Exam 3

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Ensure a patent airway

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

"I will take this medication on an empty stomach."

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?

"It is hypoxemia that persists even with 100% oxygen administration."

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

"The blood clot interferes with perfusion in the lungs."

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

"What is your occupation?"

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.)

Amoxicillin, Ciprofloxacin, Doxycycline

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

22-year-old client with asthma Client with well-controlled diabetes Healthy 72-year-old client Client who is taking medication for hypertension

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately?

Alanine aminotransferase (ALT): 180 U/L

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

Allow visitors at the clients bedside Ensure the client can communicate if awake Provide back and hand massages when turning Turn the client every two hours or more

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

Allowing the client to choose the position in bed

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

Alteplase (Activase)

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

Acknowledge the frightening nature of the illness Delegate a back rub to the unlicensed assistive personnel (UAP) Give simple explanations of what is happening. Stay with the client and speak in a quiet, calm voice.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

Adherence to proper hand hygiene Administering anti-ulcer medication Elevating the head of the bed Providing oral care per protocol

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

Antibiotics started before admission

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

Ask the spouse to explain the fear of visiting in further detail.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

Assess for other signs of hypoxia

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

Assess the cause of the agitation

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate?

Assess the client for pain when swallowing.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)

Assisting with chest tube insertion Facilitating pleural fluid sampling Performing frequent respiratory assessment Providing antipyretics as needed

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best?

Breathing so quickly can be dehydrating

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)

Chest wall stiffness Decreased muscle strength Poor vision and hearing

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

Choosing an 18 gauge, 2 inch needle

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

Cohort the clients in the same area as the unit

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

Ensuring a bag-valve mask is in the room

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

Exercise on a regular basis. Maintain a healthy weight. Stop smoking cigarettes.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened "Can't catch my breath" pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?

Facilitate a STAT pulmonary angiography.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?

Facilitate polymerase chain reaction testing.

A nurse admits a client from the emergency department. Client data are listed below:

History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority?

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below:

Immediately place the client on Airborne Precautions.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

Increase heparin rate

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?

Inform the client that antibiotics will be needed for 60 days.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)

International normalized ratio (INR): 6.3 Prothrombin time: 35 seconds

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

Interrupt the procedure to administer oxygen

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?

It is hypoxemia that persists even with 100% oxygen administration

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?

It will prevent ulcers from the stress of mechanical ventillation

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication? (Select all that apply.)

Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available. Use strict aseptic technique when using the drug delivery system

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

Large chefs salad and muffin

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?

Listen to pts lung sounds

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

Notify RRT

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

Notify Rapid Response Team

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

Older people often have more gauge symptoms, so an X-ray is essential

A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?

Oral fluconazole (Diflucan)

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

Platelet count: 82,000/L

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

Prepare preoperative teaching for an inferior vena cava (IVC) filter.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

Prepare to assist with intubation

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

Prepare to assist with intubation.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide frequent oral care per protocol

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care every 4 hours.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

Strict vegitarian

Which teaching point is most important for the client with bacterial pharyngitis?

Take antibiotics as directed

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

Teach client to sneeze in upper sleeve

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

Teach the client about factor V Leiden testing.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

Visiting Nurses for directly observed therapy

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

The upper peak airway pressure limit alarm is on

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

c. "Try warm, moist heat packs on your face."

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?

c. Fexofenadine (Allegra)