Exam 3 Nur 240

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: A permanent tracheal stoma would be necessary. One vocal cord was removed along with a portion of the larynx. The voice was spared and a tracheostomy would be in place until the airway was established. A portion of the vocal cord was removed.

A permanent tracheal stoma would be necessary.

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." "You only record urine output in an adult undergarment; you do not record diarrhea output." :If the undergarment is soiled, document this fact but do not estimate its contents." "We do not record fluids absorbed into undergarments."

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? "Can you tell me why you are here this morning?" "When was the last time you had anything to eat or drink?" "Do you want me to call the hospital chaplain before you have anesthesia?" "Which medications do you take daily?"

"When was the last time you had anything to eat or drink?"

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? "While my pneumatic compression device is on, I don't need to do leg exercises." "Every 2 hours while I am awake, I will take deep breaths and cough." "I will sit up in bed before using my incentive spirometer." "I will splint my incision while I cough."

"While my pneumatic compression device is on, I don't need to do leg exercises."

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? "After surgery you will have a sore throat, but you will be able to speak." "After surgery you will have to use an electric larynx to communicate." "A speech therapist will evaluate you and recommend a system of communication after surgery." "You can use writing or a communication board to communicate."

"You can use writing or a communication board to communicate."

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 50 gtt/min 30 gtt/min 20 gtt/min 40 gtt/min

50 gtt/min

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? 30 drops/mL 120 drops/mL 60 drops/mL 90 drops/mL

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? 42 gtt/min 83 gtt/min 5,000 gtt/min 167 gtt/min

83 gtt/min

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? A client has a respiratory rate of 10 breaths per minute. A client has respiratory acidosis. A client exhibits symptoms of dyspnea. A client requires permanent ventilation

A client requires permanent ventilation

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? Airborne and contact precautions Contact precautions Droplet precautions Contact and droplet precautions

Airborne and contact precautions

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? Direct the client to leave glasses at home for safety. Give the glasses to the family until the client is returned to the room. Allow the client to wear glasses until after anesthetic is administered. Allow the client to wear glasses until just before anesthetic is administered.

Allow the client to wear glasses until just before anesthetic is administered.

A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client? Information about allergic agents Chronic disease history Amount of blood loss Environment of the operating room

Amount of blood loss

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Ask client to perform Valsalva maneuver. Apply petroleum-based ointment and sterile occlusive dressing. Apply pressure to insertion site for at least 3 minutes. Instruct client to remain flat for 30 minutes.

Apply pressure to insertion site for at least 3 minutes.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? Apply pressure to the surgical site to decrease bleeding. Notify the health care provider. Assess the client's vital signs. Determine the possible cause of the client's bleeding.

Apply pressure to the surgical site to decrease bleeding.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? Apply an oxygen saturation monitor. Check the client's blood pressure. Notify the health care provider. Apply warm blankets to the client.

Apply warm blankets to the client.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks? Applying steroidal nasal spray Applying nasal packing Administering nasal lavage Preparing the patient for a septoplasty

Applying nasal packing

What is the lab test commonly used in the assessment and treatment of acid-base balance? Urinalysis Complete blood count Arterial blood gas Basic metabolic panel

Arterial blood gas

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? Encourage the client to create an advance directive. Assess the client's allergy status. Have the client perform leg exercises every 30 minutes. Administer analgesia (pain medications).

Assess the client's allergy status.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased potassium levels Decreased potassium levels Decreased oxygen levels Increased sodium level

Decreased potassium levels

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort? Maintaining a calm environment Keeping the client recumbent Allowing family members to visit often Providing solid food during postoperative day 1

Maintaining a calm environment

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis

Metabolic alkalosis

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic alkalosis

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition? Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Incrusted mucous membranes Erosion of the trachea Hardened secretions Noisy breathing

Noisy breathing

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client? Place a sign on the client's bed. Inform the client to tell the anesthesiologist. Note the allergy on the client's record. Obtain latex-free gloves for the client's room.

Note the allergy on the client's record.

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? Ask the client if he still wants to proceed with the procedure. Have the client's family member sign the consent form. Notify the physician of the oversight. Immediately have the client sign the consent form.

Notify the physician of the oversight.

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? AB negative O negative A positive B positive

O negative

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following? Supraglottic laryngectomy Hemilaryngectomy Total laryngectomy Partial laryngectomy

Partial laryngectomy

A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education? Cordectomy Partial laryngectomy Total laryngectomy Vocal cord stripping

Partial laryngectomy

Which nursing action will best promote pain management for a client in the postoperative phase? Providing food and medication Performing relaxation techniques Dimming the lights Breathing into a paper bag

Performing relaxation techniques

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? Calcium Potassium Chloride Phosphorous

Potassium

Most cases of acute pharyngitis are caused by which of the following? Bacterial infection Viral infection Systemic infection Fungal infection

Viral infection

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Pressure-cycled Negative-pressure Time-cycled Volume-controlled

Volume-controlled

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Pressure-cycled Volume-controlled Time-cycled Negative-pressure

Volume-controlled

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Air-leak chamber Suction control chamber Collection chamber

Water-seal chamber

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct? "If you learn how to perform these exercises correctly, you will not need supplemental oxygen during surgery." "These types of exercises help distract you from the postoperative pain." "These techniques will prevent trapped air from accumulating in your lungs." "After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."

"After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "You need to start using the incentive spirometer 2 days after surgery." "Breathe in and out quickly." "Before you do the exercise, I'll give you pain medication if you need it." "Don't use the incentive spirometer more than 5 times every hour."

"Before you do the exercise, I'll give you pain medication if you need it."

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states "The 'tickle' in your throat will improve with cold liquids." "Do not use a humidifier; it will make your problem worse." "It is fine to speak in a whisper. This does not strain your voice." "Do not smoke and avoid being around others who are smoking."

"Do not smoke and avoid being around others who are smoking."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? "Family members should continue to talk to the client." "Limit the amount of protein in the diet." "Clean the tracheostomy tube with alcohol and water." "Oral intake of fluids should be limited for 1 week only."

"Family members should continue to talk to the client."

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid in the tissue space between and around cells." "Fluid inside cells." "Fluid outside cells." "Watery plasma, or serum, portion of blood."

"Fluid in the tissue space between and around cells."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: "I should sleep on my side all night long." "I should eat a high-protein diet." "I should become involved in a weight loss program." "I need to keep my inhaler at the bedside."

"I should become involved in a weight loss program."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I should drink 1,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid." "I need to drink no more than 1,000 mL/day" "I should drink 2,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? "I have environmental allergies." "I was chewing ice chips all day long." "I used my voice in excess over the weekend." "I smoke a pack of cigarettes a day."

"I was chewing ice chips all day long."

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? "Yes—you should be off all of your medications for 24 hours before surgery." "No—you should stay on your normal medication schedule before the surgery." "I will need to check with your health care provider about that." "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery."

"I will need to check with your health care provider about that."

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'll stop being contagious when I have a negative acid-fast bacilli test." "I'm clear when my chest X-ray is negative." "I'm contagious as long as I have night sweats."

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've had a GI virus for the past 3 days with severe diarrhea." "I've been taking antacids almost every 2 hours over the past several days." "I've had a fever for the past 3 days that just doesn't seem to go away." "I was breathing so fast because I was so anxious and in so much pain."

"I've been taking antacids almost every 2 hours over the past several days."

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider? "I've been taking ibuprofen for my hip pain twice a day." "My hip pain has prevented me from doing the things I enjoy." "I have not had anything to eat or drink for 8 hours." "My other hip will probably need to be done eventually."

"I've been taking ibuprofen for my hip pain twice a day."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? "Unfortunately, your own blood cannot be reinfused during surgery." "We now have artificial blood products, so giving your own blood is not necessary." "Let me refer you to the blood bank so they can provide you with information." "This surgery has a very low chance of hemorrhage, so you will not need blood."

"Let me refer you to the blood bank so they can provide you with information."

A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response? "You do not have to worry. It will be fine." "Have you ever had surgery before?" "Tell me what you are most worried about." "I will have the anesthesiologist talk to you."

"Tell me what you are most worried about."

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy? "I will not be able to have the tracheostomy removed." "Tell my spouse about it, I do not want to touch it." "I must carry tissues with me." "I must give up my love of pool aerobics."

"Tell my spouse about it, I do not want to touch it."

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? "The operating table is a firm surface; we need to be sure your skin looks okay." "The covers underneath you need to be straightened out. They look messy." "We needed to be sure you didn't have any skin breakdown before surgery." "We wanted to be sure we didn't leave any sponges or syringes underneath you."

"The operating table is a firm surface; we need to be sure your skin looks okay."

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? "If possible, lie flat on your back while you're doing your breathing exercises." "Try to do your exercises every 1 to 2 hours." "It's best to do your exercises before a meal rather than after eating and drinking." "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done."

"Try to do your exercises every 1 to 2 hours."

The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? "Wait for assistance before moving in bed." "Use a pillow to splint the incision." "Change your position frequently." "Raise the head of the bed before turning."

"Use a pillow to splint the incision."

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? "You must consume a diet low in fat by limiting dairy products and concentrated sweets." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." "You must consume a diet rich in protein, such as chicken, fish, and beans."

"You must consume a diet rich in protein, such as chicken, fish, and beans."

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give? "Your symptoms should go away soon, just try to get some rest." "You should rest, increase your fluids, and take Ibuprofen." "Have you tried a topic nasal decongestant; they work well." "Antibiotics will be prescribed, which will make you feel better."

"You should rest, increase your fluids, and take Ibuprofen."

What commonly used intravenous solution is hypotonic? 0.45% NaCl 10% dextrose in water lactated Ringer's 0.9% NaCl

0.45% NaCl

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? 75 mL/hr for the first 15 minutes, then 200 mL/hr As fast as the client can tolerate 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours

1 unit over 2 to 3 hours, no longer than 4 hours

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? 75 mL/hr for the first 15 minutes, then 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours As fast as the client can tolerate 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 6 seconds with 3 episodes/hour. 4 seconds with 2 episodes/hour. 10 seconds with 5 episodes/hour. 8 seconds with 4 episodes/hour

10 seconds with 5 episodes/hour.

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 600 gtt/min 100 gtt/min 60 gtt/min 160 gtt/min

100 gtt/min

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? 5-mm induration Reddened area 15-mm induration A blister

15-mm induration

A client is undergoing a knee replacement tomorrow morning and is ordered nothing by mouth (NPO) prior to surgery. The client asks the nurse how long before the procedure can water be taken in. Based on the nurse's knowledge of standard protocols, what is the nurse's best response? 2 hours 6 hours 12 hours 4 hours

2 hours

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? No fluid is normally present 20 mL or less 20-40 mL More than 40 mL

20 mL or less

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 3,750 3,000 500 1,000

3,000

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? A face mask A nasal cannula A rigid shell A ventilator

A face mask

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? Packed red blood cells A hypotonic solution An isotonic solution A hypertonic solution

A hypotonic solution

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for A cut or slice in the tubing from the ventilator A kink in the ventilator tubing Higher than normal endotracheal cuff pressure Malfunction of the alarm button

A kink in the ventilator tubing

On auscultation, which finding suggests a right pneumothorax? Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax Bilateral inspiratory and expiratory crackles Bilateral pleural friction rub

Absence of breath sounds in the right thorax

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Acute respiratory distress syndrome Atelectasis Metabolic alkalosis Respiratory acidosis

Acute respiratory distress syndrome

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. Administer furosemide as ordered. Ask provider to order a low-salt diet. Treat the underlying condition that contributes to increased fluid volume. Increase oral intake to flush excess fluids. Reduce infusing fluid volume as ordered.

Administer furosemide as ordered. Ask provider to order a low-salt diet. Treat the underlying condition that contributes to increased fluid volume. Reduce infusing fluid volume as ordered.

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? Administer intradermal injections into each child's inner forearm. Administer a subcutaneous injection into each child's umbilical area. Administer a subcutaneous injection at a 45-degree angle into each child's deltoid. Administer intramuscular injections into each child's vastus lateralis.

Administer intradermal injections into each child's inner forearm.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? Administer one intramuscular injection of penicillin. Provide the client with oral penicillin that will last for 5 days. Ask an accompanying homeless friend to monitor the client's follow-up. Provide emphatic oral instructions for the client.

Administer one intramuscular injection of penicillin.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Encourage the client to deep-breathe and cough every 2 hours. Auscultate breath sounds bilaterally every 4 hours. Administer oxygen by nasal cannula as ordered. Instruct the client to breathe into a paper bag.

Administer oxygen by nasal cannula as ordered.

Constant bubbling in the water seal of a chest drainage system indicates which problem? Tidaling Increased drainage Air leak Tension pneumothorax

Air leak

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection? An antibiotic such as amoxicillin An antiviral agent such as acyclovir An ointment such as bacitracin An antihistamine such as Benadryl

An antiviral agent such as acyclovir

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter A peripheral venous catheter inserted to the antecubital fossa An implanted central venous access device (CVAD)

An implanted central venous access device (CVAD)

The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.) Stay on bed rest during the febrile stage of the illness. Drink warm or hot liquids during the acute stage of the disease. Apply an ice collar. Try a liquid or soft diet during the acute stage of the disease. Gargle with an alcohol-based mouthwash.

Apply an ice collar. Try a liquid or soft diet during the acute stage of the disease. Stay on bed rest during the febrile stage of the illness.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? Apply a moustache dressing. Place the client in a semi-Fowler's position. Apply direct continuous pressure. Provide a nasal splint.

Apply direct continuous pressure.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply. Ask the client to rate pain on a scale from zero to ten Review prior medical history Give pain medication as prescribed Obtain vital signs, especially heart rate and blood pressure Give sublingual nitroglycerin as prescribed

Ask the client to rate pain on a scale from zero to ten Obtain vital signs, especially heart rate and blood pressure Give sublingual nitroglycerin as prescribed

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? Infection Aspiration Bowel alterations Respiratory distress

Aspiration

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal ischemia Aspiration pneumonia Pressure necrosis Tracheal bleeding

Aspiration pneumonia

The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? Remove graduated compression stockings. Mark the client's skin to indicate the location of the surgery. Place the client in a side-lying position. Assure that diagnostic testing has been completed and results are available.

Assure that diagnostic testing has been completed and results are available.

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? Assess capillary refill. Monitor heart rhythm. Obtain vital signs. Auscultate lung sounds.

Auscultate lung sounds.

For a client with an endotracheal (ET) tube, which nursing action is the most important? Turning the client from side to side every 2 hours Providing frequent oral hygiene Monitoring serial blood gas values every 4 hours Auscultating the lungs for bilateral breath sounds

Auscultating the lungs for bilateral breath sounds

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? Avoid salty or excessively sweet fluids. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth. Use regular gum and hard candy.

Avoid salty or excessively sweet fluids.

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? Take aspirin for nasal discomfort. Administer normal saline nasal drops as ordered. Avoid sports activities for 6 weeks. Decrease the amount of daily fluids.

Avoid sports activities for 6 weeks.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? Bleeding Difficulty swallowing Throat pain Difficulty talking

Bleeding

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated? Vital capacity of 12 mL/kg PaO2 60 mmHg with an FiO2 <40% Blood pressure increase of 20 mm Hg Heart rate <100 bpm

Blood pressure increase of 20 mm Hg

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to Blow the nose before applying medication into the nares. Clean the medication container once each day. Wait 10 seconds before administering the second spray. Tilt the head back when activating the spray of the medication.

Blow the nose before applying medication into the nares.

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system. Complete the table by selecting the intervention associated with each body system. Cardiac/Select...Note response to stimulation. Monitor urinary function. Provide verbal stimulation. Use sidelying position for lethargic clients. Respiratory/Select...Check pupillary response. Monitor muscle strength. Auscultate bowel sounds .Assess skin color. Neurologic/Select...Encourage leg exercises. Encourage leg exercises. Assess the dressing for drainage. Gently touch the client.

Cardiac: Provide verbal stimulation. Respiratory: Assess skin color Neurologic: Gently touch the client.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. Restrict from sports activities for 6 weeks. Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Keep the nasal packing in place for 72 hours to help reshape the form of the nose.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Restrict from sports activities for 6 weeks. Elevate the head of the bed for sleeping during the first week

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? Aspiration Drug ingestion Direct lung damage Chemical irritation

Chemical irritation

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Chest tube drainage, 190 mL/hr Heart rate, 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1-to-10 scale

Chest tube drainage, 190 mL/hr

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? Educating the client about postoperative protocols Client safety Establishing a nurse-client rapport Providing emotional support for the client and family

Client safety

What client would be most in need of an endotracheal tube? A client status post tonsillectomy Ambulatory clients Comatose clients Older adult clients

Comatose clients

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? Continuous positive airway pressure (CPAP) Oxygen by nasal cannula Bilevel positive airway pressure (BiPAP) Mechanical ventilation

Continuous positive airway pressure (CPAP)

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? Correct use of incentive spirometry Correct technique for rhythmic breathing Correct use of a ventilator Correct use of a mini-nebulizer

Correct use of incentive spirometry

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Shortness of breath Obvious trauma Cough or change in chronic cough Pain on inspiration

Cough or change in chronic cough

A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer? Albumin Whole blood Cryoprecipitate Platelets

Cryoprecipitate

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Deciding the size of the IV catheter. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Administering the IV solution. Determining the amount of IV solution.

Deciding the location of the IV catheter. Administering the IV solution. Deciding the size of the IV catheter.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Increased potassium levels Decreased potassium levels Decreased oxygen levels

Decreased potassium levels

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Decreased potassium levels Increased potassium levels Decreased oxygen levels

Decreased potassium levels

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? The surgical site is dry with encrustations. Drainage is <30 mL/day for 2 consecutive days. The stoma is healed, about 6 weeks after surgery. The patient is able to assist with his own suctioning.

Drainage is <30 mL/day for 2 consecutive days.

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Ascites Dyspnea Hypertension Syncope

Dyspnea

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Nonproductive cough and normal temperature Hemoptysis and dysuria Sore throat and abdominal pain Dyspnea and wheezing

Dyspnea and wheezing

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+.

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? Postoperative bleeding Edema of the upper airway Infection Plugged tracheostomy tube

Edema of the upper airway

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? Elevated myoglobin levels Elevated B-type natriuretic peptide (BNP) levels Elevated white blood count Elevated troponin levels

Elevated B-type natriuretic peptide (BNP) levels

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to: Eliminate alcohol ingestion. Use nasal oxygen at night. Take a hypnotic medication at hours of sleep. Sleep on the back.

Eliminate alcohol ingestion.

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? Emotional support Referral for counseling Family counseling Referral for vocational training

Emotional support

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Encourage increased fluid intake. Place client on bed rest. Offer nutritious snacks 2 times a day.

Encourage increased fluid intake.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Maintaining a cool room temperature Encouraging increased fluid intake Elevating the head of the bed 30 degrees

Encouraging increased fluid intake

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Incentive spirometry Use of a cooling blanket Encouragement of coughing Endotracheal suctioning

Endotracheal suctioning

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? Provide a splint postoperatively Apply a warm pack postoperatively Ensure mouth breathing Apply pressure to the convex portion of the nose

Ensure mouth breathing

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions? Every 1 to 2 hours Every 4 to 6 hours Every 2 to 4 hours Every 30 to 60 minutes

Every 2 to 4 hours

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? Assess the client's rationale and affirm that she has made a good decision. Remind the client that she has signed the informed consent documents. Ask the client about her understanding of the potential benefits of the surgery. Explore the client's feelings and inform the surgeon.

Explore the client's feelings and inform the surgeon.

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: Nausea Myalgias Fever Headache

Fever

The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increased exposure to industrial pollutants Increase in women smokers Increased incidence among the elderly Few early symptoms

Few early symptoms

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Hemorrhage Damage to surrounding tissues Lung contusion Fibrotic changes in lungs

Fibrotic changes in lungs

The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? You may eat anything you want following surgery. Food and liquids will be held in the immediate postoperative period. You will receive a diet high in vitamin B. In the immediate postoperative period, you will receive a soft diet high in carbohydrates.

Food and liquids will be held in the immediate postoperative period.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Gastroesophageal reflux disease (GERD) Respiratory failure (RF)

Gastroesophageal reflux disease (GERD)

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis? Gram-negative Klebsiella Pseudomonas aeruginosa Group A, beta-hemolytic streptococci Staphylococcus aureus

Group A, beta-hemolytic streptococci

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status? pH: 6.45 SaO2: 89% PaCO2: 48 mm Hg (6.38 kPa) HCO3: 25 mEq/L (25 mmol/L)

HCO3: 25 mEq/L (25 mmol/L)

The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure? Select all that apply. Shortness of breath and auscultated crackles bilaterally in the bases may occur during a febrile reaction. Hives, itching, and anaphylaxis may occur during an allergic reaction. Dyspnea, dry cough, and pulmonary edema may occur during a bacterial reaction. Fever, hypertension, abdominal pain and dry, flushed skin may occur during circulatory overload. Fever, chills, headache and malaise may occur during a febrile reaction. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

Hives, itching, and anaphylaxis may occur during an allergic reaction. Fever, hypertension, abdominal pain and dry, flushed skin may occur during circulatory overload. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? Hoarseness for 2 weeks Laryngitis following a cold Epistaxis, twice last week Aphonia following a football game

Hoarseness for 2 weeks

The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? How to manage the need for fluid restriction How to milk the chest tubing How to take prophylactic antibiotics correctly How to splint the incision when coughing

How to splint the incision when coughing

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Increased smooth muscle contractility Pulmonary hypotension Hypercapnia Systemic hypotension

Hypercapnia

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypotension, hyperoxemia, and hypercapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia

Hypercapnia, hypoventilation, and hypoxemia

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrome. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath.

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Impaired gas exchange Decreased cardiac output Anxiety

Impaired gas exchange

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? Position the client in bed with pillows placed under his knees to hasten venous return. Keep the client cool and uncovered to prevent elevated temperature. Keep the client from ambulating until the day after surgery. Implement leg exercises and turn the client in bed every 2 hours.

Implement leg exercises and turn the client in bed every 2 hours.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery? Inability to ambulate Alert and oriented ×4 Inability to see from left eye Voiding on a regular basis

Inability to ambulate

Which clinical manifestation of hemorrhage is related to carotid artery rupture? Increased blood pressure Shallow respirations Increased pulse rate Dry skin

Increased pulse rate

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is Acute pain related to upper airway irritation Deficient fluid volume related to increased fluid needs Deficient knowledge related to prevention of upper respiratory infections Ineffective airway clearance related to excess mucus production

Ineffective airway clearance related to excess mucus production

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Ineffective breathing pattern. Risk for falls. Ineffective airway clearance. Impaired tissue integrity.

Ineffective airway clearance.

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response? Explain the rationale for preoperative fasting to the client. Have the OR postpone the surgery due to the risk of aspiration Inform the anesthesiologist or surgeon of this fact. Assess the client's abdomen by inspection and auscultation.

Inform the anesthesiologist or surgeon of this fact.

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? Inform the client that anesthesia will prevent the bladder from emptying during surgery. Inform the operating room staff and assist the client to the bathroom. Insert a catheter into the bladder. Remind the client that bladder fullness is a common preoperative sensation.

Inform the operating room staff and assist the client to the bathroom.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs? Encourage sweet foods. Initiate enteral feedings. Offer plenty of thin liquids. Liberally season foods.

Initiate enteral feedings.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Initiate oxygen therapy. Administer a heparin bolus and begin an infusion at 500 units/hour. Perform nasopharyngeal suctioning. Administer analgesics as ordered.

Initiate oxygen therapy.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? Assist or place the client in a supine position for the exercises. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds. Instruct the client to place the palms of both hands along the upper posterior rib cage. Instruct the client to exhale gently and completely before inhaling.

Instruct the client to exhale gently and completely before inhaling.

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Intravenous therapy Monitoring edema Electrolyte management Nutrition management Fluid restriction Hypervolemia management

Intravenous therapy Electrolyte management Nutrition management

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)? It requires the client to hold a throat vibrator against the neck. It will result in a low, gruff-sounding voice. It enables the client to form words with the lips. It requires the insertion of a prosthesis into the trachea.

It requires the insertion of a prosthesis into the trachea.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. Ask the operating room staff to delay the procedure until the consent is signed. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Send the client to the operating room and inform the staff that the consent form needs to be signed.

Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery.

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? Cancer of the tonsils Laryngeal polyps Cancer of the pharynx Laryngeal cancer

Laryngeal cancer

The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy? Pain Xerostomia Dysphasia Laryngeal necrosis

Laryngeal necrosis

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 nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? Have the client perform incentive spirometry. Determine whether the client can now perform forced expiratory technique (FET). Percuss the client's lungs and thorax. Measure the client's oxygen saturation.

Measure the client's oxygen saturation.

The nurse is preparing a client for coronary artery bypass graft cardiac surgery. Which interventions should the nurse provide during the preoperative phase? Select all that apply. Assess the midsternal and leg dressings. Measure the legs for graduated compression stockings. Explain what to expect after the surgery. Instruct the client how to use the incentive spirometer. Prep the skin of the chest and legs with surgical prep.

Measure the legs for graduated compression stockings. Explain what to expect after the surgery. Instruct the client how to use the incentive spirometer.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Maintaining continuous bubbling in the water-seal chamber Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Keeping the collection chamber at chest level

Measuring and documenting the drainage in the collection chamber

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? Immediately administer a cleansing enema. Contact the physician to come assess the client. Monitor the client closely and promote fluid intake. Increase the rate of the client's intravenous infusion.

Monitor the client closely and promote fluid intake.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Offer small amounts of preferred beverage frequently. Leave water on the bedside table. Have a loved one tell the client to drink more. Ask the client every hour to drink more fluid.

Offer small amounts of preferred beverage frequently.

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? Place the client in the prone position. Do not administer any further medication. Place the client in a flat position with legs elevated 45 degrees. Remove extra coverings on the client to keep temperature down.

Place the client in a flat position with legs elevated 45 degrees

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? Instruct the client to perform Valsalva maneuver. Place the client in semi-Fowler's position. Assist the client to ambulate every 2 to 3 hours. Attempt to overhydrate the client with fluids.

Place the client in semi-Fowler's position.

The circulating nurse is caring for an older adult client undergoing removal of a liver tumor. The spouse is waiting in the family waiting area. Which actions by the nurse would be appropriate during the intraoperative phase? Select all that apply. Explain in detail to the client's spouse what is happening during the surgery. Provide emotional support to the client and spouse immediately before the surgery. Bring the client's spouse to be with the client as soon as possible. Notify the client's spouse when the procedure is over. Go into the waiting area to determine if the spouse has had something to eat and drink while waiting.

Provide emotional support to the client and spouse immediately before the surgery. Bring the client's spouse to be with the client as soon as possible. Notify the client's spouse when the procedure is over.

The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action? Refer the client to a social worker or psychologist. Provide the client with audiovisual materials about the surgery. Reassure the client and family that outcomes are nearly always positive. Give the client his or her cell phone number.

Provide the client with audiovisual materials about the surgery.

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? Exercise tolerance tests Chest x-ray Arterial blood gas values Pulmonary function studies

Pulmonary function studies

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Rate of the IV solution Manufacturer of the IV catheter Client's reaction to the procedure Type of IV solution Location of the IV catheter access Gauge and length of the IV catheter

Rate of the IV solution Client's reaction to the procedure Type of IV solution Location of the IV catheter access Gauge and length of the IV catheter

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? Measure the patient's pulse oximetry Record the observation Apply a compression dressing to the area Report the finding to the physician immediately

Record the observation

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which is the appropriate action for the nurse? Decontaminate the visible portion of the catheter, and then gently reinsert. Apply a new dressing and observe for signs of infection over the next several hours. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. Remove the IV catheter and reinsert another in a different location.

Remove the IV catheter and reinsert another in a different location.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Elevate the arm. Apply a warm compress. Slow the rate of IV fluids. Remove the IV.

Remove the IV.

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to Report decreased congestion. Use a room vaporizer to loosen secretions. Assume an upright position to facilitate drainage. Increase fluid intake.

Report decreased congestion.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Cardiac distress Wound infection Respiratory obstruction Dehydration

Respiratory obstruction

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Apply antiseptic and a dressing. Position the client on the left side. Restart infusion in another vein and apply a warm compress. Elevate the client's head.

Restart infusion in another vein and apply a warm compress.

The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Look on the chart for a living will if a durable power of attorney for health care cannot be located.

Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Ensuring that humidified oxygen is always introduced through the tube Routinely deflating the cuff Deflating the cuff before removing the tube Checking the cuff pressure every 6 to 8 hours

Routinely deflating the cuff

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Sacral area Abdomen Face Hands

Sacral area

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if a kink has developed in the tubing. See if the wall suction unit has malfunctioned. See if the chest tube is clogged. See if there are leaks in the system.

See if there are leaks in the system.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if the chest tube is clogged. See if the wall suction unit has malfunctioned. See if there are leaks in the system. See if a kink has developed in the tubing.

See if there are leaks in the system.

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis? Sinus x-rays Sinus aspirates CT scan MRI

Sinus aspirates

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: Do not perform saline irrigations to the nares. Sleep with the head of bed elevated. You may drink 1 glass of alcohol daily. Caffeinated beverages are allowed.

Sleep with the head of bed elevated.

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx? Sore throat Deviated trachea Facial pain Nausea

Sore throat

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. Oral route Spinal block Nerve block Inhalation Epidural block Intravenous

Spinal block Nerve block Epidural block

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first Exerts pressure against the worker's abdomen Places both arms around the worker's waist Makes a fist with one hand with the thumb outside the fist Stands behind the worker, who has hands across the neck

Stands behind the worker, who has hands across the neck

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Start an IV of normal saline as prescribed. Encourage fluid intake.

Start an IV of normal saline as prescribed.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? Stop the transfusion immediately. Infuse saline at a rapid rate. Prepare to give an antihistamine. Administer oxygen

Stop the transfusion immediately.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Sudden onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function

Sudden onset of lung impairment in a client who had normal lung function

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply. Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present. Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present. Local or systemic manifestations may indicate an infection is present at the site. Bleeding at the site when the IV is discontinued indicates an infection is present.

Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? Hand-held showers Swimming Wearing a scarf over the stoma Coughing

Swimming

A nurse is responsible for monitoring indicators of potential complications after laryngectomy. Which indicators would be priority concerns? Select all that apply. Tachycardia and tachypnea Persistent high tracheostomy cuff pressure Impaired swallowing Rapid capillary refill Somnolence and hypotension

Tachycardia and tachypnea Persistent high tracheostomy cuff pressure Impaired swallowing Somnolence and hypotension

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? Assist the client to a side-lying position to cough. Teach the client how to splint the abdomen while coughing. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. Administer respiratory treatments to encourage coughing.

Teach the client how to splint the abdomen while coughing.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Pulmonary contusion Flail chest Cardiac tamponade Tension pneumothorax

Tension pneumothorax

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home? The client is alert and oriented with a blood pressure 122/74 mm Hg and respirations 18 breaths/min, able to ambulate, is not nauseated or vomiting, reports a pain level of 5 on a 0-10 scale, and has no excessive bleeding or drainage. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. The client is alert and oriented with a blood pressure of 136/90 mmHg and respirations 18 breaths/minute, states mild nausea but no vomiting, pain under control with pain medication, able to void and pass gas, and has mild expected drainage. The client is alert and oriented with a blood pressure 102/60 mm Hg and respirations 18 breaths/minute, is slightly dizzy, but not nauseated or vomiting, denies pain, and has no excessive bleeding or drainage.

The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.

A client has had laryngeal surgery. What are the expected client outcomes? Select all that apply. The client maintains an adequate caloric intake. The client can manage his or her own secretions. The client can swallow without difficulty. The client's breathing patterns improve. The client's suture line remains intact.

The client maintains an adequate caloric intake. The client can manage his or her own secretions. The client's suture line remains intact.

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application? The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs. The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots. The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots.

The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? The client has a decreased sensation of thirst. Urine becomes more diluted. The renal system retains more water. The frequency of voiding increases.

The renal system retains more water.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The system has an air leak. The chest tube is obstructed. The client has a pneumothorax.

The system has an air leak.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Absence of bloody drainage in the anterior/upper tube The tissues give a crackling sensation when palpated. Bloody drainage is observed in the collection chamber. Skin around tube is pink.

The tissues give a crackling sensation when palpated.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Tighten the roller clamp to stop the infusion. Milk the air in the direction of the drip chamber. Tap the tubing below the air bubbles. Twist the tubing around a pencil.

Tighten the roller clamp to stop the infusion.

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? CBC with differential Nasal culture Transillumination of the sinus Magnetic resonance imaging (MRI)

Transillumination of the sinus

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy? Recommend the long-term use of zinc lozenges Season food to suit an increased sense of taste and smell Offer plenty of thin liquids when intake resumes Use enteral feedings after the procedure

Use enteral feedings after the procedure

Which statement most accurately describes the process of osmosis? Water shifts from high-solute areas to areas of lower solute concentration. Solutes pass through semipermeable membranes to areas of lower concentration. Water moves from an area of lower solute concentration to an area of higher solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries.

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? Weigh the client before and after meals. Weigh the client without soiled incontinence pads. Weigh the client's wet linen or dressing. Weigh the volume of IV fluid before instilling.

Weigh the client's wet linen or dressing.

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? a feeling of swelling at the back of the throat headaches in the morning weight loss discomfort when drinking cold liquids

a feeling of swelling at the back of the throat

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: a partial airway obstruction. the normal return of reflexes. the effects of anesthesia. the type of surgery.

a partial airway obstruction.

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have difficulty swallowing foods" trouble with your breathing" a foul odor to your breath" a persistent cough or sore throat"

a persistent cough or sore throat"

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: a winged infusion needle. an 18-gauge needle. an intermittent infusion device. a central venous access.

a winged infusion needle.

A client has presented to a clinic for a preoperative consult, during which the client has expressed concern about having to fast before surgery. What should the nurse discuss with the client reflecting current standards by the American Society of Anesthesiologists related to fasting prior to surgery? allowing clear liquids up to 2 hours before surgery with an order by the health care provider not eating or drinking anything after midnight the night before surgery fasting is still often recommended as medically unnecessary allowing eating and drinking until just prior to anesthetic being administered

allowing clear liquids up to 2 hours before surgery with an order by the health care provider

A nurse explains the effects of conscious sedation to a client undergoing a colonoscopy. Which of the following occurs with conscious sedation? altered mood loss of cardiopulmonary function lowered pain threshold total amnesia

altered mood

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is amoxicillin-clavulanic acid. cefprozil. cefuroxime. ampicillin.

amoxicillin-clavulanic acid.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a woman age 45 years a man age 50 years an infant age 4 months an adolescent age 17 years

an infant age 4 months

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? an older adult man with a fractured hip an adolescent having arthroscopic surgery a woman experiencing a cesarean birth a young adult with a fractured leg

an older adult man with a fractured hip

The nurse knows the term perioperative phase refers to care given to the client: before, during, and after the operative phase. immediately before an operative procedure. immediately after the operative phase. from the start of surgery until its conclusion.

before, during, and after the operative phase.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and chloride calcium and phosphorus potassium and sodium chloride and magnesium

calcium and phosphorus

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? cardiac function optic function auditory function skeletal function

cardiac function

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for pulmonary embolism. dehydration. pneumonia. carotid artery hemorrhage.

carotid artery hemorrhage.

Which is a common anion? calcium chloride magnesium potassium

chloride

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: turn and reposition himself every 2 hours. continue to take antibiotics for the entire 10 days. follow up with the physician in 2 weeks. maintain fluid intake of 40 oz (1,200 ml) per day.

continue to take antibiotics for the entire 10 days.

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. administering inhalation anesthetics counting sponges before and after surgery positioning the client on the operating table administering regional nerve blocks monitoring the client's vital signs

counting sponges before and after surgery positioning the client on the operating table monitoring the client's vital signs

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration increased blood volume and intracellular dehydration decreased blood volume and intracellular dehydration

decreased blood volume and intracellular dehydration

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply. decreased peripheral circulation decreased thermoregulation ability increased oxygenation of blood increased cardiac output increased vascular rigidity

decreased peripheral circulation decreased thermoregulation ability increased vascular rigidity

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? hemorrhage alterations in fluid and electrolyte balance delayed wound healing and wound infection nutritional maintenance

delayed wound healing and wound infection

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching nausea and vomiting fingerprinting over sternum distended neck veins

distended neck veins

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? diagnostic surgery elective surgery emergency surgery palliative surgery

emergency surgery

Edema happens when there is which fluid volume imbalance? water deficit extracellular fluid volume deficit water excess extracellular fluid volume excess

extracellular fluid volume excess

The process of filtration begins at the: glomerulus. Loop of Henle. collecting ducts. Bowman's capsule.

glomerulus.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? hemolytic transfusion reaction: incompatibility of blood product allergic reaction: allergy to transfused blood bacterial reaction: bacteria present in the blood febrile reaction: fever develops during infusion

hemolytic transfusion reaction: incompatibility of blood product

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? isotonic hypertonic hypotonic plasma

hypertonic

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? hypermagnesemia hypophosphatemia hypocalcemia hypokalemia

hypocalcemia

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? hyponatremia hypokalemia hypermagnesemia hypercalcemia

hypokalemia

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? hypervolemia hypovolemia circulatory overload edema

hypovolemia

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? risk for chronic low self-esteem risk for infection impaired verbal communication deficient knowledge

impaired verbal communication

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? increased capillary permeability increased hydrostatic pressure decreased colloid oncotic pressure blockage of the lymph nodes

increased hydrostatic pressure

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis? excessive protein intake increased exposure to the health care environment more than 8 hours of sleep per night interference with sinus drainage

interference with sinus drainage

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? isotonic hypertonic colloid hypotonic

isotonic

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that: laryngeal cancer occurs primarily in women. laryngeal cancer is one of the most preventable types of cancer. inhaling polluted air isn't a risk factor for laryngeal cancer. adenocarcinoma accounts for most cases of laryngeal cancer.

laryngeal cancer is one of the most preventable types of cancer.

A client who has been diagnosed with an early glottis cancer would likely undergo which type of surgery? laser microsurgery vocal cord stripping total laryngectomy partial laryngectomy

laser microsurgery

A client will be having a surgical procedure requiring general anesthesia. Which desired outcomes of general anesthesia does the nurse expect to observe? Select all that apply. loss of consciousness depressed reflexes relaxed skeletal muscles loss of sensation in specific area analgesia

loss of consciousness depressed reflexes relaxed skeletal muscles analgesia

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: low calcium. high magnesium. low potassium. high sodium.

low calcium.

The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene? massages legs prior to application elevates the legs 15 minutes after applying stockings measures calf circumference cleanses hands with alcohol-based hand rub

massages legs prior to application

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply. medications given in operating room performance of time-out before surgery drains inserted in surgery length of surgery all personnel present in operating room

medications given in operating room drains inserted in surgery length of surgery

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? diminished cognitive ability and hypertension nausea, vomiting, and constipation muscle weakness, fatigue, and constipation muscle cramping and tetany

muscle cramping and tetany

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? muscle cramping and tetany diminished cognitive ability and hypertension muscle weakness, fatigue, and constipation nausea, vomiting, and constipation

muscle cramping and tetany

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: level of consciousness (LOC). extremities for signs of cyanosis. oxygen saturation level. hemoglobin, hematocrit, and red blood cell levels.

oxygen saturation level.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.35, PaCO2 48 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.46, PaO2 80 mm Hg

pH 7.28, PaO2 50 mm Hg

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? paralytic ileus abdominal infection hernia development normal response

paralytic ileus

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: rapid fluid administration. a systemic blood infection. phlebitis. an infiltration.

phlebitis.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets cryoprecipitate albumin granulocytes

platelets

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as consolidation. hemothorax. pleural effusion. pneumothorax.

pleural effusion.

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? preoperative intraoperative postoperative postanesthesia care unit (PACU)

preoperative

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? informed consent preoperative checklist procedural pause (time-out) operative site marking

procedural pause (time-out)

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? procedural pause (time-out) preoperative checklist informed consent operative site marking

procedural pause (time-out)

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options. The nurse monitors the client for Select...muscle weakness, purulent nasal drainage, polyphagia Select..., a finding indicative of Select...rhinosinusitis, bacterial pharyngitis, viral pneumonia Select..., a noted complication of nasogastric tubes.

purulent nasal drainage rhinosinusitis

A decrease in arterial blood pressure will result in the release of: insulin. protein. thrombus. renin.

renin

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: sit upright, leaning slightly forward. blow his nose and then put lateral pressure on his nose. hold his nose while bending forward at the waist. lie supine with his neck extended.

sit upright, leaning slightly forward.

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? altered metabolism and excretion of drugs fluid and electrolyte imbalance respiratory depression from anesthesia slow wound healing

slow wound healing

The primary extracellular electrolytes are: phosphorous, calcium, and phosphate. magnesium, sulfate, and carbon. potassium, phosphate, and sulfate. sodium, chloride, and bicarbonate.

sodium, chloride, and bicarbonate.

Who is legally responsible for obtaining the client's informed consent for a surgical procedure? the surgeon the registered nurse the admissions clerk any licensed person

the surgeon

The nurse recognizes that palliative surgery is performed for what purpose? to make or confirm a diagnosis to remove a part of the body that is diseased to lessen the intensity of an illness to restore function to tissue that is traumatized

to lessen the intensity of an illness

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action? to reduce the potential for blood clots to avoid restriction of mobility to prevent compromising circulation to prevent pain and discomfort

to prevent compromising circulation

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? exhibit no bleeding void normally eat without nausea verbalize absence of pain

void normally