Exam 1

The nurse monitors a client in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. Subcutaneous emphysema at the insertion site b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. A large air leak in the water-seal chamber

400 mL of blood in the collection chamber

The emergency room nurse is caring for a client who has a sucking chest wound resulting from a gunshot wound. The client has a blood pressure of 100/60 mm/Hg, a weak pulse, and a respiratory rate of 40 breaths/min. Which of the following actions should be the priority for the nurse to take? a. Apply a three-sided, occlusive dressing over the wound b. Prepare the client for chest tube insertion c. Administer prescribed analgesic d. Position the client in semi-Fowler's position

Administer prescribed analgesic

An hour after a thoracotomy, a client complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Assist the client with incentive spirometry. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Clamp the chest tube in two places.

Administer the prescribed morphine.

A client is thrombocytopenic, their complete blood count (CBC) indicates this. Which action should the nurse include in the plan of care? Select all that apply a. Use electric razors. b. Encourage increased oral fluids. c. Check temperature orally. d. Avoid intramuscular injections. e. Increase intake of iron-rich foods.

Avoid intramuscular injections.

A client received nifedipine (Procardia) for his idiopathic pulmonary arterial hypertension (IPAH). Which assessment would best indicate to the nurse that the client's condition is improving? a. Client reports a decrease in exertional dyspnea. b. Blood pressure (BP) is less than 140/90 mm Hg. c. Client's chest x-ray indicates clear lung fields. d. Heart rate is between 60 and 100 beats/minute.

Client reports a decrease in exertional dyspnea

A client who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Adjust the dial on the wall regulator. d. Continue to monitor the collection device.

Continue to monitor the collection device.

The nurse is assessing a client who has a magnesium level of 3.0 mEq/L. Which of the following findings should the nurse expect to observe? a. tachycardia b. increased urine output c. hypertension d. diminished deep tendon reflexes

Diminished deep tendon reflexes

A client who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH). b. Prepare for platelet transfusion. c. Discontinue the heparin infusion. d. Administer prescribed warfarin (Coumadin).

Discontinue the heparin infusion.

The nurse is caring for a client who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Monitor for Trousseau's and Chvostek's signs. b. Maintain the client on bed rest. c. Auscultate lung sounds every 4 hours. d. Encourage fluid intake up to 4000 mL every day.

Encourage fluid intake up to 4000 mL every day.

The nurse is caring for a newly admitted 25-year-old male who is in sickle cell crisis. Which of the following interventions should be of highest priority for this client? a. Administering pain medication prn b. Encouraging fluid intake of at least 200 mL/hour c. Placing the client in high Fowler's position d. Obtaining hourly blood pressure readings

Encouraging fluid intake of at least 200 mL/hour

The nurse assesses a client who has been hospitalized for 2 days. The client has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1°F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Weight gain of 2 pounds (1 kg) over the admission weight d. Gradually decreasing level of consciousness (LOC)

Gradually decreasing level of consciousness (LOC)

The nurse is reviewing the biopsy results for a client admitted with unexplained weight loss. The nurse notes the pathology shows the presence of Reed-Sternberg cells. The nurse should understand the client is experiencing which of the following? a. Hodgkin's lymphoma b. Chronic myeloid leukemia c. Non-hodgkin's lymphoma d. Acute lymphocytic leukemia

Hodgkin's lymphoma

The nurse is reviewing the laboratory data for a client with renal failure and notes that the client is experiencing hyperphosphatemia. The nurse should assess the client for which of the following additional electrolyte imbalances? a. Hypokalemia b. Hypocalcemia c. Hypomagnesium d. Hyponatremia

Hypocalcemia

The nurse is caring for a client with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should: a. assist the client with light weight bearing. b. apply heat to the knee. c. perform passive range of motion to the knee. d. immobilize the knee joint.

Immobolize the knee joint.

The nurse is caring for a client who reports sudden onset of dyspnea and "feeling of doom." The nurse suspects the client is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? a. Initiate high-flow oxygen b. Initiate strict bedrest c. Administer prescribed morphine IV d. Administer prescribed heparin IV

Initiate high-flow oxygen

The nurse is transferring a client up to the chair, who has a pneumothorax and has a left pleural chest tube connected to dry suction drainage system. The nurse notes that during transfer, the chest tube disconnected from the drainage system. Which of the following actions should the nurse take? a. Insert the chest tube into bottle of sterile water b. Apply occlusive dressing to the end of the chest tube c. Connect chest tube to wall suction d. Clamp the chest tube

Insert the chest tube into bottle of sterile water

The nurse is providing care for a client with disseminated intravascular coagulation (DIC) who develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for which of the following? a. ischemia b. hematuria c. petechiae d. hemoptysis

Ischemia.

The nurse is monitoring a client who is receiving a prescribed intravenous transfusion of packed red blood cells. Which of the following findings should indicate to the nurse the client is experiencing fluid volume overload? Select all that apply a. hypotension b. Jugular vein distention c. cold clammy skin d. Confusion e. Dyspnea

Jugular vein distention Confusion Dyspnea

A client who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic alkalosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic acidosis

Metabolic acidosis

The nurse is educating about which foods to avoid that are high in potassium to a client with renal failure who is receiving dialysis. Which of the following foods that are high in potassium chosen by the client would indicate to the nurse that teaching was effective? Select all that apply. a. White pasta b. Milk c. Cantaloupe d. Apple e. Mashed potatoes

Milk, potatoes, and cantaloupe

A client admitted with multiple myeloma, which action will the nurse include in the plan of care? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Limit weight bearing and ambulation. d. Assess lymph nodes for enlargement.

Monitor fluid intake and output

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in client teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

Need for follow-up appointments to screen for malignancy

A client with cor pulmonale and right-sided heart failure, receives prescribed therapies from the nurse. Which assessment could be used to evaluate the effectiveness of the therapies? a. Palpate for heaves or thrills over the heart. b. Auscultate for crackles in the lungs. c. Observe for distended neck veins. d. Monitor for elevated white blood cell count.

Observe for distended neck veins

The emergency room nurse is assessing a client who sustained a blunt chest trauma in a motor vehicle accident and notes bruising over the chest and right flank. Which of the following findings observed by the nurse would best indicate the client is experiencing a flail chest? a. Subcutaneous emphysema b. Diminished breath sounds c. Paradoxical chest movement d. Tracheal shift towards the left

Paradoxical chest movement

The nurse is caring for a client being treated for autoimmune thrombocytopenic purpura. Which of the following findings should the nurse assess to determine efficacy of the treatment? a. Potassium levels b. Platelet count c. Partial prothrombin time (PTT) d. White blood cell count

Platelet count

The nurse is assessing a client who is post-operative 8 hours from a left pneumonectomy for lung cancer. Which of the following should the nurse expect to find? a. Pleural chest tubes attached to wall suction b. Sternal incision with dressing c. Diminished breath sounds bilaterally with auscultation d. Positioned on the unaffected side

Pleural chest tubes attached to wall suction

A client with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the client for the procedure? a. Start a peripheral IV line to administer sedatives. b. Remind the client not to eat or drink anything for 6 hours. c. Position the client sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.

Position the client sitting up on the side of the bed.

The nurse is assessing a client in sickle cell crisis who reports pain in the hands and feet. The nurse notes a pulse oximetry reading of 91%. Which of the following prescribed interventions should the nurse implement first? a. Administer morphine 4 mg IV push b. Administer an intravenous fluid bolus c. Provide 2L of oxygen by nasal cannula d. Cover the client with warm blankets

Provide 2L of oxygen by nasal cannula

A client with a 42 pack-year history of cigarette smoking, which information about prevention of lung disease should the nurse include? a. Resources for support in smoking cessation b. Erlotinib (Tarceva) therapy to prevent tumor risk c. Computed tomography (CT) screening for cancer d. Reasons for annual sputum cytology testing

Resources for support in smoking cessation

The nurse is caring for a client who is experiencing a panic attack and notes the client's arterial blood gas (ABG) results are pH 7.50, CO2 27, HCO3 24. The nurse should interpret the results as which of the following? a. Metabolic acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic alkalosis

Respiratory alkalosis

Which information obtained by the nurse assessing a client admitted with multiple myeloma is most important to report to the health care provider? a. Urine sample has Bence-Jones protein. b. Serum calcium level is 15 mg/dL. c. Client is complaining of severe back pain. d. Client reports no stool for 5 days.

Serum calcium level is 15 mg/dL.

When caring for a client with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the client's food tray? a. Grape juice b. Mixed green salad c. Skim milk d. Fried chicken breast

Skim milk

A client who is diagnosed with a lung abscess, which intervention will the nurse include in the plan of care? a. Teach the client to avoid the use of over-the-counter expectorants. b. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. c. Assist the client with chest physiotherapy and postural drainage. d.Notify the health care provider immediately about any bloody or foul-smelling sputum.

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

The nurse is developing the plan of care for a group of assigned clients. Which of the following clients should the nurse identify as having the highest risk for developing a pulmonary embolism? a. The client who had a heart catherization and is on bedrest. b. The client who had a left hip arthroplasty and is unable to bear weight. c. The client who had a laparoscopic appendectomy and is ambulating with assistance. d. The client who had a cataract extraction and has a prescription to avoid bending over.

The client who had a left hip arthroplasty and is unable to bear weight.

The nurse is developing the plan of care for a group of assigned clients with drainage tubes. Which of the following clients should the nurse identify as having a risk for hypokalemia? a. The client who has a tracheostomy tube connected to humidified oxygen. b. The client who has an indwelling urinary catheter to gravity drainage. c. The client who has a nasogastric tube to intermittent suction. d. The client who has a pleural chest tube to water seal.

The client who has a nasogastric tube to intermittent suction.

The nurse is caring for a client who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Use the push-pause method to flush the CVAD after giving medications. b. Obtain an order from the health care provider to change CVAD dressing. c. Avoid using friction when cleaning around the CVAD insertion site. d. Position the client's face toward the CVAD during injection cap changes.

Use the push-pause method to flush the CVAD after giving medications.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. prothrombin time. d. thrombin time.

bleeding time

After receiving change-of-shift report, which client should the nurse assess first? a. client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. client with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates c. client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water

client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

Which client statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I should take the iron with orange juice about an hour before eating." b. "I should increase my fluid and fiber intake while I am taking iron tablets." c. "I will take a stool softener if I feel constipated occasionally." d. "I will call my health care provider if my stools turn black."

"I will call my health care provider if my stools turn black."

The nurse is providing teaching to a client with polycythemia vera regarding prevention of complications. Which of the following statements by the client would indicate that more teaching is required? a. "I will limit the amount of red meat in my diet." b. "I will limit my fluid intake each day." c. "I should apply my support hose upon waking." d. "I should use an electric razor when shaving."

"I will limit my fluid intake each day."

The nurse provides discharge teaching for a client who has two fractured ribs from an automobile accident. Which statement, if made by the client, would indicate that teaching has been effective? a. "I will use the incentive spirometer every hour or two during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I am going to buy a rib binder to wear during the day." d. "I should plan on taking the pain pills only at bedtime, so I can sleep."

"I will use the incentive spirometer every hour or two during the day."

The nurse is assessing four clients at the neighborhood clinic. Which of these clients should the nurse identify to be at risk for the development of iron-deficiency anemia? a. 50-year old male who is following a high-fat and high-protein diet b. 43-year old male who had gastric bypass surgery one year ago. c. 35-year old male recently diagnosed with chronic renal failure. d. 26-year old woman in her second trimester of pregnancy

26-year old woman in her second trimester of pregnancy