Combo with Respiratory System NCLEX ?s and 1 other
What does central cyanosis indicate?
Hypoexmia
brown green or yellow
Purulent
blood+water
Serosanguinous
Identify initial assessment findings for a patient with EARLY STAGE LEFT sided heart failure
- fatigue - breathlessness - dizziness - confusion as a result of tissue hypoxia from the diminished CO
THE NURSE IS PREPARING TO ADMINISTER A MEDICATION VIA NG TUBE. WHAT GUIDELINE IS APPROPRIATE FOR THE NURSE TO FOLLOW WHEN ADMINISTERING A DRUG VIA THIS ROUTE? FLUSH THE TUBE WITH WATER BETWEEN EACH MED
...
Which of the following laboratory values would you expect in a client experiencing prolonged immobility? 1. Elevated calcium 2. Decreased sodium 3. Elevated hemoglobin 4. Elevated potassium
1. Elevated calcium
A client had a left- sided cerebral vascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enternal feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? 1. Hematuria 2. Unilateral neglect 3. Limited ROM in the right hip 4. Coughing up moderate amount clear, thin sputum
1. Hematuria
Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? (choose all that apply) 1. The client's weight 2. How cooperative the client is 3. The client's nutritional status 4. The presence of intravenous (IV) tubes
1. The client's weight 2. How cooperative the client is 4. The presence of intravenous (IV) tubes
The client at greatest risk for developing adverse effects of immobility is a: 1. 3-year-old child with a fractured femur 2. 78-year-old man in traction for a broken hip 3. 48-year-old woman following a thyroidectomy 4. 38-year-old woman undergoing a hysterectomy
2. 78-year-old man in traction for a broken hip
A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. A trapeze bar 2. A small transfer board 3. A powered standing-assist device 4. An ankle foot orthotic (AFO) for the affected foot
2. A small transfer board
A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record? 1. Rebound hypotension 2. Positional hypotension 3. Orthostatic hypotension 4. Central venous hypotension
3. Orthostatic hypotension
You are caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following client statements reflects a need for further education? 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if i need to have a bone mineral density check this year." 3. "If i don't drink milk at dinner, i will eat broccoli or cabbage to get the calcium that i need in my diet." 4. "The more frequently i walk the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."
4. "The more frequently i walk, the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."
The nurse is caring for a client who has right-sided weak-ness. The nurse needs to help the client walk. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. Hold the client's left hand while walking 2. Hold the client's right hand while walking 3. Put a gait belt on the client and provide support on the left side 4. Put a gait belt on the client and provide support on the right side
4. Put a gait belt on the client and provide support on the right side
A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be: 1. Pain 2. Impaired skin integrity 3. Altered tissue perfusion 4. Risk for activity intolerance
4. Risk for activity intolerance
The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: 1. prevent varicose veins 2. prevent muscular atrophy 3. ensure joint mobility and prevent contractures 4. facilitate the return of venous blood to the heart
4. facilitate the return of venous blood to the heart
C
52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant: a) temperature b) radial pulse c) respiratory rate d) oxygen saturation
1, 2, 4, 7
82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. HR 2. Skin turgor 3. Smoking history 4. Allergies to antibiotics 5. Recent BM's 6. BP in right arm 7. Client's normal temperature 8. BP in distal extremity
A GRADUATE NURSE IS ADMINISTERING SEVERAL MEDICATIONS TO A NEWLY ADMITTED PATIENT. WHO IS LEGALLY RESPONSIBLE FOR THE DRUGS ADMINISTERED BY THIS NURSE? A THE NURSE ADMINISTERING THE DRUG B PHARMACIST WHO DISPENSED C NURSE MANAGER D PHYSICIAN WHO WROTE THE ORDER
A
AT WHAT POINT SHOULD THE NURSE DO THE 3 CHECKS OF MEDICATION ADMINISTRATION? A AS THE NURSE REACHES FOR THE DRUG PACKAGE B WHEN REVIEWING THE PATIENT;S MAR C AT THE BEGINNING OF SHIFT D AFTER RETRIEVING THE DRUG
A
THE NURSE SHOULD USE EXTREME CAUTION WHEN APPLYING HEAT THERAPY TO WHICH OF THE FOLLOWING PATIENTS: A UNCONSCIOUS B HIGH PAIN SENSITIVITY C VENOUS ULCER D RECEIVING STEROIDS
A
UPON RESPONDING TO A PATIENTS CALL BELL, THE NURSE DISCOVERS THAT THE PATIENT'S WOUND HAS DEHISCED. INITIAL NURSING MANAGEMENT INCLUDES WHICH OF THE FOLLOWING A COVERING THE WOUND AREA WITH STERILE TOWELS MOISTENED WITH STERILE 0.9% SALINE B CLOSING WOUND WITH STERI STRIPS C HOLDING WOULD TOGETHER AND COVER WITH BLANKET D POURING H202 INTO ABDOMINAL CAVITY AND PACKING WITH GAUZE
A
D
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic
A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory
Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain
2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.
Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis
Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect.
A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome
Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
Answer A. The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler.
A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis
Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min
Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction
4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site.
Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increase oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray
Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, - hypercapnia, - dyspnea on exertion and at rest - oxygen desaturation with exercise - and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min
Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.
A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss
Answer B. The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the clients take three deep breaths c. Asking the client to split into the collection container d. Asking the client to obtain the specimen after eating
Answer B. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning
A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum
Answer C. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds.
Answer C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly b. Inhale through the nose c. Hold the breath after inhalation d. Take two inhalations during one breath
Answer C. Instructions for using a metered-dose inhaler include - shaking the canister, - holding it right side up, - inhaling slowly and evenly through the mouth, - delivering one spray per breath, - and holding the breath after inhalation.
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds
Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids
Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after.
A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum
Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination.
Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration
Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and Sx include - pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation - shallow respirations - splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate
Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. T his is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
Presence of overdistended and non-functional alveoli is a condition called: a. Bronchitis b. Emphysema c. Empyema d. Atelectasis
Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.
Identify what is included during the assessment phase of the nursing process for a cardiopulmonary focus.
Assessment • In-depth history of the client's normal and present cardiopulmonary function • Past impairments in circulatory or respiratory functioning • Patient history including a review of drug, food, and other allergies • Physical examination of the client's cardiopulmonary status reveals the extent of existing signs and symptoms. • Use PQRST for pain / HPI for other symptoms • Review of laboratory and diagnostic test results
DURING A SKIN ASSESSMENT, THE NURSE RECOGNIZES THE 1ST INDICATION THAT A PRESSURE ULCER MAY BE DEVELOPING WHEN SHE NOTICES THE SKIN IS WHICH COLOR? A BLUE B WHITE C YELLOW D RED
B
PATIENT TELLS NURSE "I CANT GET ANY SLEEP AROUND HERE" NURSES FIRST RESPONSE: A ADD MORE CARBS TO DINNER B ASSESS FACTORS THAT PATIENT BELIEVES TO BE PROBLEM C TEACH PATIENT RELAXATION TECHNIQUES AND REDUCE NOISE ON THE UNIT D OBTAIN PRN ODER FOR SEDATIVE
B
THE NURSE WOULD RECOGNIZE WHICH OF THE FOLLOWING PATIENTS TO HAVE IMPAIRED WOUND HEALING A NPO FOLLOWING SURGERY B OBESE WOMAN WITH TYPE 1 DIABETES C MAN WITH SEDENTARY LIFESTYLE AND LIFELONG SMOKER D A WOMAN WHO'S BREAST RECONSTRUCTION SURGERY REQUIRED NUMEROUS INCISION
B
WHEN ADMINISTERING ORAL MEDICATIONS, WHICH OF THE FOLLOWING PRACTICES SHOULD THE NURSE FOLLOW(SELECT ALL THAT APPLYS) A DISPENSE MULTIPLE LIQUID MEDICATIONS INTO A SINGLE CUP TO REDUCE THE NUMBER OF CONTAINERS THE PATIENT MUST HANDLE B PERFORM HAND HYGIENE BEFORE AND AFTER MEDICATION ADMINISTRATION C STAY AT THE BEDSIDE UNTIL THE PATIENT HAS FINISHED ALL MEDICATIONS D KEEP THE PATIENTS MAR AT THE BEDSTIME AT ALL TIMES E VERIFY THE PATIENTS RESPONSE TO THE MEDICATION 30 MINUTES AFTER ADMINISTRATION, OR AS APPROPRIATE FOR THE DRUG
B C E
THE NURSE WOULD RECOGNIZE THAT AN OBESE MALE PATIENT WHO HAS BEEN DIAGNOSED WITH OBSTRUCTIVE SLEEP APNEA FACES AN INCREASED RISK OF WHICH OF THE FOLLOWING? A DEPRESSION B RESPIRATORY ACIDOSIS C HEART DISEASE D SEIZURES
C
THE PHYSICIANS ADMITTING ORDERS INDICATE THAT THE PATIENT IS TO BE PLACED IN A FOWLERS POSITION, UPON POSITIONING THIS PATIENT, HOW MUCH WILL THE NURSE ELEVATE THE HEAD? A 15 B 90 C 45-60 D 30
C
WHICH MEDICATION WILL DELAY HEALING OF A POST-OP WOUND A LAXATIVE B ANTIHYPERTENSIVE C CORTICOSTEROID D K+ SUPPLEMENT
C
PRIOR TO STARTING A TUBE FEEDING, THE NURSE ASSESSES THE PH AND COLOR OF THE PATIENT'S GASTRIC CONTENTS AND RECEIVES A PH READING OF 6.2 AND THE ASPIRATE IS OFF-WHITE COLOR. A STOMACH B SMALL INTESTINE C COLON D RESPIRATORY TRACT
D
THE DRESSING CHANGE ON A DEEP UPPER-ARM WOUND IS PAINFUL FOR THE PATIENT. WHEN PREPARING A CARE PLAN FOR THE PATIENT, THE NURSE WILL INCORPORATE WHICH OF THE FOLLOWING MEASURES: A ADMINISTER ANALGESIC IMMEDIATELY BEFORE DRESSING CHANGE B PERFORM DRESSING CHANGE WHEN PATIENT IS FATIGUED FROM PT C PERFORM DRESSING CHANGE DURING MEALTIME SO PATIENT IS DISTRACTED D ADMINISTER ANALGESIC 30-45 MIN BEFORE DRESSING CHANGE
D
WHICH ONE OF THE NUTRITIONAL GUIDELINES SHOULD THE NURSE GIVE A WOMAN IN HER 2ND TRIMESTER OF PREGNANCY A EAT NORMAL NUMBER OF CALORIES BUT INCREASE FRUITS AND VEGETABLES B MAINTAIN REG CALORIE INTAKE, BUT TAKE SUPPLEMENTS C EAT AS MUCH AS YOU CAN D MORE CALORIES AND HIGH IN NUTRIENTS
D
D
Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension
What does FIO2 stand for?
Fraction of Inspired oxygen concentration
Stage III pressure Ulcer
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV pressure Ulcer
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with this type of pressure ulcer.
What are the 10 Rights of Medication Administration
Medication Assessment Dose Documentation Route Patient Education Timing Evaluation Refusal (MADDRPETER)
Stage I pressure Ulcer
Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators
Stage II pressure Ulcer
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
1, 5, 2, 4, 3
Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37.3 (99.4) 4) HR= 72 BPM 5) RR= 28 BrPM
blood
Sanguinous
D
The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.
A
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.
C
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.
D
The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering
B
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.
D
The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.
D
The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respirations. C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
D
The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
How often should a nurse assess the skin and nares of the patient with a nasal cannula?
The nurse should assess the client's nares and ears for skin breakdown every 6 hours.
C
The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference
True or False The character of the exudate, in amount, color and odor, can help to identify the exact nature of the infection
True
D
Which of the following vlues for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic
a 48-year-old client doesn't smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client? a. Do you smoke or inhale marijuana or other herbal products? b. Have you had allergy testing? c. Have you received a flu or pneumonia vaccination? d. Have you tried to stop smoking?
a. Do you smoke or inhale marijuana or other herbal products?
The position of a conscious client during suctioning is: a. Fowler's b. Supine position c. Side-lying d. Prone
a. Fowler's Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.
During a physical assessment, the nurse documents eupnea on the client's medical record. What does this finding suggest? a. Normal respirations b. Slow respirations c. Irregular respirations d. Rapid respirations
a. Normal respirations
After inspecting a client's thorax, the nurse writes "AP:T 1:2, bilateral symmetrical movements, sternum midline, respiratory rate 16 and regular." What do these findings suggest? a. Nothing. These findings are normal. b. The client has pneumonia. c. The client has a respiratory illness. d. The client has allergies.
a. Nothing. These findings are normal.
23. The accumulation of fluids in the pleural space is called: a. Pleural effusion b. Hemothorax c. Hydrothorax d. Pyothorax
a. Pleural effusion
A client with a strained trapezius muscle complains of having occasional shortness of breath. What might be the reason for this symptom? a. The strained muscle is an accessory muscle of respiration. b. The diaphragm muscle is also injured. c. There is an undiagnosed heart problem. d. There is a blood clot in his lung.
a. The strained muscle is an accessory muscle of respiration.
Prior to listening to a client's lung sounds, the nurse palpates the sternum and feels a horizontal bump on the bone. What does this finding suggest to the nurse? a. This is the angle of Louis. b. The manubrium is damaged. c. The costal angle is greater than normal. d. The xiphoid process is misshaped.
a. This is the angle of Louis.
A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? a. Two to three pillow orthopnea b. Dyspnea on excursion c. Resting apnea d. Dyspnea at rest
a. Two to three pillow orthopnea
The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Left of the sternum, third intercostal space b. Above the clavicles c. Below the scapula d. Right of the sternum, sixth intercostal space
b. Above the clavicles The apex of each lung is slightly superior to the inner third of the clavicle.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.
b. Grasp the retention sutures to spread the opening.
The nurse is assessing the client's lung bases posteriorly. At which area can the nurse assess this portion of the lung? a. Right anterior axillary line b. Scapular line c. Midsternal line d. Left midclavicular line
b. Scapular line
In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area? a. Screening for environmental triggers b. Smoking cessation c. Develop action plans d. Identify those at risk
b. Smoking cessation
The mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? a. I see what you mean. That seems odd. b. The chest of a child appears round and is normal. c. I wouldn't worry about that. d. Did you tell the doctor about this?
b. The chest of a child appears round and is normal.
While palpating the posterior thorax of a client, the nurse notes increased fremitus. What does this finding suggest to the nurse? a. The client needs to speak up. b. The client has a thick chest wall. c. The client could either have fluid in the lungs or have an infection. d. Nothing. This is a normal finding.
c. The client could either have fluid in the lungs or have an infection.
B
besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch
The client tells the nurse he sometimes coughs up "thick yellow mucous." What does this information suggest to the nurse? a. He might have an allergy. b. He might have a fungal infection. c. He might have episodic lung infections. d. He might have tuberculosis.
c. He might have episodic lung infections Rationale: The color and odor of any mucus is associated with specific diseases or problems. Green or yellow mucus often signals a lung infection.
A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? a. She has a history of smoking. b. She is using accessory muscles to breathe. b. She is in pending respiratory failure. c. Nothing. This is normal.
c. Nothing. This is normal.
What is atelectasis?
collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs
The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine position b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen
d. Hyperventilating the client with 100% oxygen
After examining a 75-year-old male client, the nurse writes down "barrel chest." What does this finding suggest? a. The client has a history of smoking. b. The client has osteoporosis. c. The client has long-standing respiratory disease. d. This is a change associated with aging.
d. This is a change associated with aging.
The nurse sees that the client will breathe deeply and then stop breathing for a short while. Which of the following does this observation suggest? a. This client is hyperventilating. b. This client is in a diabetic coma. c. This client has pneumonia. d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.
d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.
Describe Tachypnea
respirations > 35 clinical significance/contributing factors: - respiratory failure - response to fever - anemia - pain - respiratory infection - anxiety (emergencies SNS system kicks in)
Describe the clinical signs of RIGHT sided heart failure.
weight gain distended neck veins hepatomegaly and splenomegaly dependent peripheral edema
