) Monitor the client for ototoxicity C) Place the client on a 24hr urine collection analysis D) Monitor for hypoglycemia

INCORRECT -> A) Weigh the client weekly The nurse should weigh the client daily to determine the amount of fluid excreted after administration of the loop diuretic. CORRECT -> B) Monitor the client for ototoxicity The nurse should monitor the client for ototoxicity and reinforce that the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications, such as aminoglycoside antibiotics. INCORRECT -> C) Place the client on a 24-hr urine collection analysis The nurse should monitor the client's intake and output to determine effectiveness of the loop diuretic. A 24-hr urine collection is completed for a study of kidney function. INCORRECT -> D) Monitor for hypoglycemia The nurse should monitor the client for hyperglycemia because a loop diuretic can inhibit insulin release.

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy pink sputum. The nurse auscultates loud, bubbly sounds of inspiration. Which of the following adventitious breath sounds should the nurse document? A) Wheezes B) Coarse crackles C) Rhonchi D) Friction rub

INCORRECT -> A) Wheezes The client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway. CORRECT -> B) Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing. INCORRECT -> C) Rhonchi The client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound. INCORRECT -> D) Friction rub The client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.

A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply) Jugular vein distension Moist crackles Postural hypotension Increased heart rate Fever

Jugular vein distension is CORRECT. The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles is CORRECT. This is an indicator of pulmonary edema that can quickly lead to death. Postural hypotension is INCORRECT. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia. Increased heart rate is CORRECT. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses. Fever is INCORRECT. Fever is common in clients who are experiencing dehydration, not fluid volume excess.

A nurse in the emergency room is caring for a client who is experiencing acute respiratory failure which of the following laboratory findings should the nurse expect Arterial pH 7.50 PaCo2 25 mmHg SaO2. 92% Paco2 58mmhg

Paco2 58mmhg The nurse should expect the client to have lower partial pressures of oxygen.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? a. Dyspnea on exertion b. Tracheal deviation c. Pericardial rub d. Weight loss

a

A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? a. Absence of adventitious breath sounds b. Presence of a nonproductive cough c. Decrease in the respiratory rate at rest d. SaO2 86% on room air

a

A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a. Weight gain of 0.9 kg (2 lb) in 24 hours b. Increase of 10 mmHg in systolic blood pressure c. Dyspnea with exertion d. Dizziness when rising quickly

a

A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? a. "You might no longer be able to feel chest pain" b. "Your level of activity intolerance will not change" c. "After 6 months, you will no longer need to restrict your sodium intake" d. You will be able to stop talking immunosuppressants after 12 months

a

A nurse in an emergency department is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse monitor for? a. Confusion b. Friction rub c. Hypertension d. Dry skin

a Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

A nurse is caring for a client following the insertion of a permanent pacemaker. Which of the following client statement indicates a potential complication of the insertion procedure? a. "I can't get rid of these hiccups" b. "I feel dizzy when I stand" c. "My incision site stings" d. "I have a headache"

a Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately? a. Slurred speech b. Irregular pulse c. Dependent edema d. Persistent fatigue

a The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A nurse is planning a presentation for a group of clients who have HTN. Which of the following lifestyle modification should the nurse include? (select all that apply) a. Limited alcohol intake b. Regular exercise program c. Decreased magnesium intake d. Reduced potassium intake e. Tobacco cessation

a, b, e

Which statements indicate to the nurse the client diagnosed with asthma understands the teachingregarding inhaled corticosteroid medications? Select all that apply. a. "I should call my doctor if I have a sore throat or mouth." b. "I must taper off the medications and not stop taking them abruptly." c. "These drugs will be most effective if taken at bedtime." d. "These drugs are not good at the time of an attack." e. "If I need both inhalers, I should take my bronchodilator first.

a. "I should call my doctor if I have a sore throat or mouth." d. "These drugs are not good at the time of an attack." e. "If I need both inhalers, I should take my bronchodilator first.

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonaryembolism? Select all that apply. a. A client who has a BMI of 30 b. A client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation

a. A client who has a BMI of 30 c. A client who has a fractured femur e. A client who has chronic atrial fibrillation

patient is admitted to the emergency department with a severe exacerbation of asthma. Whichfinding is of most concern to the nurse? a. Unable to speak and sweating profusely b. PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg c. Presence of inspiratory and expiratory wheezing d. Peak expiratory flow rate at 60% of personal best

a. Unable to speak and sweating profusely

A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for Which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

a. absence of breath sounds

A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of anthrax? a. dry cough b. rhinitis c. sore throat d. swollen lymph nodes

a. dry cough

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. eat high-calorie foods first b. increase intake of water at meals c. perform active rang-of-motion exercises before meals d. keep saltine crackers nearby for snacking

a. eat high-calorie foods first

The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has laterstage COPD? a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3− 30 mEq/L b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3− 18 mEq/L c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3− 25 mEq/L d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3− 35 mEq/L

a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3− 30 mEq/L

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism a. sudden onset of dyspnea b. tracheal deviation c. bradycardia d. difficulty swallowing

a. sudden onset of dyspnea

A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. total lung capacity b. vital lung capacity c. functional residual capacity d. residual volume

a. total lung capacity

a nurse is assisting a provider who's performing a thoracentesis at the beside of a client. which of the following actions should the nurse take? a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. c.) Instruct the client to take deep breaths during the procedure. d.) Position the client laterally on the affected side before the procedure. e.) Apply pressure to the site after the procedure.

a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. e.) Apply pressure to the site after the procedure.

A nurse is assessing a client who has L-sided HF. Which of the following manifestations should the nurse expect to find? a. Increased abdominal girth b. Weak peripheral pulses c. Jugular venous neck distention d. Dependent edema

b

A nurse is caring for a client who is being treated for HF and has a prescription for Furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication? a. SOB b. Lightheadedness c. Dry cough d. Metallic taste

b

A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? a. a client who has hypothyroidism b. a client who has DM c. a client whose daily calorie intake consists of 25% fat d. a client who consumes two 12 oz bottles of beer a day

b

A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat HTN. The nurse should instruct the client to notify their provider if they experience which of the following adverse effect of this medication? a. Tendon pain b. Persistent cough c. Frequent urination d. Constipation

b

A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to SVT. The nurse should prepare to assist with which of the following interventions? a. Initiate chest compression b. Vagal stimulation c. Administration of atropine IV d. Defibrillation

b The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.

A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching? a. Apply the new patch to the same site as the previous patch b. Place the patch on an area of skin away from skin folds and joints c. Keep the patch on 24 hours per day d. Replace the patch at the onset of angina

b The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

A nurse is caring for a client who is 8 hour postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report? a. Mediastinal drainage 100 mL/hr b. Blood pressure 160/80 mmHg c. Temperature 37.1C (98.8F) d. Potassium 4.0 mEq/L

b The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who is admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? a. Obtain the client's current weight b. Review serum electrolyte values c. Determine the time of the last digoxin dose d. Check the clients urine output

b Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome? a. tympanic temp 38 C (100.4 F) b. PaO2 50 mmHg c. rhonchi d. hypopnea

b. PaO2 50 mmHg

a nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. which of the following actions should the nurse take? a. Obtain blood samples to test platelet function. b. Prepare for replacement of the missing clotting factor. c. Administer aspirin for the client's pain. d. Place the bleeding joint in the dependent position.

b. Prepare for replacement of the missing clotting factor.

A nurse is tranfusing a unit of B-positive FFP to a client whose blood type is O-neg. Which of the following actions should the nurse take? a. Continue to monitor for manifestations of a transfusion reaction. b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. c. Continue the transfusion and repeat the type and crossmatch. d. Prepare to administer a dose of diphenhydramine IV.

b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

The client is admitted to the emergency department with chest trauma. Which clinical manifestationsindicate to the nurse the diagnosis of a pneumothorax? a. Bronchovesicular breath sounds and bradypnea b. Unequal lung expansion and dyspnea c. Frothy, bloody sputum and consolidation d. Barrel chest and polycythemia

b. Unequal lung expansion and dyspnea

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing techniques accomplishes Which of the following? a. increases O2 intake b. promotes carbon dioxide elimination c. uses the intercostal muscles d. strengthens the diaphragm

b. promotes carbon dioxide elimination

A nurse is caring for an older client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for Which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis d. metabolic acidosis

b. respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. how to eliminate environmental triggers that precipitate attacks b. the client's perception of the disease process and what might have triggered past attacks c. the client's med regimen d. manifestations of respiratory infections

b. the client's perception of the disease process and what might have triggered past attacks

A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that Which of the following is the purpose of the treatments? a. to encourage deep breaths b. to mobilize secretions in the airways c. to dilate the bronchioles d. to stimulate the cough reflex

b. to mobilize secretions in the airways

a nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? A.) Blood-tinged sputum B.) Decreased tactile fremitus C.) Resonance with percussion D.) Peripheral edema

blood-tinged sputum rationale:The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? a. "my arthritis is really bothering me bc I haven't taken my aspirin in a week" b. "my BP shouldn't be high bc I took my BP medication this morning" c. "I took my warfarin last night according to my usual schedule" d. "I will check my blood sugar because I took a reduced dose of insulin this morning"

c Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

A nurse is caring for a client who had an onset of chest pain 24 hours ago. The nurse should identify that an increase in which of the following values is diagnosis of myocardial infarction (MI)? a. Myoglobin b. C-reactive protein c. Creatine kinase-MB d. Homocysteine

c Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.

A nurse in an emergency department is caring for a client who has a bp of 254/139 mmHg. The nurse recognize that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? a. Initiate seizure precautions b. Tell the client to report vision changes c. Elevate the head of the client bed d. Start a peripheral IV

c The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

A nurse is reviewing the lab results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following lab values? a. cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL b. cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL c. cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL d. cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL

c These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.

A nurse is caring for a client who is 1 hour postoperative following an aortic aneursym repair. Which of the following findings can indicate shock and should be reported to the provider? a. Serosanguinous drainage on dressing b. Severe pain with coughing c. Urine output of 20 mL/hr d. Increase in temperature from 36.8C (98.2F) to 37.5 (99.5F)

c Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

A nurse is reviewing orders for a client who has acute dyspnea and diaphoresis. The client states, "I amanxious and unable to get enough air." Vital signs are HR 117/min, respirations 38/min, temperature101.2°F and blood pressure 100/54 mm Hg. Which of the following actions is the priority? a. Notify the provider. b. Administer heparin via IV infusion. c. Administer oxygen therapy. d. Obtain chest x-ray

c. Administer oxygen therapy. ABC question

The client had a right-sided chest tube inserted 2 hours ago for a pneumothorax. Which action shouldthe nurse implement if there is no fluctuation (tidaling) in the water seal compartment? a. Obtain an order for a STAT chest x-ray. b. Increase the amount of wall suction. c. Check the tubing for kinks or clots. d. Monitor the client's pulse oximeter reading

c. Check the tubing for kinks or clots.

A patient is admitted to the coronary care unit following a cardiac arrest and successfulcardiopulmonary resuscitation. When reviewing the health care provider's admission orders, whichorder should the nurse question? a. Oxygen at 4 L/min per nasal cannula b. Morphine sulfate 2 mg IV every 10 minutes until the pain is relieved c. Tissue plasminogen activator (tPA) 100 mg IV infused over 3 hours d. IV nitroglycerin at 5 mcg/minute and increase 5 mcg/minute every 3 to 5 minutes

c. Tissue plasminogen activator (tPA) 100 mg IV infused over 3 hours

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider the nurse should document this finding as which of the following? a. friction rub b. crackles c. crepitus d. tactile fremitus

c. crepitus

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. pericardial friction rub b. weight gain c. night sweats d. cyanosis of the fingertips

c. night sweats Night sweats and fevers are clinical manifestations of tuberculosis.

A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? a. hyperventilate the client to 100% O2 prior to obtaining the specimen b. apply ice to the site after obtaining the specimen c. perform an Allen's test prior to obtaining the specimen d. Release pressure applied to the puncture site 1 min after the needle is withdrawn.

c. perform an Allen's test prior to obtaining the specimen The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. The Allen test, also known as the modified Allen test, is a medical procedure that evaluates blood flow to the hand through the radial and ulnar arteries in the wrist. I

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? a. clamp the chest tube if there is continuous bubbling in the water seal chamber b. keep the chest tube drainage system at the level of the right atrium c. tape all connections between the chest tube and drainage system d. empty the collection chamber and record the amount of drainage every 8 hrs.

c. tape all connections between the chest tube and drainage system. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.

A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? a. if the test is positive, it means you have an active case of TB b. if the test is positive, you should have another TB skin test in 3 weeks c. you must return to the clinic to have the test read in 2 or 3 days d. a nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance.

c. you must return to the clinic to have the test read in 2-3 days The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.

A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior to the procedure? a. Hemoglobin 14.4 g/dL b. History of peripheral arterial disease c. Urine output 200 mL/4 hour d. Previous allergic reaction to shell fish

d

A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? a. "I'm still hungry after the bowl of cereal I ate at 0700" b. "I didn't tale my heart pills this morning because the doctor told me not to" c. "I have had chest pain a couple of time since I saw my doctor in the office last week" d. "I smoked a cigarette this morning to calm my nerves about having this procedure"

d Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

A nurse is assessing a client who has history a deep-vein thrombosis and is receiving Warfarin. Which of the following findings should indicate to the nurse that the medication is effective? a. Hemoglobin 14 g/dL b. Minimal bruising of extremities c. Decreased bp d. INR 2

d The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds. a. increase the heparin infusion flow rate by 2 mL/hr b. Continue to monitor the heparin infusion as prescribed c. Request a prothrombin time (PT) d. Stop the heparin infusion

d The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse in an ED is caring for a client who had an anterior MI. The client's history reveals they are 1 week postop following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated? a. administering IV morphine sulfate b. administering O2 at 2 L/min via nasal cannula c. helping the client to the bedside commode d. assisting with thrombolytic therapy

d The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? a. Ventricular depolarization b. Guillian-Barre syndrome c. Myelodysplastic syndrome d. Valvular disease

d Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care? a. Instruct the client on a long-term cardiac conditioning program. b. Administer scheduled doses of acetaminophen. c. Check for peak laboratory markers of myocardial damage. d. Monitor for bleeding.

d. Monitor for bleeding.

A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client? a. lying flat on the affected side b. prone with the arms raised over the head c. supine with the head of the bed elevated d. sitting while leaning forward over the bedside table

d. sitting while leaning forward over the bedside table

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? a. the client is unable to speak b. the client's airway secretions were last suctioned 2 hrs ago c. the client coughs and expectorates a large mucous plug d. the nurse auscultates coarse crackles in the lung fields

d. the nurse auscultates coarse crackles in the lung fields

A nurse is providing discharge teaching to a client who is postoperative following a rhinopasty. Which of the following instructions should the nurse include? a. apply warm compresses to the face b. take aspirin 650 mg by mouth for mild pain c. close your mouth when sneezing d. lie on your back with your head elevated 30 degrees when resting

lie on your back with your head elevated 30 degrees when resting The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.