Exam 2
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention? - 60 mm Hg - 45 mm Hg - 80 mm Hg - 35 mm Hg
80 mmHg
A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? Chronic obstructive pulmonary disease (COPD) Mitral valve prolapse Anaphylaxis Acute respiratory distress syndrome (ARDS)
Acute respiratory distress syndrome (ARDS)
A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. What should the nurse instruct the client to do? - Avoid brushing the teeth until the nasal packing is removed. - Take aspirin to control nasal discomfort. - Avoid activities that elicit the Valsalva maneuver. - Apply heat to the nasal area to control swelling.
Avoid activities that elicit the Valsalva maneuver
A client with sepsis has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and assisted with the initiation of mechanical ventilation. Which is the highest priority for the nurse at this time? Assess the surgical dressing for infection. Assess urine output. Confirm the placement of the endotracheal tube. Administer intravenous fluids.
Confirm the placement of the endotracheal tube
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55 mm Hg), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first? Administer vancomycin intravenously. Insert an indwelling urinary catheter. Obtain stat portable chest X-ray. Draw blood cultures.
Draw blood cultures
A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? colostomy irrigation nasogastric tube irrigation IV catheter insertion instilling eye drops
IV catheter insertion
A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system? - Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. - Ensure that the chest tube is clamped when moving the client out of the bed. - Verify that the air vent on the water-seal drainage system is capped when the suction is off. - Make sure that the drainage apparatus is always below the client's chest level.
Make sure that the drainage apparatus is always below the client's chest level
A client is admitted to the emergency department with a broken humerus after a motor vehicle collision. Significant assessment findings include respiratory rate 28 breaths/min and arterial blood gas (ABG) readings of pH 7.51, PaCO2 30 mm Hg (3.99 kPa), HCO3 23 mEq/L (23 mmol/L), and PaO2 90 mm Hg (11.97 kPa). Which nursing action would be a priority? - Administer albuterol (salbutamol) inhaler. - Offer reassurance, and treat the client's pain. - Continuously assess pulse oximetry. - Administer lorazepam sublingually.
Offer reassurance, and treat the client's pain
A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values (pH 7.35, PaCO2 25, HCO3- 22, PaO2 95). Which finding is abnormal? - PaO2 - pH - HCO3- - PaCO2
PaCO2
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make? - The oxygen level is low but poses no risk for the client. - The client's PaO2 level is within normal range. -The client is severely hypoxic. - The client requires oxygen therapy with very low oxygen concentrations.
The client is severely hypoxic
A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding? - The lung has collapsed. - The chest tube is in the pleural space. - The lung has fully expanded. - The mediastinal space has decreased.
The lung has fully expanded
A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take? - Call respiratory therapy for a breathing treatment. - Use a sterile suction kit to suction the client. - Teach the client pursed lip breathing. - Encourage the use of the incentive spirometer.
Use a sterile suction kit to suction the client
Which client is most at risk for developing disseminated intravascular coagulation (DIC)? a client admitted with suspected cocaine overdose a client with a stage IV pressure ulcer a client with heart failure and renal failure a client with an amniotic fluid embolism
a client with an amniotic fluid embolism
An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding? pleuritic chest pain and cough respiratory rate of 24 breaths/minute temperature of 101.3°F (38.5°C) acute onset delirium
acute onset delirium
An older adult client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? - osteoarthritis - vegetarian diet - age - daily bathing
age
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first? - chest X-ray - albuterol nebulizer - sputum culture - ipratropium inhaler
albuterol nebulizer
An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? - applying an oximeter and initiating respiratory therapy - implementing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules - inserting an IV line and initiating antibiotic therapy - placing the client on bed rest and obtaining a prescription for a blood gas analysis
applying an oximeter and initiating respiratory therapy
A client with emphysema is at a greater risk for developing what acid-base imbalance? - chronic respiratory acidosis - respiratory alkalosis - metabolic alkalosis - chronic metabolic acidosis
chronic respiratory acidosis
Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? - dizziness - dyspnea - mental confusion - blurred vision
dizziness
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? - dyspnea and wheezing - sore throat and abdominal pain - hemoptysis and dysuria - nonproductive cough and normal temperature
dyspnea and wheezing
The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms? Select all that apply: - fever - crackles or rhonchi - dry cough - bradycardia - pericardial friction rub - use of accessory muscles during respiration
fever, use of accessory muscles during respiration, crackles or rhonchi
In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? fluid overload, sepsis, and vasodilation third spacing, heart failure, and diuresis myocardial infarction, fluid overload, and diuresis hemorrhage, sepsis, and anaphylaxis
hemorrhage, sepsis, and anaphylaxis
Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? - low-sodium diet - bland, soft diet - high-calorie, high-protein diet - low-fat, low-cholesterol diet
high-calorie, high-protein diet
A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH? decreased blood pressure increased body temperature increased urine output increased respiratory rate
increased respiratory rate
After teaching a client how to instill nose drops, the nurse evaluates that the client's technique is correct when the client: - lies supine for several minutes after instilling the drops. - uses a new dropper for each medication instillation. - uses sterile technique when handling the dropper. - blows the nose gently after instilling the medicine.
lies supine for several minutes after instilling the drops
A nurse is caring for a client receiving radiation for Hodgkin's lymphoma who begins to exhibit confusion. Upon further assessment, the nurse notes that the client has warm, flushed, dry skin; a heart rate of 110 beats per minute; and a temperature of 101.8° F (38.8° C). Which is the nurse's next best action? Perform a thorough neurological exam. Place the client in a high Fowler's position. Call a code. Notify the healthcare provider.
notify the HCP
A client had surgery for a deviated nasal septum. Which finding would indicate that bleeding is occurring even if the nasal drip pad remains dry and intact? - nausea - increased pain - repeated swallowing - increased respiratory rate
repeated swallowing
A client has these arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition? - metabolic alkalosis - metabolic acidosis - respiratory acidosis - respiratory alkalosis
respiratory acidosis
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance? - respiratory alkalosis - metabolic acidosis - metabolic alkalosis - respiratory acidosis
respiratory acidosis
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? - absence of glucose - absence of protein - specific gravity of 1.03 - urine pH of 3.0
urine pH of 3.0
An older adult has developed a urinary tract infection, and is at risk for urosepsis. Which signs or symptoms should the nurse monitor? Select all that apply. change in level of consciousness increased heart rate decreased urinary output decreased temperature increased respiratory rate
- increased heart rate - decreased urinary output - increased respiratory rate - change in level of consciousness
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? - Suction if cough is ineffective. - Administer sedatives to promote rest. - Turn the client every 4 hours. - Administer oxygen every 2 hours.
Suction if cough is ineffective
The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube? - facilitating "milking" of the tubes - removing air - preventing clots - removing fluid
removing fluid
When administering atropine sulfate preoperatively to a client scheduled for lung surgery, what should the nurse tell the client? - "This medicine will make you drowsy." - "This medicine will reduce the risk of postoperative infection." - "This medicine will help you relax." - "This medicine will make your mouth feel dry."
"This medicine will make your mouth feel dry."
Which client is the most appropriate candidate for outpatient care? A client who is receiving treatment for sepsis after their blood culture came back positive. A client whose reports of irregular bowel movements have necessitated a colonoscopy. A woman who has previously borne two children and is entering the second stage of labor. A client with a history of depression who is currently expressing suicidal ideation.
A client whose reports of irregular bowel movements have necessitated a colonoscopy
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? - 3 to 5 days - 6 to 12 months - 1 to 3 weeks - 2 to 4 months
6 to 12 months
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? - Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. - Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage. - Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. - A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device
Which measure should the nurse perform when suctioning a tracheostomy tube? - Change the tracheostomy tube after suctioning the client. - Administer high concentrations of oxygen before suctioning the client. - Apply suction while inserting the suction catheter into the tube. - Select a suction catheter that approximates the diameter of the tracheostomy tube.
Administer high concentrations of oxygen before suctioning the client
A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next? Insert a peripheral intravenous fluid line and infuse normal saline. Administer a prescribed antipyretic. Place cold, wet compresses on the client's head. Obtain a portable ECG monitor.
Insert a peripheral intravenous fluid line and infuse normal saline
A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? - decreased hearing acuity - increased urinary frequency - impaired color discrimination - increased appetite
decreased hearing acuity
A nurse is accessing an implanted vascular access port. What action will the nurse take first in maintaining sterile technique? Don sterile gloves. Perform hand hygiene. Clean the skin with a recommended skin preparation solution. Apply a sterile drape.
Perform hand hygiene
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? - Position in high Fowler's position and administer an albuterol sulfate inhaler. - Position in Fowler's position and administer oxygen. - Position in a semi-prone position and encourage deep breathing. - Position in orthopneic position and encourage the client to calm down.
Position in high Fowler's position and administer an albuterol sulfate inhaler
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? - Administer amnioinfusion. - Start I.V. oxytocin infusion as ordered. - Reposition the client. - Prepare for cesarean birth.
Prepare for cesarean birth
The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (wearing gown, standard goggles, N95). What should the nurse do next? - Wear a powered air purifying respirator (PAPR) face shield. - Use goggles that include the hairline. - Change to a surgical mask. - Proceed to suction the client's tracheostomy.
Proceed to suction the client's tracheostomy
Following a thoracotomy, the client has pain of 9 on a 10-point scale. What should the nurse do thirty minutes after administering the highest dose of the prescribed pain medication? - Reassure the client. - Reassess the client. - Reposition the client. - Readjust the pain medication dosage as needed.
Reassess the client
If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first? - Decrease the rate of compressions. - Reposition the airway. - Try using a bag-mask device. - Intubate the client.
Reposition the airway
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 a urinary output of 50 mL in the past 3 hours a white blood cell count of 19,000/mm3 a SaO2 reading of 92%
a urinary output of 50 mL in the past 3 hours
The nurse is caring for a client with suspected sepsis. A new prescription for ceftriaxone is entered on the medication administration as due daily at 1000. It is currently 2200. When should the nurse administer the first dose of ceftriaxone? as soon as it becomes available on the unit close to 0400 to help adjust to standard dosing times 2300 (one hour from time of prescription) at the time on the medication administration record (1000)
as soon as it becomes available on the unit
A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? vital signs every 4 hours blood chemistry of serum lactate intravenous dextrose in water at 75 mL/hour blood chemistry of AST, alkaline phosphates
blood chemistry of serum lactate
A client is admitted with a suspected bacterial infection. What laboratory finding does the nurse apply as the best indication that the infection is in the acute phase? white blood cell count 14,000 cells/mm3 (14x109/L) immature neutrophils 12% on white blood cell differential absolute neutrophil count of 15,000 cells/µL platelet count 300,000/mm3 (300x109/L)
immature neutrophils 12% on white blood cell differential
Which nursing intervention is most important in preventing septic shock? administering IV fluid replacement therapy as ordered obtaining vital signs every 4 hours for all clients monitoring red blood cell counts for elevation maintaining asepsis of indwelling urinary catheters
maintaining asepsis of indwelling urinary catheters
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? - manual resuscitation bag - oxygen analyzer - water-seal chest drainage set-up - tracheostomy cleaning kit
manual resuscitation bag
A client with Stevens-Johnson syndrome exhibits the following clinical manifestations. Which assessment finding requires priority action by the nurse? oral temperature of 102.2°F (39°C) pain level of 5 on a 0-10 scale respiratory rate of 16 breaths per minute numbness and tingling of the upper extremities
oral temperature of 102.2°F (39°C)
A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder? - pH 7.28, PaO2 50 mm Hg - pH 7.35, PaCO2 48 mm Hg - pH 7.46, PaO2 80 mm Hg - pH 7.36, PaCO2 32 mm Hg
pH 7.28, PaO2 50 mm Hg
A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 ml. How many milliliters of medication would the nurse pour to administer the correct dose? Record your answer as a whole number.
24
A nurse in a diabetes clinic receives phone calls from four clients with type 1 diabetes. The nurse returns the call of the client reporting what symptoms as highest priority? "I'm nauseated this morning and can keep only fluids down." "I noticed that my urine has a foul odor, and I have a fever." "My blood sugar was 55 mg/dL (3 mmol/L) , so I didn't take my insulin." "I'm thirsty all the time, and I'm urinating a lot."
"I noticed that my urine has a foul odor, and I have a fever."
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? - Maintain adequate oxygenation. - Reduce the client's anxiety. - Maintain adequate circulating volume. - Decrease chest pain.
Maintain adequate oxygenation
The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (ties on side, opening on gauze facing up). The nursing policy manual recommends use of the gauze pad. What should the nurse do? - Ask the unlicensed assistive personnel to tie the tracheostomy tube ties in the back of the client's neck. - Ask a registered nurse to change the ties and position another gauze pad around the stoma. - Make sure the gauze pad is dry and the client is in a comfortable position. - Reposition the gauze pad around the stoma with the open end downward.
Make sure the gauze pad is dry and the client is in a comfortable position.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? - Monitor vital signs and oxygen saturation every 15 to 30 minutes. - Assess intake and output and maintain adequate hydration. - Suction the client as needed to obtain a sputum specimen for culture and sensitivity. - Reassure the client that intubation and mechanical ventilation will be temporary.
Monitor vital signs and oxygen saturation every 15 to 30 minutes
A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action? Obtain STAT hemoglobin and group and match. Draw blood cultures and white blood cell count. Send client to diagnostic imaging for pelvic x-ray. Administer 5 mg morphine intravenously.
Obtain STAT hemoglobin and group and match
A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 mL/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places.
7.71
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? - Impaired gas exchange - Decreased cardiac output - Ineffective tissue perfusion (cardiopulmonary) - Anxiety
Impaired gas exchange
A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for their first day on the unit. An agency nurse and an experienced nurse are also present on the unit. The charge nurse should assign the new graduate to the care of a middle-age client who had a kidney transplant 3 days ago, an elderly client in acute renal failure, and an elderly client with urinary sepsis. a client who had an ileal conduit 3 days ago, an elderly client with a urinary tract infection (UTI), and an adolescent with kidney stones. an elderly client with bladder cancer awaiting surgery, an elderly client who had a prostatectomy and bladder irrigation 2 days ago, and an elderly client with renal insufficiency. an elderly client just admitted for acute stroke, a young adult client with suspected kidney stones, and a middle-age client with suspected pyelonephritis.
an elderly client with bladder cancer awaiting surgery, an elderly client who had a prostatectomy and bladder irrigation 2 days ago, and an elderly client with renal insufficiency
A nurse is performing a respiratory assessment on a client with pneumonia. The nurse asks the client to say "ninety-nine" several times. Through the stethoscope, the nurse hears the words clearly over the client's left lower lobe. What term should the nurse use to document this finding? - bronchophony - tactile fremitus - egophony - crepitation
bronchophony
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for? barium enema colonoscopy nasogastric (NG) tube insertion surgery
surgery
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? - trace peripheral edema, previously +2 - blood pressure 140/80 mm Hg - crackles auscultated halfway up lungs, previously in bases - PaO2 80 mm Hg
trace peripheral edema, previously +2
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? temperature 100.7° F (38.2° C), BP 118/68 mm Hg, HR 84 bpm, RR 20 breaths/min temperature 97.5° F (36.4° C), BP 98/64 mm Hg, HR 98 bpm, RR 18 breaths/min temperature 99.5° F (37.5° C), BP 126/80 mm Hg, HR 58 bpm, RR 16 breaths/min temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min
temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? - "This disease may come back later if I am under stress." - "I'll always have a positive test for tuberculosis." - "I'll stay in isolation for 6 weeks." - "I'll have to take the medication for up to a year."
"I'll stay in isolation for 6 weeks."
Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider, the nurse should make which recommendation? "May we have a prescription for restraining this client?" "Do you want to request a computed tomography scan to rule out stroke?" "Would you like a stat potassium level done?" "Shall I collect and send a urine sample for culture and sensitivity?"
"Shall I collect and send a urine sample for culture and sensitivity?"
For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour? - 22 - 30 - 8 - 50
22
A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next? - Reassure the client that the machine is working and will administer medication to relieve the pain. - Let the client rest so the client is not stimulated to cough. - Encourage the client to take deep breaths to help control the pain. - Obtain a more detailed assessment of the client's pain using a pain scale.
Obtain a more detailed assessment of the client's pain using a pain scale
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? a core body temperature of 97.9° F (36.6° C) polydipsia urine output of 90 mL over the past 6 hours confusion when listening to explanations of procedures
urine output of 90 mL over the past 6 hours
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? "generally caused by decreased blood volume" "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" "severe hypersensitivity reaction resulting in massive systemic vasodilation."
"a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume"
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply: - Compare ABG findings with previous results. - Document presenting signs and symptoms. - Administer I.V. bicarbonate. - Maintain intake and output records. - Suction the client's airway.
- Compare ABG findings with previous results. - Maintain intake and output records. - Document presenting signs and symptoms.
The nurse receives shift hand-off on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply. 32 mL of urine in 2 hours pulse rate of 32 beats per minute temperature increase tachypnea blood pressure decrease
- temperature increase - blood pressure decrease - 32 mL of urine in 2 hours - tachypnea
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? - Administer an ordered decongestant. - Instruct the client to breathe into a paper bag. - Offer the client fluids frequently. - Administer ordered supplemental oxygen.
Instruct the client to breathe into a paper bag
When assessing a client for early sepsis, which assessment finding would most concern the nurse? mean arterial pressure less than 70 mmHg purulent drainage from surgical site pale, yellow urine two-second capillary refill
mean arterial pressure less than 70 mmHg
The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply. abdominal surgery age gender weight diabetes mellitus
- age - abdominal surgery - diabetes mellitus
For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply. client who had diagnostic laparoscopy for abdominal pain client with four vessel coronary artery bypass graft with bilateral chest tubes client in the intensive care unit on a ventilator with sepsis client who had outpatient endoscopy for anemia client who had extended low anterior resection for colonic mass
- client who had extended low anterior resection for colonic mass - client in the intensive care unit on a ventilator with sepsis - client with four vessel coronary artery bypass graft with bilateral chest tubes
