EXAM 3 PREPU
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? A. "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." B. "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." C."Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." D."That's correct, but be sure that you don't increase your laxative doses over time."
A. "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A. 24-hour specimen B. clean-catch specimen C. random specimen D. intermittent specimen
A. 24-hour specimen
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? A. 3 in (7.5 cm) B. 1 in (2.5 cm) C. 2 in (5.0 cm) D. 5 in (12.5 cm)
A. 3 in (7.5 cm)
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? A. A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min B. A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence C. A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm D. A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min
A. A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency).
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? A. Coarse crackles B. Pleural friction rubs C. Sonorous wheezes D. Sibilant wheezes
A. Coarse crackles
There are two types of antitussives, centrally acting and peripherally acting. Which are centrally acting antitussives? (Select all that apply.) A. Codeine B. Dextromethorphan C. Guaifenesin D. Benzonatate E. Eucalyptus
A. Codeine B. Dextromethorphan
The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? A. Crackles in the lower lobes B. Inspiratory stridor C. Expiratory stridor D. Wheezing in the upper lobes
A. Crackles in the lower lobes
A 27-year-old athlete with newly diagnosed asthma presents for patient education regarding situations that could precipitate an asthma attack. The nurse teaches that acute episodes of asthma may last minutes to hours. In this teaching, which precipitants would the nurse state may cause the asthma? (Select all that apply.) A. Exercise B. Allergens C. Pollutants D. Warm weather
A. Exercise B. Allergens C. Pollutants
A patient has an increased respiratory rate. Which causes an increased respiratory rate? A. Increased carbon dioxide C. Decreased carbon dioxide D. Increased oxygen E. Decreased pH
A. Increased carbon dioxide
Which structure in the brain controls respiration? A. Medulla B. Pons C. Thalamus D. Hypothalamus
A. Medulla
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? A. Pleural effusion B. Tachypnea C. Wheezes D. Pneumonia
A. Pleural effusion
A client is being evaluated for a possible diagnosis of emphysema. What client characteristic should the nurse monitor to provide evidence of the disorder? A. Respiratory expiration B. Respiratory inspiration C. Presence of a fever D. Evidence of underlying trauma
A. Respiratory expiration Chronic obstructive pulmonary disease is caused by two related disorders—emphysema and chronic bronchitis—both of which result in airflow obstruction on expiration,
An instructor is teaching a class about the disorders that may affect the movement of gases into and out of the lungs. The instructor determines the need for additional teaching when the students identify which condition as being involved? A. Sinusitis B. Bronchitis C. Atelectasis D. Cystic fibrosis
A. Sinusitis ---this is upper respiratory----
After teaching a group of students about inhaled steroids, the instructor determines that the teaching was successful when the students state: A. The drugs are not for use during an acute attack. B. The drugs are systemically absorbed when inhaled. C. The drugs action leads to suppression of beta adrenergic receptor activity. D. The drugs are slowly absorbed from the respiratory tract.
A. The drugs are not for use during an acute attack
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: A. atelectasis. (Stiff lungs) B. bronchospasm. (tightening of the muscles that line the airways) C. croup. (upper airway infection that blocks breathing and has a distinctive barking cough) D. epiglottitis.
A. atelectasis.
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? A. cloudy, foul odor B. light yellow, clear C. clear, dark amber D. strongly aromatic, amber
A. cloudy, foul odor
The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? A. Right lateral B, Left lateral C. Prone D. Semi-Fowler's
B, Left lateral
Which range for urine output in 24 hours is considered normal for an adult? A. 1,000-1,200 mL B. 1,200-1,500 mL C. 1,600-1,900 mL D. 2,000-2,400 mL
B. 1,200-1,500 mL
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? A. Ask the client if he left his earplugs in his ears. B. Check the client's ear canals for cerumen. C. Use facial expressions and sign language to communicate. D. Speak to the older adult client in a high-frequency tone of voice.
B. Check the client's ear canals for cerumen.
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? A. Fine crackles B. Coarse crackles C. Sibilant wheeze D. Sonorous wheeze
B. Coarse crackles
A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client? A. Movement of all extremities B. Depth of respirations C. Level of consciousness D. Sensation in extremities
B. Depth of respirations
Which agent would a nurse expect the health care provider to prescribe for a client experiencing motion sickness? A. Clemastine B. Meclizine C. Cyproheptadine D. Hydroxyzine
B. Meclizine
Inspection of the female external genitalia begins with what? A. Inguinal area B. Mons pubis C. Pubic hair D. Skin
B. Mons pubis
The client uses his sympathomimetic inhaler frequently. The nurse evaluates the client for which of the following symptoms related to frequent use of the sympathomimetic inhaler? A. Fatigue B. Nervousness C. Bradycardia D. Hypotension
B. Nervousness
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? A. The client is on a low protein diet. B. The client is dehydrated. C. The client has a history of osteoarthritis. D. The client is lactose intolerant.
B. The client is dehydrated.
The nurse is assessing an adult male client when the nurse observes gynecomastia in the client. The nurse should ask the client if he is taking any medications for A. inflammation. B. depression. C. infection. D. ulcers.
B. depression.
The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be prescribed? A. vitamin A B. vitamin B12 C. vitamin C D. vitamin D
B. vitamin B12 This helps prevent vitamin B12-deficiency anemia, which can occur because ileostomies are placed before the terminal ileum where vitamin B12 is absorbed.
The client has been diagnosed with asthma and is being treated with two inhalers, albuterol and flunisolide. The nurse teaches the client that the two medications should be administered in what order? A. Flunisolide first, wait five minutes and then follow with albuterol B.Albuterol first, wait five minutes and then follow with flunisolide C.Flunisolide followed immediately by albuterol D. Albuterol followed immediately by flunisolide
B.Albuterol first, wait five minutes and then follow with flunisolide
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? A. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." B. "Take in a small amount of air very quickly and then exhale as quickly as possible." C. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." D. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
C. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe? A. Spontaneous pneumothorax B. Chronic obstructive pulmonary disease (COPD) C. Asthma D. Pneumonia
C. Asthma
A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? A. Expand the thoracic cavity. B. Relax the respiratory muscles. C. Contract the abdominal muscles. D. Elevate the ribs and sternum.
C. Contract the abdominal muscles
A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority? A. Movement of lower leg B. Adequacy of circulation C. Patency of airway D. Neurovascular status of the left leg
C. Patency of airway
While reviewing a client's history, an allergy to which of the following would alert the nurse to a possible problem with the use of ipratropium? A. Eggs B. Dairy C. Peanuts D. Shellfish
C. Peanuts
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? A. Hyperresonance B. Dullness C. Resonance D. Tympany
C. Resonance
The spinous process termed the vertebra prominens is in which cervical vertebra? A. Fifth. B. Sixth. C. Seventh. D. Eighth.
C. Seventh
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? A. Fine crackles occurring late in inspiration B. Course crackles occurring from early inspiration to early expiration C. Sibilant wheezes heard primarily during expiration but may also be heard on inspiration D. Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle
C. Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? A. They are loud, high-pitched sounds heard primarily over the trachea and larynx. B. They are medium-pitched blowing sounds heard over the major bronchi. C. They are low-pitched, soft sounds heard over peripheral lung fields. D. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
C. They are low-pitched, soft sounds heard over peripheral lung fields.
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? A. tap water B. normal saline C. distilled water D. mineral oil
C. distilled water
The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client? A. "You need to sign up for the clinic's stop smoking program." B. "You should decrease your intake of fried foods." C. "It is important for you to do 30 minutes of exercise three times a week." D. "Take your blood pressure medications exactly as your doctor prescribed them."
D. "Take your blood pressure medications exactly as your doctor prescribed them."
A client is prescribed an antitussive agent with codeine. Which statement by the client indicates that the nurse's teaching has been effective? A. "I will take this medication whenever I am coughing." B. "This medication will make me anxious and nervous." C. "I will call my health care provider if I develop diarrhea when I take it." D. "This medication will cause drowsiness, and I will not drive."
D. "This medication will cause drowsiness, and I will not drive."
A client reports a hacking cough. The client asks if taking an antihistamine would be helpful. The nurse's best response is: A. Antihistamines are not used for this issue. B. Antihistamines are recommended for extended use, as long as you monitor for adverse effects. C. Antihistamines are not recommended for this issue; only antibiotics are useful. D. Antihistamines are not recommended because they can dry lower respiratory secretions and worsen secretion retention and cough.
D. Antihistamines are not recommended because they can dry lower respiratory secretions and worsen secretion retention and cough.
Which medication causes constipation? A. Magnesium antacids B. Bisacodyl C. Aspirin D. Iron supplements
D. Iron supplements
A nurse on rounds observes that a client who has been eating food rather hastily has begun to cough. The nurse knows that if food accidentally becomes lodged in a particular structure of the respiratory system that coughing can usually dislodge it. Based on this information which structure of the respiratory system does this involve? A. Trachea B. Esophagus C. Epiglottis D. Larynx
D. Larynx
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? A. Auscultate for the presence of crackles B. Palpate for tactile fremitus C. Percuss to determine diaphragmatic excursion D. Observe for the use of accessory muscles
D. Observe for the use of accessory muscles
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A. Spontaneous pneumothorax B. Chronic obstructive pulmonary disease (COPD) C. Asthma D. Pneumonia
D. Pneumonia
Due to complications, a male postoperative patient has been unable to mobilize for several days following surgery and has developed atelectasis. Which process would his care team anticipate with relation to his health problem? A. Vasodilation in the alveolar vessels in the affected region of his lung B. Increased workload for the left side of the patient's heart C.Increased blood flow to the area of atelectasis D. Redirection of blood flow into the lung regions that are hypoxic
D. Redirection of blood flow into the lung regions that are hypoxic
Elevated sebaceous glands, known as Montgomery glands, are located in the breast's A. nipples. B. hair follicles. C. lactiferous ducts. D. areolas.
D. areolas.
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: A. atelectasis. B. pulmonary fibrosis. C. asthma. D. croup.
D. croup.
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? A. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. B.Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. C. Ask the client to bear down until the catheter is expelled. D. Remove the catheter from the vagina and attempt to insert it into the bladder.
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? A. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. B.Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. C. Ask the client to bear down until the catheter is expelled. D. Remove the catheter from the vagina and attempt to insert it into the bladder.