Exam 2

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance? A) Thick, white plaques on the tongue surface B) Dry appearance with fissures present C) Diffuse reddened lesions that bleed easily D) Firm, raised nodules that are pink or red

A) Thick, white plaques on the tongue surface

Question about shortness of breath in ER; RR 40/min

Answer: Administer oxygen via face mask

Question about can't cough anything up

Answer: Drink water--> loosen secretions in the airway

Question about a Bucks traction

Answer: asses temp; examine skin; monitor peripheral pulses

Question about Difference between casts

Answer: synthetic cast is lighter

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results

B) Baseline arterial blood gas (ABG) levels

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."

B. "I will take my bronchodilators after meals."

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

B. Increased anteroposterior diameter of the chest

Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause: A. Nasal congestion B. Nervousness C. Lethargy D. Hyperkalemia

B. Nervousness

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? A. increase the oxygen flow to 3L/min B. evaluate the client's respiratory status C. call EMS for the client D. have the client cough and expectorate secretions

B. evaluate the client's respiratory status

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response? A) The physician may feel that mechanical ventilation will have to be used long-term. B) Long-term use of an endotracheal tube diminishes the normal breathing reflex. C) When an endotracheal tube is left in too long it can damage the lining of the windpipe. D) It is much harder to breathe through an endotracheal tube than a tracheostomy.

C) When an endotracheal tube is left in too long it can damage the lining of the windpipe.

The nurse is instructing a patient about pursed lip breathing and the pt asks the nurse about its purpose. The nurse should tell the pt. 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 cardon dioxide elimination

D. promote cardon dioxide elimination

Question about ABGs... which one is respiratory acidosis

PaCO2 50

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. What is the nurse highest priority? a. Administering a nebulizer beta- adrenergic b. Initiating oxygen therapy c. Providing immediate rest for the client d. Positioning the client in high-Fowler's

a. Administering a nebulizer beta- adrenergic

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension tractions is primarily function? a. allows bony healing to begin before surgery b. provides rigid immobilization of the fracture site c. lengthens the fractured leg to prevent serving of blood vessels d. provides comfort by reducing muscle spams and provides fracture

d. provides comfort by reducing muscle spams and provides fracture

A nurse is caring for a client who has fractured right femur and is in balanced suspension traction. the client is reporting pain from muscle spams. Which of the following actions should the nurse take first? a. administer an opioid analgesic b. obtain a prescription to adjust the weight amount c. offer a muscle relaxant to the client d. realign the client's position

d. realign client's position

Discharge teaching to a patient receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. tachycardia b. nonproductive cough c. hypoglycemia d. sedation

a. tachycardia

The health care provider orders ipratropium bromide (atrovent), albuterol (proventil), and beclomethasone (Vanceril) inhalers for a patient. What is the nurse's best actions? a. Question the order; three inhalers should not be given at one time. b. Administer the albuterol, wait 5 minutes, administer ipratropium bromide, then beclomethasone several minutes later. c. Administer each inhaler at 30-minute intervals. d. Administer beclomethasone, wait 2 minutes, administer ipratropium bromide, then albuterol several minutes later.

b. Administer the albuterol, wait 5 minutes, administer ipratropium bromide, then beclomethasone several minutes later.

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? a. instruct the client to flex and extend ankle twice daily b. monitor pedal pulses every hour c. remove the weights every four hours d. evaluate pressure points daily

b. Monitor pedal pulses every hour

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? a. "skeletal traction has less risk fro infection than skin traction" b. "clients with skin traction have more mobility than those with skeletal traction" c. "skeletal traction is more appropriate than skin traction for reducing a fracture" d. "clients with skin traction have more discomfort that those with skeletal traction"

c. "skeletal traction is more appropriate than skin traction for reducing a fracture"

A child is brought to the emergency department for treatment of an acute asthma attack. The nurse prepares to administer which of the following meds first? a. oral corticosteroids b. a leukotriene modifier c. B2 agonist d. a non steroidal anti-inflam

c. B2 agonist

The nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the expect? a. nausea b. dysphagia c. agitation d. hypotension

c. agitation

the nurse administers which of the following medications as part of pharmacological treatment aimed at prevention of pulmonary embolism? a. streptokinase b. aquamephyton (vitamin k) c. enoxaparin (lovenox) d. protamine sulfate

c. enoxaparin (lovenox)

The nurse clarifies that in a greenstick fracture, the: a. line of the fracture goes across the bone in right angle to the longitudinal axis b. periosteum is not torn away from the bone c. fracture is incomplete and one side is bent d. fracture occurred in one of the long bones of the body

c. fracture is incomplete and one side is bent

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following meds should the nurse anticipate administering? a. furosemide b. dexamethasone c. heparin d. atropine

c. heparin

A nurse is caring for a client who has an unrepaired femur fracture of the mid shaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a. measure the circumference of the thigh b. palpate the femoral pulse c. monitor the client's calf for edema d. instruct client to wiggle his toes

d. instruct client to wiggle his toes

When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first? a. offer reassurance to the patient b. activate the hospitals rapid response team c. call the health care provider to reinsert the tube d. manually ventilate the patient with 100% oxygen

d. manually ventilate the patient with 100% oxygen

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1. Giving pin care once a shift 2. Massaging the skin of the right leg with lotion every 8 hours 3. Inspecting the skin on the right leg at least once every 8 hours 4. Releasing the weights on the right leg for range-of-motion exercises daily

3. Inspecting the skin on the right leg at least once every 8 hours

A nurse is reinforcing teaching about self-management strategies with a client with emphysema. which of the following statements indicates client understands the instructions? a. "I will follow a diet high in calories and protein" b. I will inhale slowly through pursed lips to help me breathe better. c. I will avoid flu shot d. I will lie on my stomach to practice abdominal breathing every day

a. "I will follow a diet high in calories and protein"

The nurse is caring for a client how has heart failure and a history of asthma. The nurse reviews the providers orders and recognizes that clarification is needed for which of the following medications? a. Carvedilol (beta-blocker) b. fluticasone c. captopril d. isosorbide dinitrate

a. Carvedilol (beta-blocker)

A nurse is caring for a client who's has emphysema. Which of the following findings should the nurse expect to assess in the client? (Select all that apply.) a. Dyspnea b. Bradycardia c. Barrel chest d. Clubbing of the fingers

a. Dyspnea c. Barrel chest d. Clubbing of the fingers

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (SATA) a. Elevate the HOB to at least 30 b. Administer pantoprazole as prescribed c. Reposition the endotracheal tube to the opposite side of the mouth daily d. Very prescribed ventilator setting daily e. Apply restraints if client become agitated

a. Elevate the HOB to at least 30 b. Administer pantoprazole as prescribed c. Reposition the endotracheal tube to the opposite side of the mouth daily

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? a. Increased calcium Excretion b. Decreased RBC production c. Increased insulin production d. Decreased sodium excretion

a. Increased calcium Excretion

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. It helps prevent early airway collapse. b. It increases inspiratory muscle strength c. It decreases use of accessory breathing muscles. d. It prolongs the inspiratory phase of respiration.

a. It helps prevent early airway collapse.

A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. It is 0830 and the client will begin physical therapy at 0900. Which of the following is an appropriate nursing intervention for this client at this time? a. Offer to administer analgesia b. Tell the client to bend forward at waist when getting out of bed c. Position client leg in adducted position d. Bathe and dress the client

a. Offer to administer analgesia

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following intervention should the nurse implement to prevent pressure points from developing around the edge of the splint? a. Reposition the client to keep him from staying in one position in bed b. Remove weight for few minutes each hour c. Apply lotion to the edge of the splint d. Apply foot plate to the bed.

a. Reposition the client to keep him from staying in one position in bed

the nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? a. stridor b. occasional pink-tinged sputum c. respiratory rate of 24 breaths/minute d. a few basilar lung crackles on the right

a. Stridor (crazy breathing sound)

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? a. When adventitious breath sounds are auscultated b. Every 2 hours when the client is awake c. When there is a need to prevent the client from coughing d. When the nurse needs to stimulate cough reflex.

a. When adventitious breath sounds are auscultated

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/ min via nasal cannula. Which of the following actions should the nurse take? a. attach a humidifier bottle to the base of the flow meter b. remove the nasal cannula while the client eats c. secure the oxygen tubing to the bed sheet near the clients head d. apply petroleum jelly to the nares as needed to soothe mucous

a. attach a humidifier bottle to the base of the flow meter

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neuromuscular status of the client's affected extremity? (SATA) a. color b. temperature c. ecchymosis d. skin integrity e. sensation

a. color b. temperature e. sensation

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. increased respiratory rate of 18 to 44/minB. b. increased oral temperature of 36.6 C to 37.7 CC. c. increased blood pressure from 112/68 to 120/72D. d. Increased heart rate from 68 to 72

a. increased respiratory rate from 18-44 breaths/ minute

if a patient has severe acute asthma (asthmatic attack) or life-threatening asthma and is wheezing and then the breath sounds become quiet, yet the patient is struggling to breathe, what could you surmise? a. patient is having an exacerbation--> give quick relief of short acting inhaled beta2 agonists (SABA) such as Albuterol or Levalbuterol

a. patient is having an exacerbation--> give quick relief of short acting inhaled beta2 agonists (SABA) such as Albuterol or Levalbuterol

the nurse determines that the patient is not experiencing adverse effects of albuterol after noting which patient vital sign? a. pulse rate of 72/minute b. temperature of 98.4 c. oxygen saturation 96% d. respiratory rate of 18/minute

a. pulse rate of 72/minute

A nurse is providing discharge teaching to a client has a plaster of Paris walking cast on his left lower leg. Which of the following instruction should the nurse include? a. report numbness and pain in the toes b. apply ice to your foot after walking c. a musty odor is normal as the cast ages d. there is no need to cover the cast when showering

a. report numbness and pain in the toes

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following intervention should the nurse take to reduce the risk for ventilator associated pneumonia? a. rinse the client's mouth with an antimicrobial solution every 4 hours b. Position the head of the client's bed in the flat position. c. Turn the client every 4 hr. d.Perform hand hygiene prior to suctioning the client's endotracheal tube.

a. rinse the client's mouth with an antimicrobial solution every 4 hours

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? a. warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.

a. warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? a. white patches on the tongue

a. white patches on the tongue

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too light, which of the following findings should the nurse expect to observe first? a. change in temperature of the toes b. pallor of the toes c. edema of the toes d. inability to move toes

b. pallor of the toes

A patient is prescribed ipratropium and cromolyn sodium. what will the nurse teach the patient? a. do not take these medications within 4 hours of each other b. take the ipratropium at least 5 minutes before the cromolyn c. administer both meds together in a metered-dose inhaler d. take the ipratropium only in the mornings

b. take the ipratropium at least 5 minutes before the cromolyn

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occur? a. the client complains of pain b. the client develops a life-threatening situation c. the client needs to have a x-ray of the femur performed d. the client has to be repositioned in the bed

b. the client develops a life-threatening situation

the nurse caring for the client provides instructions regarding administration of the medication. which statement by the client indicates an understanding of how to take these medications? a. "I will take the two puffs of the fluticasone propionate first and then the two puffs of the albuterol." b."I will take the two puffs of the albuterol first and then the two puffs of the fluticasone propionate." c. "I will alternate a single puff of each, beginning with the fluticasone propionate." d. "I will alternate a single puff of each, beginning with the albuterol."

b."I will take the two puffs of the albuterol first and then the two puffs of the fluticasone propionate."

A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first? a. suction as needed b. clean tracheostomy inner cannula and stoma c. listen to lung sounds d. change the tracheostomy dressing as needed

c. listen to lung sounds

An adult client is admitted for diagnosis and treatment of the left lung lesion. A bronchoscopy was performed under local anesthesia. What nursing action is of highest priority when he returns following the bronchoscopy? A. Collect all sputum for examination. B. Assess level of consciousness frequently. C. Withhold food and fluids until gag reflex has returned. D. Monitor blood pressure and pulse at 10 minute intervals.

c. withhold fluids and food until gag reflex returned

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect? a. Poor circulation b. Pressure from the cast c. Uneven cast drying d. Infection

d. Infection

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

At 11 p.m. a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. Morphine b. alprazolam (Xanax) c.propranolol (Inderal) d. albuterol (proventil)

d. albuterol (proventil)

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the affected arm? a. bounding distal pulse b. acute pain c. ecchymosis of the surrounding skin d. increasing edema

d. increasing edema