helpful prep u questions

a nurse performs an ABG sampling at 0930 on a client who has a heparin drip infusing. at which of the following times will it be appropriate for the nurse to discontinue holding pressure on the puncture site 0935 0940 0945 0950

0950

A physician has ordered amoxicillin 100 P.O. BID (Ampicillin). The nurse should teach the client to: Select all that apply. 1. Drink 2,500 mL of fluids daily. 2. Void frequently, at least every 2 to 3 hours. 3. Take time to empty the bladder completely. 4. Take the last dose of the antibiotic for the day at bedtime. 5. Take the antibiotic with food.

1, 2, 3, 4. Ampicillin may be given with or without food, but the nurse should instruct the client to obtain an adequate fluid intake (2,500 mL) to promote urinary output and to flush out bacteria from the urinary tract. The nurse should also encourage the client to void frequently (every 2 to 3 hours) and empty the bladder completely. Taking the antibiotic at bedtime, after emptying the bladder, helps to ensure an adequate concentration of the drug during the overnight period.

The nurse is teaching a client newly diagnosed with prostate cancer. Which of the following points should be included in the instruction? Select all that apply. 1. Prostate cancer is usually multifocal and slow-growing. 2. Most prostate cancers are adenocarcinoma. 3. The incidence of prostate cancer is higher in African American men, and the onset is earlier. 4. A prostate specific antigen (PSA) lab test greater than 4 ng/mg will need to be monitored. 5. Cancer cells are detectable in the urine.

1, 2, 3, 4. Cancer of the prostate gland is the second-leading cause of cancer death among American men and is the most common carcinoma in men older than age 65. Incidence of prostate cancer is higher in African American men, and onset is earlier. Most prostate cancers are adenocarcinoma. Prostate cancer is usually multifocal, slow-growing, and can spread by local extension, by lymphatics, or through the bloodstream. Prostate-specific antigen (PSA) greater than 4 ng/mg is diagnostic; a free PSA level can help stratify the risk of elevated PSA levels. Metastatic workup may include skeletal x-ray, bone scan, and CT or MRI to detect local extension, bone, and lymph node involvement. The urine does not have prostate cancer cells.

When caring for a client with a history of benign prostatic hypertrophy (BPH), the nurse should do which of the following? Select all that apply. 1. Provide privacy and time for the client to void. 2. Monitor intake and output. 3. Catheterize the client for post void residual urine. 4. Ask the client if he has urinary retention. 5. Test the urine for hematuria.

1, 2, 4, 5. Because of the history of benign prostatic hypertrophy (BPH), the nurse should provide privacy and time for the client to void. The nurse should also monitor intake and output, assess the client for urinary retention, and test the urine for hematuria. It is not necessary to catheterize the client.

A client is to have radiation therapy after a modified radical mastectomy. The nurse should teach the client to care for the skin at the site of therapy by: 1. Washing the area with water. 2. Exposing the area to dry heat. 3. Applying an ointment to the area. 4. Using talcum powder on the area.

1. A client receiving radiation therapy should avoid lotions, ointments, and anything that may cause irritation to the skin, such as exposure to sunlight, heat, or talcum powder. The area may safely be washed with water if it is done gently and if care is taken not to injure the skin.

A client asks the nurse, "Where is cancer usually found in the breast?" When responding to the client, the nurse uses a diagram of a left breast and indicates that most malignant tumors occur in which quadrant of the breast? 1. Upper outer quadrant. 2. Upper inner quadrant. 3. Lower outer quadrant. 4. Lower inner quadrant.

1. About half of malignant breast tumors occur in the upper outer quadrant of the breast. For no known reason, cancer appears in the left breast more often than in the right breast. The upper outer quadrants of the breast, and especially the axillary area, should be covered thoroughly in the clinical breast examination and breast self-examination.

During the admission workup for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which of the following approaches would offer the best guide for the nurse to answer questions raised by this apprehensive preoperative client? 1. Tell the client as much as she wants to know and is able to understand. 2. Delay discussing the client's questions with her until she is convalescing. 3. Delay discussing the client's questions with her until her apprehension subsides. 4. Explain to the client that she should discuss her questions first with the physician.

1. An important nursing responsibility is preoperative teaching, and the most frequently recommended guide for teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues about which the client has concerns is likely to aggravate the situation and cause the client to feel distrust. As a general guide, the client would not ask the question if she were not ready to discuss her situation. The nurse is available to answer the client's questions and concerns and should not delay discussing these with the client.

A 65-year-old client has been told by the physician that his prostate cancer was graded at stage IIB. The client inquires if this means he is going to die soon. The best response by the nurse is which of the following? 1. "Prostate cancer at this stage is very slow growing." 2. "Prostate cancer at this stage is very fast growing." 3. "Prostate cancer at this stage has spread to the bone." 4. "Prostate cancer at this stage is difficult to predict."

1. Clients who have stage IA or IIB prostate cancer have an excellent survival rate. Prostate cancer is usually slow growing, and many men who have prostate cancer do not die from it. A stage I or II tumor is confined to the prostate gland and has not spread to the extrapelvic region or bone

A priority nursing diagnosis for the client who is being discharged to home 3 days after transurethral resection of the prostate (TURP) is: 1. Deficient fluid volume. 2. Imbalanced nutrition: Less than body requirements. 3. Impaired tissue integrity. 4. Ineffective airway clearance.

1. Deficient fluid volume is a priority diagnosis because the client needs to drink a large amount of fluids to keep the urine clear. The urine should be almost without color. About 2 weeks after TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the surgeon or go to the emergency department if at any time the urine turns bright red. The client is not specifically at risk for nutritional problems after TURP. The client is not specifically at risk for impaired tissue integrity because there is no external incision, and the client is not specifically at risk for airway problems because the procedure is done under spinal anesthesia.

A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about a breast prosthesis and wigs. After answering the questions directly, the nurse should also: 1. Provide a list of resources, including the local breast cancer support group. 2. Offer a referral to the social worker. 3. Call the home health care agency. 4. Contact the plastic surgeon.

1. Giving the client a list of community resources that could provide support and guidance assists the client to maintain her self-image and independence. The support group will include other women who have undergone similar therapies and can offer suggestions for breast products and wigs. Because the client is asking about specific resources, she does not need a referral to a social worker, home health agency, or plastic surgeon.

The nurse is performing a digital rectal examination. Which of the following finding is a key sign for prostate cancer? 1. A hard prostate, localized or diffuse. 2. Abdominal pain. 3. A boggy, tender prostate. 4. A nonindurated prostate.

1. On digital rectal examination, key signs of prostate cancer are a hard prostate, induration of the prostate, and an irregular, hard nodule. Accompanying symptoms of prostate cancer can include constipation, weight loss, and lymphadenopathy. Abdominal pain usually does not accompany prostate cancer. A boggy, tender prostate is found with infection (e.g., acute or chronic prostatitis).

A 72-year-old male is in the emergency department because he has been unable to void for the past 12 hours. The best method for the nurse to use when assessing for bladder distention in a male client is to check for: 1. A rounded swelling above the pubis. 2. Dullness in the lower left quadrant. 3. Rebound tenderness below the symphysis. 4. Urine discharge from the urethral meatus.

1. The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate.

The primary reason for taping an indwelling catheter laterally to the thigh of a male client is to: 1. Eliminate pressure at the penoscrotal angle. 2. Prevent the catheter from kinking in the urethra. 3. Prevent accidental catheter removal. 4. Allow the client to turn without kinking the catheter.

1. The primary reason for taping an indwelling catheter to a male client so that the penis is held in a lateral position is to prevent pressure at the penoscrotal angle. Prolonged pressure at the penoscrotal angle can cause a ureterocutaneous fistula.

A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's first course of action is to: 1. Do a breast examination and report the results to the physician. 2. Explain that pain is caused by hormonal fluctuations. 3. Reassure the client that pain is not a symptom of breast cancer. 4. Teach the client the correct procedure for breast self-examination (BSE).

1. This complaint warrants the nurse's performing an examination and reporting the results to the physician. Hormone fluctuations do cause breast discomfort, but an examination must be done at this time to assess the breast. Although pain is not common with breast cancer, it can be a symptom. Teaching the client to perform BSE is important, but it is not the priority action in this case.

the nurse is suctioning a client who had a laryngectomy. what is the maximum amount of time the nurse should suction the client • 10 sec • 15 sec • 25 sec • 30 sec

10 sec

a client requires IV vancomycin for antibiotic-resistant pneumonia. the order calls for 500 mg to be administered and the medication is supplied in a 100 mL piggyback that contains 5 mg per 1 mL to run over 1 hour. in order to administer the correct dose, a nurse should set the infusion pump to run at a rate of ___ ml per hour

100

A client with prostate cancer is treated with hormone therapy consisting of diethylstilbestrol (DES; Stilphostrol), 2 mg daily. The nurse should instruct the client to expect to have: 1. Tenderness of the scrotum. 2. Tenderness of the breasts. 3. Loss of pubic hair. 4. Decreased blood pressure

2. Diethylstilbestrol causes engorgement and tenderness of the breasts (gynecomastia). Stilbestrol is prescribed as palliative therapy for men with androgen-dependent prostatic carcinoma. An increase in blood pressure can occur. Tenderness of the scrotum and dramatic changes in secondary sexual characteristics should not occur.

In discussing home care with a client after transurethral resection of the prostate (TURP), the nurse should teach the male client that dribbling of urine: 1. Can be a chronic problem. 2. Can persist for several months. 3. Is an abnormal sign that requires intervention. 4. Is a sign of healing within the prostate.

2. Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.

A 28-year-old male is diagnosed with acute epididymitis. The nurse should assess the client for: 1. Burning and pain on urination. 2. Severe tenderness and swelling in the scrotum. 3. Foul-smelling ejaculate. 4. Foul-smelling urine.

2. Epididymitis causes acute tenderness and pronounced swelling of the scrotum. Gradual onset of unilateral scrotal pain, urethral discharge, and fever are other key signs. Epididymitis is occasionally, but not routinely, associated with urinary tract infection. Burning and pain on urination and foul smelling ejaculate or urine are not classic symptoms of epididymitis.

The primary reason for lubricating the urinary catheter generously before inserting it into a male client is that this technique helps reduce: 1. Spasms at the orifice of the bladder. 2. Friction along the urethra when the catheter is being inserted. 3. The number of organisms gaining entrance to the bladder. 4. The formation of encrustations that may occur at the end of the catheter.

2. Liberal lubrication of the catheter before catheterization of a male reduces friction along the urethra and irritation and trauma to urethral tissues. Because the male urethra is tortuous, a liberal amount of lubrication is advised to ease catheter passage. The female urethra is not tortuous, and, although the catheter should be lubricated before insertion, less lubricant is necessary. Lubrication of the catheter will not decrease spasms. The nurse should use sterile technique to prevent introducing organisms. Crusts will not form immediately. Irrigating the catheter as needed will prevent clot and crust formation.

A client is undergoing a total prostatectomy for prostate cancer. The client asks questions about his sexual function. The best response by the nurse is which of the following? 1. "Loss of the prostate gland means that you will be impotent." 2. "Loss of the prostate gland means that you will be infertile and there will be no ejaculation. You can still experience the sensations of orgasm." 3. "Loss of the prostate gland means that you will have no loss of sexual function and drive." 4. "Loss of the prostate gland means that your erectile capability will return immediately after surgery."

2. Loss of the prostate gland interrupts the flow of semen, so there will be no ejaculation fluid. The sensations of orgasm remain intact. The client needs to be advised that return of erectile capability is often disrupted after surgery, but within 1 year 95% of men have returned to normal erectile function with sexual intercourse.

The nurse is developing a program about prostate cancer for a health fair. The nurse should provide information about which of the following topics? 1. The Prostate-Specific Antigen (PSA) test is reliable for detecting the presence of prostate cancer. 2. For all men, age 50 and older, the American Cancer Society recommends an annual rectal examination. 3. Avoid lifting more than 20 lb aids in prevention of prostate cancer. 4. Regular sexual activity promotes health of the prostate gland to prevent cancer.

2. Most prostate cancer is adenocarcinoma and is palpable on rectal examination because it arises from the posterior portion of the gland. Although the PSA is not a perfect screening test, the American Cancer Society recommends an annual rectal examination and blood PSA level for all men age 50 and older, or starting at age 40 if African American or if there is family history of prostate cancer. To help achieve optimal sexual function, give the client the opportunity to communicate his concerns and sexual needs. Regular sexual activity does not prevent cancer.

The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal? 1. Soft. 2. Egg-shaped. 3. Spongy. 4. Lumpy.

2. Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the physician.

Many older men with prostatic hypertrophy do not seek medical attention until urinary obstruction is almost complete. One reason for this delay in seeking attention is that these men may: 1. Feel too self-conscious to seek help when reproductive organs are involved. 2. Expect that it is normal to have to live with some urinary problems as they grow older. 3. Fear that sexual indiscretions in earlier life may be the cause of their problem. 4. Have little discomfort in relation to the amount of pathology because responses to pain stimuli fade with age.

2. Research shows that older men tend to believe it is normal to live with some urinary problems. As a result, these men often overlook symptoms and simply attribute them to aging. As part of preventive care for men older than age 40, the yearly physical examination should include palpation of the prostate via rectal examination. Prostate specific antigen screening also is done annually to determine elevations or increasing trends in elevations. The nurse should teach male clients the value of early detection and adequate follow-up for the prostate.

The nurse should specifically assess a client with prostatic hypertrophy for which of the following ? 1. Voiding at less frequent intervals. 2. Difficulty starting the flow of urine. 3. Painful urination. 4. Increased force of the urine stream.

2. Signs and symptoms of prostatic hypertrophy include difficulty starting the flow of urine, urinary frequency and hesitancy, decreased force of the urine stream, interruptions in the urine stream when voiding, and nocturia. The prostate gland surrounds the urethra, and these symptoms are all attributed to obstruction of the urethra resulting from prostatic hypertrophy. Nocturia from incomplete emptying of the bladder is common. Straining and urine retention are usually the symptoms that prompt the client to seek care. Painful urination is generally not a symptom of prostatic hypertrophy.

The client with breast cancer is prescribed tamoxifen (Nolvadex) 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. The nurse's best response is which of the following? 1. "This drug is part of your chemotherapy program." 2. "This drug has been found to decrease metastatic breast cancer." 3. "This drug will act as an estrogen in your breast tissue." 4. "This drug will prevent hot fl ashes since you cannot take hormone replacement."

2. Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

Risk factors associated with testicular malignancies include: 1. African-American race. 2. Residing in a rural area. 3. Lower socioeconomic status. 4. Age older than 40 years.

2. The incidence of testicular cancer is higher in men who live in rural rather than suburban areas. Testicular cancer is more common in white than black men. Men with higher socioeconomic status seem to have a greater incidence of testicular cancer. The exact cause of testicular cancer is unknown. Cancer of the testes is the leading cause of death from cancer in the 15- to 35-year-old age group.

A right orchiectomy is performed on a client with a testicular malignancy. The client expresses concerns regarding his sexuality. The nurse should base the response on the knowledge that the client: 1. Is not a candidate for sperm banking. 2. Should retain normal sexual drive and function. 3. Will be impotent. 4. Will have a change in secondary sexual characteristics.

2. Unilateral orchiectomy alone does not result in impotence if the other testis is normal. The other testis should produce enough testosterone to maintain normal sexual drive, functioning, and characteristics. Sperm banking before treatment is commonly recommended because radiation or chemotherapy can affect fertility.

A client diagnosed with seminomatous testicular cancer expresses fear and questions the nurse about his prognosis. The nurse should base the response on the knowledge that: 1. Testicular cancer is almost always fatal. 2. Testicular cancer has a cure rate of 90% when diagnosed early. 3. Surgery is the treatment of choice for testicular cancer. 4. Testicular cancer has a 50% cure rate when diagnosed early.

2. When diagnosed early and treated aggressively, testicular cancer has a cure rate of about 90%. Treatment of testicular cancer is based on tumor type, and seminoma cancer has the best prognosis. Modes of treatment include combinations of orchiectomy, radiation therapy, and chemotherapy. The chemotherapeutic regimen used currently is responsible for the successful treatment of testicular cancer.

When a client is receiving hormone replacement for prostate cancer, the nurse should do which of the following? Select all that apply. 1. Inform the client that increased libido is expected with hormone therapy. 2. Reassure the client and his significant other that erectile dysfunction will not occur as a consequence of hormone therapy. 3. Provide the client the opportunity to communicate concerns and needs. 4. Utilize communication strategies that enable the client to gain some feeling of control. 5. Suggest that an appointment be made to see a psychiatrist.

3, 4. Hormone manipulation deprives tumor cells of androgens or their by-products and, thereby, alleviates symptoms and retards disease progression. Complications of hormonal manipulation include: hot flashes, nausea and vomiting, gynecomastia, and sexual dysfunction. As part of supportive care, provide explanations of diagnostic tests and treatment options and help the client gain some feeling of control over his disease and decisions related to it. To help achieve optimal sexual function, give the client the opportunity to communicate his concerns and sexual needs. Inform the client that decreased libido is expected after hormonal manipulation therapy, and that impotence may result from some surgical procedures and radiation. A psychiatrist is not needed.

Postoperatively after a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines the suction is effective when: 1. The intrathoracic pressure is decreased and the client breathes easier. 2. There is an increased collateral lymphatic flow toward the operative area. 3. Accumulated serum and blood in the operative area are removed. 4. No adhesions are formed between the skin and chest wall in the operative area.

3. A drainage tube is placed in the wound after a modified radical mastectomy to help remove accumulated blood and fluid in the area. Removal of the drainage fluids assists in wound healing and is intended to decrease the incidence of hematoma, abscess formation, and infection. Drainage tubes placed in a wound do not decrease intrathoracic pressure, increase collateral lymphatic flow, or prevent adhesion formation.

When teaching a client to perform testicular self-examination, the nurse explains that the examination should be performed: 1. After intercourse. 2. At the end of the day. 3. After a warm bath or shower. 4. After exercise.

3. After a warm bath or shower, the testes hang lower and are both relaxed and in the ideal position for manual evaluation and palpation.

A 20-year-old client is being treated for epididymitis. Teaching for this client should include the fact that epididymitis is commonly a result of a: 1. Virus. 2. Parasite. 3. Sexually transmitted infection. 4. Protozoon.

3. Among men younger than age 35, epididymitis is most frequently caused by a sexually transmitted infection. Causative organisms are usually chlamydia or Neisseria gonorrhoeae. The other major form of epididymitis is bacterial, caused by the Escherichia coli or Pseudomonas organisms. The nurse should always include safe sex teaching for a client with epididymitis. The client should also be is a mode of transmission of gram-negative rods to the epididymis.

A client with a testicular malignancy undergoes a radical orchiectomy. In the immediate postoperative period the nurse should particularly assess the client for: 1. Bladder spasms. 2. Urine output. 3. Pain. 4. Nausea.

3. Because of the location of the incision in the high inguinal area, pain is a major problem during the immediate postoperative period. The incisional area and discomfort caused by movement contribute to increased pain. Bladder spasms and elimination problems are more commonly associated with prostate surgery. Nausea is not a priority problem.

The nurse is reviewing the medication history of a client with benign prostatic hypertrophy (BPH). Which medication will likely aggravate BPH? 1. Metformin (Glucophage). 2. Buspirone (BuSpar). 3. Inhaled ipratropium (Atrovent). 4. Ophthalmic timolol (Timoptic).

3. Ipratropium is a bronchodilator, and its anticholinergic effects can aggravate urine retention. Metformin and buspirone do not affect the urinary system; timolol does not have a systemic effect.

The nurse teaches a female client that the best time in the menstrual cycle to examine the breasts is during the: 1. Week that ovulation occurs. 2. Week that menstruation occurs. 3. First week after menstruation. 4. Week before menstruation occurs.

3. It is generally recommended that the breasts be examined during the first week after menstruation. During this time, the breasts are least likely to be tender or swollen because estrogen is at its lowest level. Therefore, the examination will be more comfortable for the client. The examination may also be more accurate because the client is more likely to notice an actual change in her breast that is not simply related to hormonal changes.

A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse's best response is which of the following? 1. "It is easier for the client." 2. "A prostate examination can possibly decrease the PSA." 3. "A prostate examination can possibly increase the PSA." 4. "If the PSA is normal, the client will not have to undergo the rectal examination."

3. Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are both necessary as screening tools for prostate cancer, and both are recommended for all men older than age 50. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age-group.

During a client's urinary bladder catheterization, the nurse ensures that the bladder is emptied gradually. The best rationale for the nurse's action is that completely emptying an over-distended bladder at one time tends to cause: 1. Renal failure. 2. Abdominal cramping. 3. Possible shock. 4. Atrophy of bladder musculature.

3. Rapid emptying of an over-distended bladder may cause hypotension and shock due to the sudden change of pressure within the abdominal viscera. Previously, removing no more than 1,000mL at one time was the standard of practice, but this is no longer thought to be necessary as long as the over-distended bladder is emptied slowly.

A client with benign prostatic hypertrophy (BPH) has an elevated prostate-specific antigen (PSA) level. The nurse should? 1. Instruct the client to have a colonoscopy before coming to conclusions about the PSA results. 2. Instruct the client that a urologist will monitor the PSA level biannually when elevated. 3. Determine if the prostatic palpation was done before or after the blood sample was drawn. 4. Ask the client if he emptied his bladder before the blood sample was obtained.

3. Rectal and prostate examinations can increase serum PSA levels; therefore, instruct the client that a manual rectal examination is usually part of the test regimen to determine prostate changes. The prostatic palpation should be done after the blood sample is drawn. The PSA level must be monitored more often than biannually when it is elevated. Having a colonoscopy is not related to the findings of the PSA test. It is not necessary to void prior to having PSA blood levels tested.

A client with benign prostatic hypertrophy (BPH) is being treated with terazosin (Hytrin) 2 mg at bedtime. The nurse should monitor the client's: 1. Urine nitrites. 2. White blood cell count. 3. Blood pressure. 4. Pulse.

3. Terazosin is an antihypertensive drug that is also used in the treatment of BPH. Blood pressure must be monitored to ensure that the client does not develop hypotension, syncope, or orthostatic hypotension. The client should be instructed to change positions slowly. Urine nitrates, white blood cell count, and pulse rate are not affected by terazosin.

A client underwent transurethral resection of the prostate (TURP), and a large three-way indwelling urinary catheter was inserted in the bladder with continuous bladder irrigation. In which of the following circumstances should the nurse increase the flow rate of the continuous bladder irrigation? 1. When drainage is continuous but slow. 2. When drainage appears cloudy and dark yellow. 3. When drainage becomes bright red. 4. When there is no drainage of urine and irrigating solution.

3. The decision by the surgeon to insert a catheter after TURP or prostatectomy depends on the amount of bleeding that is expected after the procedure. During continuous bladder irrigation after a TURP or prostatectomy, the rate at which the solution enters the bladder should be increased when the drainage becomes brighter red. The color indicates the presence of blood. Increasing the flow of irrigating solution helps flush the catheter well so that clots do not plug it. There would be no reason to increase the flow rate when the return is continuous or when the return appears cloudy and dark yellow. Increasing the flow would be contraindicated when there is no return of urine and irrigating solution.

A nursing assistant tells the nurse, "I think the client is confused. He keeps telling me he has to void, but that isn't possible because he has a catheter in place that is draining well." Which of the following responses would be most appropriate for the nurse to make? 1. "His catheter is probably plugged. I'll irrigate it in a few minutes." 2. "That's a common complaint after prostate surgery. The client only imagines the urge to void." 3. "The urge to void is usually created by the large catheter, and he may be having some bladder spasms." 4. "xI think he may be somewhat confused."

3. The indwelling urinary catheter creates the urge to void and can also cause bladder spasms. The nurse should ensure adequate bladder emptying by monitoring urine output and characteristics. Urine output should be at least 50 mL/hour. A plugged catheter, imagining the urge to void, and confusion are less likely reasons for the client's complaint.

The nurse should teach a client that a normal local tissue response to radiation is: 1. Atrophy of the skin. 2. Scattered pustule formation. 3. Redness of the surface tissue. 4. Sloughing of two layers of skin

3. The most common reaction of the skin to radiation therapy is redness of the surface tissues. Dryness, tanning, and capillary dilation are also common. Atrophy of the skin, pustules, and sloughing of two layers would not be expected and should be reported to the radiologist.

During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. The best response by the nurse is which of the following? 1. "Cancer is not a punishment; it is a disease." 2. "You might feel better if you confided in your husband." 3. "Tell me more about your feelings on this." 4. "I can have the social worker talk to you if you would like."

3. The nurse should respond with an open ended statement that elicits further exploration of the client's feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict the client's feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but is not the first response needed to elicit exploration of the client's feelings.

a client undergoes surgery to repair lung injuries. postoperative prescriptions include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hr. how long will this transfusion take to infuse 2 hours 4 hours 6 hours 8 hours

4 hours

A client has a testicular nodule that is highly suspicious for testicular cancer. A laboratory test that supports this diagnosis is: 1. Decreased alpha fetoprotein (AFP). 2. Decreased beta-human chorionic gonadotropin (hCG). 3. Increased testosterone. 4. Increased AFP.

4. AFP and hCG are considered markers that indicate the presence of testicular disease. Elevated AFP and hCG and decreased testosterone are markers for testicular disease. Measurements of AFP, hCG, and testosterone are also obtained throughout the course of therapy to help measure the effectiveness of treatment.

Atropine sulfate is included in the preoperative orders for a client undergoing a modified radical mastectomy. The expected outcome is to: 1. promote general muscular relaxation. 2. decrease pulse and respiratory rates. 3. decrease nausea. 4. inhibit oral and respiratory secretions.

4. Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

A client is to receive belladonna and opium suppositories, as needed, postoperatively after transurethral resection of the prostate (TURP). The nurse should give the client these drugs when he demonstrates signs of: 1. A urinary tract infection. 2. Urine retention. 3. Frequent urination. 4. Pain from bladder spasms.

4. Belladonna and opium suppositories are prescribed and administered to reduce bladder spasms that cause pain after TURP. Bladder spasms frequently accompany urologic procedures. Antispasmodics offer relief by eliminating or reducing spasms. Antimicrobial drugs are used to treat an infection. Belladonna and opium do not relieve urine retention or urinary frequency.

The nurse is caring for a client who will have a bilateral orchiectomy. The client asks what is involved with this procedure. The nurse's most appropriate response would be? "The surgery: 1. Removes the entire prostate gland, prostatic capsule, and seminal vesicles." 2. Tends to cause urinary incontinence and impotence." 3. Freezes prostate tissue, killing cells." 4. Results in reduction of the major circulating androgen, testosterone."

4. Bilateral orchiectomy (removal of testes) results in reduction of the major circulating androgen, testosterone, as a palliative measure to reduce symptoms and progression of prostate cancer. A radical prostatectomy (removal of entire prostate gland, prostatic capsule, and seminal vesicles) may include pelvic lymphadenectomy. Complications include urinary incontinence, impotence, and rectal injury with the radical prostatectomy. Cryosurgery freezes prostate tissue, killing tumor cells without prostatectomy.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for: 1. Seizures. 2. Cardiac arrest. 3. Renal shutdown. 4. Respiratory paralysis.

4. If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.

Which of the following positions would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions? 1. Across her chest wall. 2. At her side at the same level as her body. 3. In the position that affords her the greatest comfort without placing pressure on the incision. 4. On pillows, with her hand higher than her elbow and her elbow higher than her shoulder.

4. Lymph nodes can be removed from the axillary area when a modified radical mastectomy is done, and each of the nodes is biopsied. To facilitate drainage from the arm on the affected side, the client's arm should be elevated on pillows with her hand higher than her elbow and her elbow higher than her shoulder. A sentinel node biopsy procedure is associated with a decreased risk of lymphedema because fewer nodes are excised.

which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease • 45 year old mother • 17 year old daughter • 8 year old son • 76 year old grandmother

76 year old grandmother

an adult has a new tracheostomy in place. he has a small amount of thin white secretions. the stoma is pink with no drainage noted. how often should the nurse preform trach care 4 hours 8 hours 24 hours every hour

8 hours

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen? A. Promptly send the specimen to the laboratory. B. Send the specimen with the next pickup. C. Send the specimen the next time a nursing assistant is available. D. Store the specimen in the refrigerator until it can be sent to the laboratory.

ANSWER A. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen

Which of the following would be an appropriate outcome for a client with rheumatoid arthritis? The client will A. manage joint pain and fatigue to perform activities of daily living. B. maintain full range-of-motion (ROM) in joints. C. prevent the development of further pain and joint deformity D. take anti-inflammatory medications as indicated by the presence of disease symptoms.

ANSWER A. An appropriate outcome for clients with rheumatoid arthritis is that they will adopt self-care behaviors to manage their joint pain, stiffness, and fatigue and be able to perform their activities of daily living. ROM exercises can help maintain mobility, but it may not be realistic to expect to be able to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for clients to understand the importance of taking their prescribed drug therapy even if their symptoms have abated.

A health care provider has been exposed to hepatitis B through a needlestick. Which of the following drugs would the nurse anticipate administering as postexposure prophylaxis? A. Hepatitis B immune globulin. B. Interferon. C. Hepatitis B surface antigen. D. Amphotericin B.

ANSWER A. Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen is a diagnostic test used to detect current infection. Amphotericin B is an antifungal.

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following? A. "I need to reduce my caloric intake to 1,200 calories a day." B. "A regular diet is recommended during pregnancy." C. "I should eat more frequent meals if I get heartburn." D. "I need to consume more fluids and fiber each day."

ANSWER A. Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the reflux of acidic secretions into the lower esophagus. Pregnant women need adequate hydration (fluids) and fiber to prevent constipation.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiration rate of 46 breaths/minute and a blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? A. Notify the physician. B. Administer a sedative. C. Try to elicit a positive Homan's sign. D. Increase the flow rate of intravenous fluids.

ANSWER A. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia are all indicative of a possible pulmonary embolism. The nurse should promptly notify the doctor of the client's condition. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homan's sign; the client is already diagnosed with a deep vein thrombosis. Increasing the intravenous flow rate may be an appropriate action, but not without first notifying the physician

The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!" Which of the following responses by the nurse is most appropriate? A. "She still has long-term memory, but her short-term memory will not return." B. "I'm so happy to hear that. Maybe she is getting better." C. "Don't get your hopes up. This is only a temporary improvement." D. "I'm glad she can sing even if she can't talk to you."

ANSWER A. The ability to remember an old song is related to long-term memory, which persists after short-term memory is lost. Therefore, the nurse would respond by providing the son with this information. Stating that the nurse is happy to hear about the change and that the client is getting better is inappropriate and inaccurate. This statement ignores the issue of long-term versus short-term memory. Telling the client not to get his hopes up because the improvement is only temporary is inappropriate. The information provided does not indicate that the client has expressive aphasia, which would be suggested by the statement that the client can't talk to the son.

A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, "It's my fault. My Mom is going to kill me. I don't even have a way home." Which of the following would be the nurse's initial intervention? A. "Hold her hands and say, "Slow down. Take a deep breath." B. "Calm down. The police can take you home." C. "Put a hand on her shoulder and say, 'It wasn't your fault."' D. "Your mother is not going to kill you. Stop worrying."

ANSWER A. The client is in a crisis and has a high anxiety level. Holding the client's hands and encouraging the client to slow down and take a deep breath conveys caring and helps decrease anxiety. Telling the client to calm down or stop worrying offers no concrete directions for accomplishing this task. It is unknown from the data who was at fault in the accident. Therefore, it would be inappropriate for the nurse to state that it wasn't the client's fault

The physician has ordered a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical-surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response? A. Send the client to the oncology floor for administration of the medication. B. Ask a nurse from the oncology floor to come to the client and administer the medication. C. Ask another nurse to help mix the chemotherapy agent. D. Ask the pharmacy to mix the chemotherapy agent and administer it.

ANSWER A. The nurse should call the oncology unit to institute a transfer. The nurse handling chemotherapy agents should be specifically trained. It is an unwise use of nursing resources to send a nurse from one unit to administer medications to a client on another unit. It is better to centralize and send the clients who need chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug must be administered by a nurse who is trained to do so.

When performing an otoscopic examination of the tympanic membrane of a 2-year-old child, the nurse would pull the pinna in which of the following directions? A. Down and back. B. Down and slightly forward. C. Up and back. D. Up and forward.

ANSWER A. When examining the tympanic membrane of a child younger than 3 years of age, the nurse should pull the pinna down and back. For an older child, the nurse should pull the pinna up and back to view the tympanic membrane

Which of the following nursing diagnoses would the nurse identify as a priority after surgical repair of a cleft lip? A. Pain. B. Risk for Infection. C. Impaired Physical Mobility. D. Impaired Parenting.

ANSWER B. After surgery, the most important nursing diagnosis should be Risk for Infection. Surgery involves an incision, which is at risk for infection. The infant with this type of procedure does have discomfort, which can be relieved with acetaminophen. Pain would be an important nursing diagnosis but not the priority. The infant may be in arm restraints or have the cuff of the sleeve pinned to the diaper or pants. It is important that the infant not touch the incision line or disrupt the sutures. There is no indication of Impaired Parenting. The parents would be reacting normally with a first reaction of shock.

A client who has Ménière's disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions would be most appropriate for the nurse to suggest for coping with the tinnitus? A. Maintain a quiet environment. B. Play background music. C. Avoid caffeine and nicotine. D. Take a mild sedative.

ANSWER B. Coping with the chronic tinnitus of Ménière's disease can be very frustrating. Providing background sound, such as music, can help camouflage the low-pitched, roaring sound of tinnitus. Maintaining a quiet environment can make the sounds of tinnitus more pronounced. Avoiding caffeine and nicotine is recommended, because this can decrease the occurrence of the tinnitus. However, avoiding these substances does not help the client with coping with tinnitus when it occurs. Taking a sedative does not affect the sounds of the tinnitus

A client has been prescribed hydrochlorothiazide (HydroDIURIL) for treatment of heart failure. For which of the following symptoms should the nurse monitor the client? A. Urinary retention. B. Muscle weakness. C. Confusion. D. Diaphoresis.

ANSWER B. Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and diaphoresis are not side effects of hydrochlorothiazide

The nurse is assigned to a client with irreversible shock. The nurse realizes that the negative outcomes of irreversible shock include severe hypoperfusion to all vital organs and failure of vital functions. Therefore, the nurse will monitor the client for A. increased alertness. B. circulatory collapse. C. hypertension. D. diuresis.

ANSWER B. Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert

Which of the following findings would the nurse most likely note in the client who is in the compensatory stage of shock? A. Decreased urinary output. B. Significant hypotension. C. Tachycardia. D. Mental confusion.

ANSWER C. In the compensatory stage of shock, the client will exhibit moderate tachycardia. If the shock continues to the progressive stage, decreased urinary output, hypotension, and mental confusion will develop as a result of failure to perfuse and ineffective compensatory mechanisms. These findings are indications that the body's compensatory mechanisms are failing

The nurse is developing a community health education program about STDs. Which information about women who acquire gonorrhea should be included? A. Women are more reluctant than men to seek medical treatment. B. Gonorrhea is not easily transmitted to women who are menopausal. C. Women with gonorrhea are usually asymptomatic. D. Gonorrhea is usually a mild disease for women.

ANSWER C. Many women who acquire gonorrhea are asymptomatic or experience mildsymptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected with a disease. Gonorrhea is easily transmitted to all women and can result in serious consequences such as pelvic inflammatory disease and infertility

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information? A. Anticipate lesions within 25 to 30 days. B. Continue sexual activity unless lesions are present. C. Report any difficulty urinating. D. Force fluids to prevent lesions from forming.

ANSWER C. The client should be encouraged to report any painful urination or urinary retention. Lesions are usually present for 17 to 20 days. The client is capable of transmitting the infection even when asymptomatic, so a barrier contraceptive should be used. Forcing fluids will not stop the lesions from forming

While feeding a term neonate at 2 hours of age, the nurse observes that the neonate has a drooping appearance on the left side of the face. The nurse notifies the physician based on the understanding that this is associated with which of the following? A. Craniotabes. B. Meningitis. C. Facial nerve damage. D. Skull fracture.

ANSWER C. The nurse notifies the physician because a drooping of one side of the face or a "one-side cry" is associated with facial nerve damage. Additionally, the mother's delivery record and history need to be reviewed for a possible cause. Craniotabes is a softening of the skull bones. The bones are so soft that indentation from the pressure of an examining finger can occur. Meningitis, or inflammation of the meninges, is associated with a rigid neck. Other symptoms may include lethargy, poor sucking reflexes, weak cry, seizures, and apnea. Skull fracture is not associated with a drooping facial appearance. Rather, it would be evidenced by a crack in the skull bone, possibly accompanied by leaking cerebrospinal fluid

The charge nurse should give a new graduate nurse who made an insulin medication error the following advice: A. "Trust your judgment; don't listen to your client." B. "Compare the insulin doses that other clients are receiving." C. "Large doses must always be double-checked." D. "Use 'U' as an abbreviation for 'Unit."'

ANSWER C. The nurse should always double-check a large dose of insulin before administering it. A nurse should always listen to the client; if a client who has been taking insulin for a long time suggests that the insulin dose is not right, the nurse should recheck the physician's order. Comparing insulin doses of other clients has no bearing on a particular client's dose. The nurse should not use "U" or "u"; the nurse should specify "unit" to avoid errors

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the following interventions should be included in the plan of care before a hydrotherapy treatment is initiated? A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. B. Increase the intravenous flow rate to offset fluids lost through the therapy. C. Apply a topical antibiotic cream to burns to prevent infection. D. Administer pain medication 30 minutes before therapy to help manage pain.

ANSWER D. Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy, unless it is an individualized need for a given client. Topical antibiotics are applied after the therapy, not before submersion in the water.

A client has his leg immobilized in a long leg cast. Which of the following assessments would indicate the early beginning of circulatory impairment? A. Inability to move toes. B. Cyanosis of toes. C. Complaints of cast tightness. D. Tingling of toes.

ANSWER D. Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Complaints of cast tightness should be investigated, because cast tightness can lead to circulatory impairment; it is not, however, an indicator of impairment

a female client is admitted to the hospital. she has smoked two packs per day for 30 years. while providing her history she becomes breathless, pauses frequently between words, and appears very anxious. she has a cough with thick white sputum production. her chest is barrel shaped. based on the data, on what condition will the nurse develop a plan of care pneumonia COPD TB asthma

COPD

Although the cause of testicular cancer is unknown, it is associated with a history of: 1. Undescended testes. 2. Sexual relations at an early age. 3. Seminal vesiculitis. 4. Epididymitis.

Cryptorchidism (undescended testes) carries a greatly increased risk for testicular cancer. Undescended testes occurs in about 3% of male infants, with an increased incidence in premature infants. Other possible causes of malignancy include chemical carcinogens, trauma, orchitis, and environmental factors. Testicular cancer is not associated with early sexual relations in men, even though cervical cancer is associated with early sexual relations in women. Testicular cancer is not associated with seminal vesiculitis or epididymitis.

client who was admitted with a gunshot wound. the client has a BP 108/55, HR 124, RR 36, temp: 101.4 F, SaO2 95% on 15 L/min nonrebreather mask. the client reports dyspnea and pain. The nurse reasses the client 30 min later. which of the following assessment findings should the nurse report to the health care provider: SaO2 of 90% tracheal deviation headache bp of 104/54 HR of 154 hemoptysis distended neck veins nausea

SaO2 of 90% tracheal deviation HR of 154 hemoptysis distended neck veins

A nurse is preparing to admit a client with a confirmed case of tuberculosis. which action is essential to infection control for this client: • providing a positive pressure airflow room • wearing gown and gloves when handling the client's stool or urine • using a NIOSH approved N95 respirator mask for staff and visitors • keeping the client quarantined in the room until antibiotic therapy has been initiated

Using a NIOSH approved N95 respirator mask for staff and visitors

which of the following clients are at risk for the devlopment of ARF and/or ARDS. select all that apply a 14 year old boy who serceived 2 min of CPR following a near drowning incident a client post coronary artery bypass graft with two chest tubes a client with a hemoglobin level of 14.5 a client with an exacerbation of cystic fibrosis a client with dysphagia a client with a sinus infection

a 14 year old boy who serceived 2 min of CPR following a near drowning incident a client post coronary artery bypass graft with two chest tubes a client with an exacerbation of cystic fibrosis a client with dysphagia

which of the following individuals has the highest priority for receiving seasonal influenza vaccination a 60 year old man with a hiatal hernia a 36 year old woman with 3 children a 50 year old woman caring for a spouse with cancer a 60 year old woman with osteoarthritis

a 50 year old woman caring for a spouse with cancer

which of the following should be readily available at the bedside of a client with a chest tube in place a tracheostomy tray another sterile chest tube a bottle of sterile water a spirometer

a bottle of sterile water

which of the following clients are at an increased risk for the development of laryngeal cancer. select all that apply a client who paints houses for a living a client who uses chewing tobacco a radiology technician who takes xrays of clients daily a client who smokes only cigars, not cigarettes a client who lives with a spouse who smokes cigarettes

a client who paints houses for a living a client who uses chewing tobacco a client who smokes only cigars, not cigarettes a client who lives with a spouse who smokes cigarettes

a nurse in the ED is caring for a client who reports dyspnea and rust colored sputum that has persisted for nearly 3 weeks. lung cancer is suspected, and diagnostic tests are ordered. a CT scan reveals the presence of a mass at the base of the bronchial tree. the client asks "what is a bronchoscopy" an appropriate response by the nurse is "a bronchoscopy is when a needle is inserted between two ribs and a piece of the tumor is aspirated a set of xrays are taken that provide a three dimensional picture of your lungs magnetic fields and radio waves are used to obtain sectional pictures of your lungs that outline the tumor a flexible tube is inserted through your mouth and into your lungs to see the tumor and obtain a biopsy

a flexible tube is inserted through your mouth and into your lungs to see the tumor and obtain a biopsy

which of the following is an expected outcome for a client with carbon dioxide poisoning a relatively matched v/q ratio a low v/q ratio a high v/q ratio an equal PaO2 and PaCO2 ratio

a relatively matched v/q ratio

A client newly diagnosed with tuberculosis is being admitted with the prescription for isolation precautions for tuberculosis. the nurse should assign the client to which type of room: • a room at the end of the hall for privacy • a private room to implement contact precautions • a room near the nurses' station to ensure confidentiality • the implementation of contact precautions for possible TB requires a private room assignment

a room at the end of the hall for privacy

a nurse is caring for several clients. which of the following clients are at risk for a pulmonary embolism. select all that apply a woman who is taking birth control pills a woman who is postmenopausal a client who has a fractured femur a client who smokes one pipe daily a client who is a marathon runner a client who has heart failure and chronic a-fib

a woman who is taking birth control pills a client who has a fractured femur a client who smokes one pipe daily a client who has heart failure and chronic a-fib

which of the following findings would suggest pneumothorax in a trauma victim pronounced crackles inspiratory wheezing dullness on percussion absent breath sounds

absent breath sounds

when instructing clients on how to decrease the risk of COPD the nurse should emphasize which of the following participate regularly in aerobic exercises maintain a high protein diet avoid exposure to people with known respiratory infections abstain from cigarette smoking

abstain from cigarette smoking

a nurse is caring for a client following an open thoracotomy for removal of a large tumor. extensive blood loss during the procedure required fluid resuscitation of the client. the client is cyanotic and in respiratory distress with pink, frothy sputum coming from the mouth. the nurse should immediately put the client in high fowler's position give a 200 ml fluid bolus activate the respiratory code system have the client cough and deep breathe

activate the respiratory code system

a client uses a metered dose inhaler (MDI) to aid in management of asthma. which action indicates to the nurse that the client needs further instruction regarding its use. select all that apply activation of the MDI is not coordinated with inspiration the client inspires rapidly when using the MDI the client holds his breath for 3 seconds after inhaling with the MDI the client shakes the MDI after use the client performs puffs in rapid succession

activation of the MDI is not coordinated with inspiration the client inspires rapidly when using the MDI the client holds his breath for 3 seconds after inhaling with the MDI the client shakes the MDI after use the client performs puffs in rapid succession

a client is admitted to the emergency department with a headache, weakness, and slight confusion. the physician diagnoses carbon monoxide poisoning. what should the nurse do first initiate gastric lavage maintain body temperature administer 100% oxygen by mask obtain a psychiatric referral

administer 100% oxygen by mask

a 34 year old female with a history of asthma is admitted to the emergency department. the nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. auscultation of the lung fields reveals greatly diminished breath sounds. based on these findings, which action should the nurse take to initate care of the client initiate oxygen therapy as prescribed and resasses the client in 10 minutes draw blood for an arterial blood gas encourage the client to relax and breathe slowly through the mouth administer bronchodilators as prescribed

administer bronchodilators as prescribed

a nurse in an ED is caring or a client who has advanced lung cancer. the client reports dyspnea on exertion and at rest, and her family states that she has become disoriented over the last 72 hr a chest xray reveals a baseball sized mediastinal tumor. vital signs are as follows: HR 104, BP 88/42, RR 38, T 100.2 F, SaO2 89% on RA. which of the following interventions should the nurse implement first notify the health care provider obtain a CT scan to determine the exact location of the tumor administer oxygen provide family support

administer oxygen

a nurse is caring for a milddle adult female client who is admitted to the CCU with acute dyspnea and dipahoresis. the client states that she is anxious because she feels that she cannot get enough air. vital signs: hr 117, rr 38, temp 101.2 F, bp 100/54. which of the following actions is the highest prioity obtain an abg initiate a heparin drip administer oxygen therapy obtain a spiral CT scan

administer oxygen therapy

a nurse in an ED is caring for a 40 year old male client who was admitted following an MVA. physical assessment reveals absent breath sounds in the left lower lobe. the client is dyspneic, bp 111/68, hr 124, rr 38, temp 101.4 F, SaO2 of 92% on RA. which of the following actions should the nurse take first obtain a chest xray prepare for chest tube insertion administer oxygen via high-flow mask obtain iv access

administer oxygen via high-flow mask

A 79 year old client is admitted to the hospital with a diagnosis of bacterial pneumonia. while obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. which of the following would most likely be a predisposing factor for the diagnosis of pneumonia: • age • osteoarthritis • vegetarian diet • daily bathing

age

the nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation standard precautions contact precautions droplet precautions airborne precautions

airborne precautions

a client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33, PCO2 48, PO2 58; HCO3 26 albuterol (proventil) nebulizer chest xray ipratropium (atrovent) inhaler sputum culture

albuterol (proventil) nebulizer

an 86 year old female was admitted to the hospital two days ago with pneumonia. she now has an order to be up in the chair as much as possible. how will the nurse plan the client's morning care get her up before breakfast. have her eat in the chair, then bathe while still lup allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair, and rest for a few minutes. allow her to wash her hands and face - nurse to complete bath allow her to eat in bed, get her up, and provide her with a pan of water for her to bathe get her up before breakfast, have her bathe before breakfast, eat in the chair, then a rest in the chair

allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair, and rest for a few minutes. allow her to wash her hands and face - nurse to complete bath

a client presents to an emergency department following a motorcycle crash. a nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the chest and torso, crepitus and tachypnea. based on this assessment the nurse should • assist the placement of a cervical collar • anticipate the need to intubate the client • provide chest compressions • tape the chest wall

anticipate the need to intubate the client

After nasal surgery the client expresses concern about how to decrease facial pain and swelling while recovering at home. which of the following discharge instruction would be most effective for decreasing pain and edema: • take analgesics every 4 hours around the clock • use corticosteroid nasal spray as needed to control symptoms • use a bedside humidifier while sleeping • apply cold compresses to the area

apply cold compresses to the area

while assessing the client the nurse notices that the client's chest tube has become dislodged. which of the following actions should the nurse take first place the tubing into sterile water to restore the water seal apply sterile gauze to the site tape or clamp all connections assess the client's respiratory status

apply sterile gauze to the site

Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the 2nd postoperative day • avoid cleaning the nares until swelling has subsided • apply water soluble jelly to lubricate the nares • keep a nasal drip pad in place to absorb secretions • use a bulb syringe to gently irrigate nares

apply water soluble jelly to lubricate the nares

a client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. the nurse should report which of the following to the health care provider arterial oxygen level of 46 mm Hg respirations of 12 lack of adventitious lung sounds oxygen saturation of 96% on room air

arterial oxygen level of 46 mm Hg

the nurse is providing follow up care to a client with tuberculosis who does not regularly take the prescribed medication. which nursing action would be most appropriate for this client ask the clients spouse to supervise the daily administration of the medications visit the client weekly to verify complaince with taking the medication notify the physician of the client's noncompliance and request a different prescription remind the client that the tuberculosis can be fatal if not treated promptly

ask the clients spouse to supervise the daily administration of the medications

The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. which of the following instructions should be included: • after surgery, nasal packing will be in place for 7 to 10 days • normal saline nose drops will need to be administered preoperatively • the results of the surgery will be immediately obvious postoperatively • aspirin containing medications should not be taken for 2 weeks before surgery

aspirin containing medications should not be taken for 2 weeks before surgery

the nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. suddenly the client becomes restless and tachypnic. the nurse should assess breath sounds remove the catheter insert a peripheral iv reposition the client

assess breath sounds

a nurse is orienting a newly licensed nurse on how to complete a routine assessment for a client who is receiving mechanical ventilaton. which of the following should be included in the newly licensed nurse's assessment of the client assess blood pressure every 6 to 8 hr assess blood pressure every 2 to 4 hr assess breath sounds every 6 to 8 hr assess breath sounds every 2 to 4 hr

assess breath sounds every 2 to 4 hr

A client has had hoarseness for more than 2 weeks. the nurse should: • refer the client to a health care provider for a prescription for an antibiotic • instruct the client to gargle with salt water at home • assess the client for dysphagia • instruct the client to take a throat analgesic

assess the client for dysphagia

a client with respiratory failure is on a ventilator. the alarm goes off. what should be the nurse's first action notify the physician assess the client to determine the cause of the alarm turn off the alarm disconnect the client and use the ambu bag to ventilate the client

assess the client to determine the cause of the alarm

the nurse reviews an aterial blood gas report for a client with COPD the results are pH 7.35, PCO2 65; PO2 70; HCO3 34 apply a 100% nonrebreather mask assess the vital signs reposition the client prepare for intubation

assess the vital signs

what is the rationale for this intervention for pulmonary embolism: monitor platelet count improves cardiac contractility restores intravascular volume assesses for thrombocytopenia

assesses for thrombocytopenia

which of the following assessments is a priority immediately after nasal surgery • assessing the client's pain • inspecting for periorbital ecchymosis • assessing respiratory status • measuring intake and output

assessing respiratory status

An elderly client with pneumonia and dementia has attempted several times to pull out the IV and foley catheter. the nurse obtains a prescription for bilateral soft wrist restraints. which nursing action is most appropriate • perform circulation checks to bilateral upper extremities each shift • attach the ties of the restraints to the bedframe • reevaluate the need for restraints and document weekly • ensure the restraint order has been signed by the physician within 72 hours

attach the ties of the restraints to the bedframe

which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client assessing the client's skin color monitoring the respiratory rate verifying the amount of cuff inflation auscultating breath sounds bilaterally

auscultating breath sounds bilaterally

A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. which of the following discharge instructions would be appropriate for the client: • avoid activities that elicit the valsalva maneuver • take aspirin to control nasal discomfort • avoid brushing the teeth until the nasal packing is removed • apply heat to the nasal area to control swelling

avoid activities that elicit the valsalva maneuver

following a thoracotomy to remove a lung tumor a nurse is preparing a client to be discharged to home. which are appropriate teaching points for the client. select all that apply avoid lifting greater than 20 pounds build up exercise endurance continue to buid endurance even when dyspneic expect return to normal activity level and strength within 1 month make time for frequent rest periods with activity

avoid lifting greater than 20 pounds build up exercise endurance make time for frequent rest periods with activity

a health care provider has just inserted nasal packing for a client with epistaxis. the client is taking ramipril (Altace) for hypertension. what should the nurse instruct the client to do • use 81 mg of aspirin daily for relief of discomfort • omit the next dose of ramipril (Altace) • remove the packing if there is difficulty swallowing • avoid rigorous aerobic exercise

avoid rigorous aerobic exercise

which finding should a nurse expect when completing an assessment on a client with chronic bronchitis • minimal sputum with cough • pink, frothy sputum • barrel chest • stridor on expiration

barrel chest

a client is admitted to the nursing unit from the recovery room following a left pneumonectomy. what will the nurse expect in the plan of care have a chest tube to water seal have a chest tube to suction be monitored closely for respiratory and cardiac complications have his left arm maintained in a sling to prevent pain and discomfort

be monitored closely for respiratory and cardiac complications

two hours after arriving on the medical-surgical unit, the client develops dyspnea. SaO2 is 91%, and the client is exhibiting audible wheezing and use of accessory muscles. which of the following medications should the nurse expect to administer antibiotic beta-blocker antiviral beta2 agonist

beta2 agonist

which of the following is an expected outcome for an adult client with well controlled asthma chest xray demonstrates minimal hyperinflation temperature remains lower than 100F arterial blood gas analysis demonstrates a decrease in PaO2 breath sounds are clear

breath sounds are clear

a nurse is caring for a client following a bronchoscopy. which of the following clien findings should the nurse report to the primary care provider? blood tinged sputum dry, non productive cough sore throat bronchospasms

bronchospasms

the nurse is to obtain a sputum specimen from a client. select the correct set of statements instructing the client in the proper technique for obtaining a sputum specimen collect the specimen right beore bed. spit carefully into the container brush your teeth, then cough into the container. do this first thing in the morning right after lunch, cough and spit into the container spit into the container then add two tablespoons of water

brush your teeth, then cough into the container. do this first thing in the morning

a nurse is caring for a client requiring positive pressure mechanical ventilation. the client has been fighting the ventilator assisted breaths, and the client's blood pressure has been steadily decreasing. which would be the most appropriate intervetnion by the nurse • place the client in the prone position • notify the respiratory therapist to increase the positive pressure settings • call the physician to suggest sedatives and paralytics • prepare to administer intravenous aminophylline

call the physician to suggest sedatives and paralytics

an adult has a chest tube to a Pleur-evac drainage system attached to a wall suction. an order to ambulate the client has been received. how should the nurse ambulate the client safely clamp the chest tube and carefully ambulate the client a short distance question the order to ambulate the client carefully ambulate the client, keeping the pleur-evac lower than the client's chest disconnect the pleur-evac from the client's chest tube, leave it attached to the bed, ambulate the client, and then reconnect the chest tube when he is returned to bed

carefully ambulate the client, keeping the pleur-evac lower than the client's chest

a confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. the nurse should put all four side rails up on the bed ask the CNA to place restraints on the client's upper extremities request that the client's roomate put the call light on when the client is attempting to get out of bed check on the client at regular intervals to ascertain the need to use the bathroom

check on the client at regular intervals to ascertain the need to use the bathroom

a client with COPD is in the thrid postoperative day following right-sided thoracotomy. during the day shift the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. based on this information which action should be taken by the evening shift nurse • work to wean oxygen down to 3L by mask • call respiratory therapy for a nebulizer treatment • check respiratory rate and notify the physician • administer dose of ordered pain medication

check respiratory rate and notify the physician

A nurse checks on a client following lower lobectomy for lung cancer. the nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. which action should be taken first: • notify the physician • give the client whatever medication was ordered to decrease anxiety • check the chest tube to make sure it is not obstructed • turn up the oxygen liter flow

check the chest tube to make sure it is not obstructed

the nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. the nurse should continue monitoring as usual; this is expected check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle decrease the suction to -15 mc H2O and continue observing the sytem for changes in bubbling during the next several hours drain half of the water from the water-seal chamber

check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle

a client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. the client's pulse rate is also increased. the nurse should check the tubing to ensure that the client is not lying on it or kinking it increase the suction lower the drainage bottles 2 to 3 feet below the level of the client's chest ensure that the chest tube has two clamps on it to prevent leaks

check the tubing to ensure that the client is not lying on it or kinking it

a nurse begins to hear high pressure alarms in the room of a client requiring respiratory assistance with a ventilator. which is the best action by the nure • wait and allow the client time to regulate breathing in coordination with the ventilator • check ventilator tubing and connections • silence the alarm and restart the ventilator • lower the tidal volumes being delivered to the client

check ventilator tubing and connections

when assessing a client with chest trauma the nurse notes that the client is taking small breaths at first then bigger breaths then a couple of small breaths then 10 to 20 seconds of no breaths. the nurse should chart the breathing pattern as cheyne stokes respiration hyperventilation obstructive sleep apnea bior's respiration

cheyne stokes respiration

which of the following clients have an increased risk for developing pneumonia. select all that apply client who has dysphagia client who has AIDS client who was vaccinated for pneumoococcus and influenza 6 months ago client who is post operative and has received local anesthesia client who has a closed head injury and is receiving ventilation client who has myasthenia gravis

client who has dysphagia client who has AIDS client who has a closed head injury and is receiving ventilation client who has myasthenia gravis

A client with a large facial tumor is scheduled for a radical neck dissection. a nurse in the preoperative best help the client considering the potential for an alteration in body image from the procedure: • show multiple photographs of clients who have had similar procedures • closely assess and monitor the client's verbal and nonverbal communication • direct the client's significant other to allow for the client's complete dependence on him or her • remind the client that it is what is on the inside that counts

closely assess and monitor the client's verbal and nonverbal communication

the nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. which of the following findings would be expected. which of the following findings would be expected normal breath sounds prolonged inspiration normal chest movement coarse crackles and rhonchi

coarse crackles and rhonchi

Which of the following is an expected outcomes or a client recovering from a total laryngectomy. the client will: • regain the ability to taste and smell food • demonstrate appropriate care of the gastrostomy tube • communicate feelings about body image changes • demonstrate sterile suctioning technique for stoma care

communicate feelings about body image changes

a client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. the nurse should instruct the client to call the physician for which of the folowing respiratory rate greater than 16 breaths/min continuous bubbling in the water-seal chamber fluid in the chest tube fluctuation of fluid in the water seal chamber

continuous bubbling in the water-seal chamber

when teaching a client to deep breathe effectively after a lobectomy the nurse should instruct the client to do which of the following contract the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds then exhale contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle relax the abdominal muscles, take a deep breath through the nose, and hold it for 3 to 5 seconds relax the abdominal muscles, take a deep breath through the mouth and exhale slowly over 10 seconds

contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle

which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma cough productive of yellow sputum bilateral expiratory wheezing chest tightness respiratory rate of 30 breaths/min

cough productive of yellow sputum

the nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. what is the most appropriate nursing interventions notify the physician insert a new chest tube cover the insertion site with petroleum gauze instruct the client to breath deeply until help arrives

cover the insertion site with petroleum gauze

which of the following are indications that a nurse should suction a client. select all that apply spontaneous cough cyanosis SaO2 greater than 95% tachypnea visualization of secretions

cyanosis tachypnea visualization of secretions

bed rest is prescribed for a client with pneumonia during the acute phase of the illness. the nurse should determine the effectiveness of bedrest by assessing the client's • decreased cellular demand for oxygen • reduced episodes of coughing • diminished pain when breathing deeply • ability to expectorate secretions more easily

decreased cellular demand for oxygen

the cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following • decreased cardiac output • pleural effusion • inadequate peripheral circulation • decreased oxygenation of the blood

decreased oxygenation of the blood

the nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. the nurse should evaluate the outcome of administering the drug by assessing which of the following. select all that apply • decreased pain when breathing • prolonged clotting time • decreased temperature • decreased respiratory rate • increased ability to expectorate secretions

decreased pain when breathing decreased temperature

The nurse should caution sexually active female clients taking isoniazid that the drug has which of the following effects: :• increases the risk of vaginal infection • has mutagenic effects on ova • decreases the effectiveness of hormonal contraceptives • inhibits ovulation

decreases the effectiveness of hormonal contraceptives

a nurse is caring for a client who has secretions in the airway. which of the following is the most effective method for clearing the secretions endotracheal suction oropharyngeal suction deep breathing and coughing nasopharyngeal suction

deep breathing and coughing

after a thoractomy the nurse instructs the client to perform deep breathing exercises. which of the following is an expected outcome of these exercises deep breathing elevates the diaphragm which enlarges the thorax and increases the lung surface available for gas exchange deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery deep breathing controls the rate of air flow to the reamining lobe so that it will not become hyperinflated deep breathing expands the alveoli and increases the lung surface available for ventiation

deep breathing expands the alveoli and increases the lung surface available for ventiation

a nurse is caring for a client with a left sided chest tube attached to a wet suction chest tube system. which obseration by the nurse would require immediate intervention • bubbling in the suction chamber • dependent loop hanging off the edge of the bed • banded connections between tubing sections • occlusive dressing over chest tube insertion site

dependent loop hanging off the edge of the bed

a nurse should measure a clients airway depth for nasopharyngeal and nasogtracheal suctioning by determining the distance from the nares to the sternum determining the distance from the corner of the mouth to the earlobe determining the distance from the tip of the nose to the earlobe inserting the catheter until resistance is met

determining the distance from the tip of the nose to the earlobe

when developing a discharge plan to manage the care of a client with COPD the nurse should advise the client to expect to develop respiratory infections easily maintain current status require less supplemental oxygen show permanent improvement

develop respiratory infections easily

a nurse observes for early manifestation of ARDS in a client being treated for smoke inhalation. which signs indicate the possible onset of ARDS in this client cough with blood tinged sputum and respiratory alkalosis decrease in both white and red blood cell counts diaphoresis and low SaO2 unresponsive to increased oxygen administration hypertension and elevated PaO2

diaphoresis and low SaO2 unresponsive to increased oxygen administration

the client diagnosed with TB is taught prevention of disease transmission. which correct answer will the client state is a means of transmission hands droplet nuclei milk products eating utensils

droplet nuclei

the nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated • dust particles • droplet nuclei • water • eating utensils

droplet nuclei

what manifestation would the client with pleural effusion display pain swelling dyspnea increased sputum production

dyspnea

which of the following are causes for concern following a throacentesis. select all that apply dyspnea localized bloody drainage contained on the dressing fever hypotension SaO2 of 95% soreness around puncture site

dyspnea fever hypotension

late or early sign of hypoxia: pale skin and mucous membranes

early

late or early sign of hypoxia: restlessness

early

late or early sign of hypoxia:elevated blood pressure

early

an adult male was diagnosed with lung cancer 18 months ago. he is now in the terminal stages and is experiencing severe generalized pain. he has ordered morphine sulfate 10 mg IM q 4-6 h prn. what is the most appropriate action by the nurse teach him that the pain medicine prescried will take away all his pain and he will have no discomfort cousel him about the addictive qualities of his prescribed narcotic inform him that he may only ask for the pain medicine every 4 hours and there is nothing else you can offer in between medication times encourage him to ask for the pain medicine before the pain becomes severe

encourage him to ask for the pain medicine before the pain becomes severe

an elderly client has fallen and broken her eighth rib on her left side. the nurse should include which of the following when developing the plan of care bind the client's chest with a 6 inche Ace bandage keep the client on bed rest for 3 days encourage the client to use her incentive spriometer and cough and deep breathe administer large doses of narcotic alagestic so that the client will be able to more fully participate in pulmonary care

encourage the client to use her incentive spriometer and cough and deep breathe

A client who has had a total laryngectomy appears withdrawn and depressed. the client keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. which nursing intervention would most likely be therapeutic for the client: • discussing the behaviour with the spouse to determine the cause • exploring future plans • respecting the need for privacy • encouraging expression of feelings nonverbally and in writing

encouraging expression of feelings nonverbally and in writing

the treatment plan for a client newly diagnosed with TB is likely to include which of the following medications as initial treament ethambutol and isoniazid streptomycin and penicillin G tetrcycline and thioridazine pyrdoxine and tetracycline

ethambutol and isoniazid

Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection. the client will: • maintain a fluid intake of 800 ml every 24 hours • experience chills only once a day • cough productively without chest discomfort • experience less nasal obstruction and discharge

experience less nasal obstruction and discharge

a client with a suspected pulmonary embolus receives a VQ scan to evaluate regional lung ventilation of airflow and regional lung blood flow. in consulting with a physician a nurse learns there is a VQ mismatch. based on this information which action should be taken by the nurse: • tell the client that tuberculosis treatment will be needed • reassure the client that he/she does not have a pulmonary embolism • explain to the client that further testing will be needed • inform the client that the test was normal

explain to the client that further testing will be needed

The client with a laryngectomy does not want his family to see him. he indicates that he thinks the opening in his throat is disgusting. the nurse should: • initiate teaching about the care of a stoma • explain that the stoma will not always look as it does now • inform the client of the benefits of family support at this time • explore why the client believes the stoma is disgusting

explore why the client believes the stoma is disgusting

delivers an FiO2 of 24% to 100% at flow rates of at least 10 L/min and provides high humidification of oxygen nasal cannula simple face mask nonrebreather mask venturi mask face tent

face tent

A nurse is planning care for a client with AIDS who has been hospitalized for Pneumocystitis carinii infection . which nursing diagnosis shoul be the nurse's first priority for this client: • fatigue related to hypermetabolism • imbalanced nutrition more than body requirements related to hypometabolism • ineffective cooping related to HIV diagnosis • fluid volume excess related to oral and intravenous fluid intake

fatigue related to hypermetabolism

a client with suspected TB will mot likely relate which clinical manifestations fatigue, weight loss, low grade fevers, night sweats asymmetrical chest expansion rapid shallow breathing, prolonged labored expiration, stridor dyspnea, hypoxemia, decreased pulmonary compliance

fatigue, weight loss, low grade fevers, night sweats

the client is receiving vecuronium (Norcuron) and is on a ventilator. which of the following medications should the nurse anticipate administering. select all that apply fentanyl furosemide midazolam famotidine dexamethasone

fentanyl midazolam

a male client is admitted following an automobile accident. he is very anxious, dyspneic, and in severe pain. the left chest wall moves in during inspiratoin and balloons out when he exhales. what condition are these symptoms most suggestive of hemothorax flail chest atelectasis pleural effusion

flail chest

the nurse is caring for a client who has had a chest tube inserted and connected to a portable water seal drainage. the nurse determines the drainage system is functioning correctly when which of the following is observed continuous bubbling in the water seal chamber fluctuation in the water seal chamber suction tubing attached to a wall unit vesicular breath sounds throught the lung fields

fluctuation in the water seal chamber

a nurse is caring for a client who has pneumonia and has a prescription for prednisone. the nurse should monitor the client for which of the following. select all that apply fluid retention tremors hyperglycemia fever black, tarry stools

fluid retention hyperglycemia fever black, tarry stools

the primary reason for infusing blood at a rate of 60 ml/h is to help prevent which of the following complications emboli formation fluid volume overload red blood cell hemolysis allergic reation

fluid volume overload

a client's arterial blood gas values are as follows: pH 7.31, PaO2 80; Pa CO2 65; HCO3 36. the nurse should assess the client for cyanosis flushed skin irritability anxiety

flushed skin

a nurse is caring for a client who has dyspnea. in which of the following postions should the nurse place the client supine dorsal recumbent fowler's lateral

fowlers

a client with pneumonia has a temperature of 102.6 is diaphoretic and has a productive cough. the nurse should include which of the following measures in the plan of care • position changes every 4 hours • nasotracheal suctioning to clear secretions • frequent linen changes • frequent offering of a bedpan

frequent linen changes

postoperative nursing management of the client following a radical neck dissection for laryngeal cancer requires • complete bed rest miminizing head movement • vital signs once a shift • clear liquid diet started at 48 hours • frequent suctioning of the laryngectomy tube

frequent suctioning of the laryngectomy tube

which of the following complication is associated with mechanical ventilation gastrointestinal hemmorhage immunosuppression increased cardiac output pulmonary emboli

gastrointestinal hemmorhage

a nurse is assessing the functioning of a client's chest drainage system. which of the following are expected client findings. select all that apply continuous bubbling in the water seal chamber gentle constant bubbling in the suction control chamber rise and fall in the level of water in the water seal chamber with inspiration and expiration exposed sutures without dressing drainage system is upright at chest level

gentle constant bubbling in the suction control chamber rise and fall in the level of water in the water seal chamber with inspiration and expiration

the nurse is caring for a client who has been placed on droplet precautions. which of the following protective gear is required to take care of this client. select all that apply gloves gown surgical mask glasses respirator

gloves gown surgical mask glasses

a client has a positive reaction to the mantoux test. the nurse interprets this reaction to mean that the client has • active tuberculosis • had contact with mycobacterium tuberculosis • developed a resistance to the tubercle bacilli • developed passive immunity to tuberculosis

had contact with mycobacterium tuberculosis

a client with acute asthma is prescribed short-term corticosteroid therapy. which is the expected outcome for the use of steroids in clients with asthma promote bronchodilation act as an expectorant have an anti-inflammatory effect prevent devleopment of respiratory infections

have an anti-inflammatory effect

a client has just had arterial blood gases drawn. what will the nurse do with the specimen collected gently shake the syringe place the sample in a syringe of warm water aspirate 0.5 mL of heparin into the syringe have the specimen analyzed immediately

have the specimen analyzed immediately

penicillin has been prescribed for a client admitted to the hospital for treatment of pneumonia. prior to administering the first dose of penicillin the nurse should ask the client • do you have a history of seizures • do you have any cardiac history • have you had any recent infections • have you had a previous allergy to penicillin

have you had a previous allergy to penicillin

the client is receiving streptomycin in the treatment regimen of tuberculosis. the nurse should assess for • decreased serum creatinine • difficulty swallowing • hearing loss • iv infiltration

hearing loss

a female client diagnosed with lung cancer is to have a left lower lobectomy. which of the following increases the client's risk of developing postoperative pulmonary complications height is 5 feet, 7 inches and weight is 110 lb the client tends to keep her real feelings to herself she ambulates and can climb one flight of stairs without dyspnea the client is 58 years of age

height is 5 feet, 7 inches and weight is 110 lb

a client hospitalized for a severe case of pneumonia is asking a nurse why a sputum sample is needed. the nurse should reply that the primary reason is to • complete the first of three samples to be collected • differentiate between pneumonia and atelectasis • encourage expectoration of secretions • help select the appropriate antibiotic

help select the appropriate antibiotic

which of the following diets would be most appropriate for a client with chronic COPD low fat, low cholesterol diet bland, soft diet low sodium diet high calorie, high protein diet

high calorie, high protein diet

a client with COPD is experiencing dyspnea and has a low PaO2 level. the nurse plans to administer oxygen as prescribed. which of the following statements is true concerning oxygen administration to a client with COPD high oxygen concentrations will cause coughing and dyspnea high oxygen concentrations may inhibit the hypoxic stimulus to breathe increased oxygen use will caue the client to become dependent on the oxygen adminisration of oxygen is contraindicated in clients who are using bronchodilators

high oxygen concentrations may inhibit the hypoxic stimulus to breathe

a nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. which of the following should the nurse recognize aas a contraindication to the therapy hip arthroplasty 2 weeks ago elevated sedimentation rate incident of exercise-induced asthma 1 week ago elevated platelet count

hip arthroplasty 2 weeks ago

Which of the following techniques for administering the Mantoux test is correct: • hold the needle and syringe almost parallel to the client's skin • pinch the skin when inserting the needle • aspirate before injecting the medication • massage the site after injecting the medication

hold the needle and syringe almost parallel to the client's skin

An elderly client had posterior packing inserted to control a severe nosebleed. after insertion of the packing the client should be closely monitored for which of the following complications: • vertigo • bell's palsy • hypoventilation • loss of gag reflex

hypoventilation

the nurse interprets which of the following as an early sign of ARDS in a client at risk elevated carbon dioxide level hypoxia not responsive to oxygen therapy metabolic acidosis severe, unexplained electrolyte imbalance

hypoxia not responsive to oxygen therapy

a nurse is teaching a class in a community center about lung cancer. which statement best demonstrates the client's understanding of the risk factors for lung cancer my husband smokes but I don't. so ireally don't need to worry about getting lung cancer i guess i will need to eat more green and yellow vegetables just because i have COPD doesn't mean that i have a higher risk i've worked with asbestos all my life and have never had any problems

i guess i will need to eat more green and yellow vegetables

The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. which states indicate that the client has understood the nurse's instructions. select all that apply • i will need to dispose of my old clothing when i return home • i should always cover my mouth and nose when sneezing • it is important that i isolate myself from family when possible • i should use paper tissues to cough in and dispose of them promptly • i can use regular plates and utensils whenever I eat

i should always cover my mouth and nose when sneezing i should use paper tissues to cough in and dispose of them promptly i can use regular plates and utensils whenever I eat

A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. which of the following statements would demonstrate to the nurse that the client understands the instructions: • i should limit the use of the inhaler to only morning and bedtime use • it is important to not shake the canister because that can damage the spray device • i should hold one nostril closed while i insert the spray into the other nostril • the inhaler tip is inserted into the nostril and pointed toward the inside nostril wall

i should hold one nostril closed while i insert the spray into the other nostril

a nurse is caring for a client who has a new prescription for heparin therapy. which of the following statements by the client should pose an immediate concern for the nurse i am allergic to morphine i take antacids several times a day i had a blood clot in my leg several yeaers ago it hurts to take a deep breath

i take antacids several times a day

17 year old client with cystic fibrosis is visiting with a nurse in preparation for leaving home for college. the nurse knows that the client needs further education if the client states: • i will bring extra cough medicine so as to not wake up my roommate at night • i will contact the college's health center and pass on my medical records • i will check to make sure they have good workout facilities • i will be really careful about washing my hands and staying away from sick friends

i will bring extra cough medicine so as to not wake up my roommate at night

an adult is ready for discharge after undergoing a total laryngectomy. the nurse is discussing safety aspects of his home care. which statement by the client best indicates that he understands the safety aspects of his care at home it is ok to swim as long as i'm careful i shold use paper tissues to cover my stoma when i'm coughing i should not wear anyting to cover my stoma i will need to use a humidifier in my house

i will need to use a humidifier in my house

A nurse is evaluating discharge teaching that has been completed for a client following total laryngectomy. which statement made by the client indicates that the client does not accept or understand the teaching: • i will be sure to carry an extra supply of facial tissue with me • i probably will not be able to go swimming • i will schedule an appointment for closure of my tracheostomy • i will check the batteries on our smoke detectors

i will schedule an appointment for closure of my tracheostomy

a nurse is completing discharge teaching with a client who has a new prescription for prednisone for asthma. which of the following client statements indicates a need for further teaching i will drink plenty of fluids while taking this medication i will tell the doctor if i have black, tarry stools i will take my medication on an empty stomach i will monitor my mouth for cold sores

i will take my medication on an empty stomach

Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after nasal surgery: • i should not shower until my packing is removed • i will take stool softeners and modify my diet to prevent constipation • coughing every 2 hours is important to prevent respiratory complications • it is important to blow my nose each day to remove the dried secretions

i will take stool softeners and modify my diet to prevent constipation

a home health nurse is caring for an older adult client who has active TB. the client lives at home with her husband. she is prescribed the following medication regimen: isoniazid, rifampin, pyrazinamide, and ethambutol. which of the following statements indicate that the client understands appropirate care measure. select all that apply it is okay to substitute once mdication for another when i run out because they all fight the infection i will wash my hands each time i cough or sneeze i will increase my intake of citrus fruits, red meats, and whole grains i am glad that i don't have to collect any more sputum specimens i will make sure that i wear a mask when i am in a public place i do not need to worry about where i go one i start taking my medication

i will wash my hands each time i cough or sneeze i will increase my intake of citrus fruits, red meats, and whole grains i will make sure that i wear a mask when i am in a public place

a long term COPD client is receiving oxygen at 1 L/min. a family member decides she "doesn't look too good" and increases her oxygen to 7 L/min. what should the nurse's initial action be thank the client's cousin and continue to observe the client immediately decrease the oygen notify the physician add humidity to the oxygen

immediately decrease the oygen

what is the rationale for this intervention for pulmonary embolism: administer dobutamine improves cardiac contractility restores intravascular volume assesses for thrombocytopenia

improves cardiac contractility

which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma incorporate physical exercise as tolerated into the daily routine monitor peak flow numbers after meals and at bedtime eliminate stressors in the work and home enviornment use sedatives to ensure uninterrupted sleep at night

incorporate physical exercise as tolerated into the daily routine

a home health nurse is visiting a client whose chronic bronchitis has recently worsened. which instruction should the nurse reinforce with this client • increase amount of bedrest • increase fluid intake • decrease caloric intake • reduce home oxygen use

increase fluid intake

a 64 year old has been smoking since he was 11 years old. he has a long history of emphysema and is admitted to the hospital because of respiratory infection that has not improved with outpatient therapy. which finding would the nurse expect to observe during the client's nursing assessment electrocardiogram changes increased anterior-posterior chest diameter slow, labored respiatory pattern weight height relationship indicating obesity

increased anterior-posterior chest diameter

which of the following physical assessment findings are normal for a client with advanced COPD increased anteroposterior chest diameter underdeveloped neck nuscles collapsed neck veins increased chest excursions with respiration

increased anteroposterior chest diameter

the nurse's assessment of a client with lung cancer reveals the following: copious secretions, dyspnea, and cough. based on these findings, what is the most appropriate nursing diagnosis impaired gas exchange ineffective airway clearance pain altered tissue perfusion

ineffective airway clearance

a client with ARDS is on a ventilator. the clients peak inspiratory pressures and spontaneous respiratory rate are increasing and the PO2 is not improving. using SBAR technique for communication, the nurse calls the physician with the reccomendation for initiating iv sedation starting high protein diet providing pain medication increasing the ventilator rate

initiating iv sedation

In which areas of the united states is the incidence of tuberculosis highest: a. rural farming areas b. inner city areas c. areas where clean water standards are low d. suburban areas with significant industrial pollution

inner city areas

the nurse is caring for a client who has asthma. the nurse should conduct a focused assessment to detect which of the following increased forced expiratory voume normal breath sounds inspiratory and expiratory wheezing morning headaches

inspiratory and expiratory wheezing

which of the following would be a significant intervention to help prevent lung cancer encourage cigarette smoker to have yearly chest radiographs instruct people about techniques for smoking cessation recommend that people have their houses and apartments checked for asbestos leakage encourage people to install central air filters in their homes

instruct people about techniques for smoking cessation

a client is prescribed metaproterenol (Alupent) via metered-dose inhaler, two puffs every 4 hours. the nurse instructs the client to report adverse effects. which of the following are potential adverse effects of metaproterenol irregular heartbeat constipation pedal edema decreased pulse rate

irregular heartbeat

which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia • coma • apathy • irritability • depression

irritability

an adult is being followed in the outpatient clinic for a dx of active T. she is reciving isoniazid, rifampin, steptomycin. which statement by the client best indicates she understands her therapeutic regimen i'm glad i only have to take these drugs for a couple of weeks i need to take these two drugs every day and come back to the clinic once a week for the shot it may work best to take these pills in the evening right before bed i'm glad my birth control pills aren't affected by these drugs - the doctor told me not to get pregnant

it may work best to take these pills in the evening right before bed

the nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. the client says. "i'm scared of having cancer. it's so horrible and i brought it on myself. i should have quit smoking years ago." what would be the nurse's best response to the client it's okay to be scared. what is it about cancer that you're afraid of it's normal to be scared. i would be too. we'll help you through it don't be so hard on yourself. you don't know if our smoking caused the cancer do you feel guilty because you smoked

it's okay to be scared. what is it about cancer that you're afraid of

A client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea. which of the following instructions would be appropriate for the nurse to give the client: • user your nasal decongestant spray regularly to help clear your nasal passages • ask the doctor for antibiotics. antibiotics will help decrease the secretion • it is important to increase your activity. a daily brisk walk will help promote drainage • keep a diary of when your symptoms occur. this can help you identify what precipitates your attacks

keep a diary of when your symptoms occur. this can help you identify what precipitates your attacks

late or early sign of hypoxia: bradycardia

late

late or early sign of hypoxia: confusion and stupor

late

late or early sign of hypoxia: cyanotic skin and mucous membranes

late

late or early sign of hypoxia: hypotension

late

the nurse administers theophylline to a client. when evaluating the effectiveness of this medication the nurse should assess the client for which of the following suppression of the client's respiratory infection decrease in bronchial secretions less difficulty breathing thinning of tenacious, purulent sputum

less difficulty breathing

The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin for treatment of tuberculosis: take the medication with antacids double the dosage if a drug does is missed increase intake of dairy products limit alcohol intake

limit alcohol intake

A client newly diagnosed with asthma is preparing for discharge. which point should a nurse emphasize during the client's teaching: • contact care provider only if nighttime wheezing becomes a concern • limit exposure to sources that trigger an attack • use peak flow meter only if symptoms are worsening • use inhaled steroid medication as a rescue inhaler

limit exposure to sources that trigger an attack

a young man is admitted with a flail chest following a car accident. he is intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive pressure). which physical finding alerts the nurse to an additional problem in repiratory function dullness to percussion in the third to fifth intercostal space, midclavicular line decreased paradoxical motion louder breath sounds on the right chest pH of 7.36 in arterial blood gases

louder breath sounds on the right chest

a young adult is admitted to the emergency department after an automobile accident .the client has severe pain in the right chest where there was an impact on the steering wheel. which is the primary client goal at this time reduce the client's anxiety maintain adequate oxygenation decrease chest pain maintain adequate circulating volume

maintain adequate oxygenation

A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. which of the following interventions should the nurse include in the plan of care: • maintain the head of the bed at 30 to 40 degrees • teach the client how to use esophageal speech • initiate small feedings of soft foods • irrigate drainage tubes as needed

maintain the head of the bed at 30 to 40 degrees

a client who has been diagnosed with tuberculosis has been placed on drug therapy. the medication regimen includes rifampin. which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin. select all that apply having eye examinations every 6 months maintaining follow up monitoring of liver enzymes decreasing protein intake in the diet avoiding alcohol intake the urine may have an orange color

maintaining follow up monitoring of liver enzymes avoiding alcohol intake the urine may have an orange color

which of the following is a prioirty goal for the client with COPD maintaining functional ability minimizing chest pain increasing carbon dioxide levels in the blood treating infectious agents

maintaining functional ability

when caring for a client with a chest tube and water seal drainage system the nurse should verify that the air vent on the water seal drainage system is capped when the suction is off strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs ensure that the chest tube is clamped when moving the client out of the bed make sure that the drainage apparatus is always below the client's chest level

make sure that the drainage apparatus is always below the client's chest level

The nurse is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago. the nursing policy manual recommends use of the gauze pad. the nurse should: • make sure the gauze pad is dry and the client is in a comfortable position • ask the nursing assistant to tie the tracheostomy tube ties in the back of the client's neck • reposition the gauze pad around the stoma with the open end downward • ask a registered nurse to change the ties and position another gauze pad around the stoma

make sure the gauze pad is dry and the client is in a comfortable position

while assessing a throacotomy incisional area from which a chest tube exits the nurse feels a crackling sensation under the fingertips along the entire incision. which of the following should be the nurse's first action lower the head of the bed and call the physician prepare an aspiration tray mark the area with a skin pencil at the outer periphery of the crackling turn off the suction of the chest drainage system

mark the area with a skin pencil at the outer periphery of the crackling

a nurse is designing the plan of care for a client following total laryngectomy. included in the plan of care is a referral to a nutritional support staff/dietician. the nurse understands that the referral is essential because the client • is most like depressed and uninteresting in eating • will have to relearn how to swallow • may have lost his or her sense of smell and taste • must learn strategies for preventing aspiration

may have lost his or her sense of smell and taste

which of the following interventions should the nurse anticipate in a client who has been diagnosed with ARDS tracheostomy use of a nasal cannula mechanical ventilation insertion of a chest tube

mechanical ventilation

A nurse is working with a client to update the client's asthma action plan. the nurse knows that this action plan should include information on: • medication adjustments that should made if peak flow is less than 50% normal • timeline for allergy skin testing • the most direct route when the client drives to the hospital • the best methods for chest physiotherapy

medication adjustments that should made if peak flow is less than 50% normal

an adult is ordered oxygen via nasal prongs. what is true of administering oxygen this way mixes room air with oxygen delivers a precise concentration of oxygen requires humidity during elivery is less traumatic to the respiratory tract

mixes room air with oxygen

a client with pneumonia is experiencing pleuritic chest pain. the nurse should assess the client for • a mild but constant aching in the chest • severe midsternal pain • moderate pain that worsens on inspiration • muscle spasm pain that accompanies coughing

moderate pain that worsens on inspiration

a client with ARDS has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/min. the client is restless and anxious. in addition to monitoring the arterial blood gas results, the nurse should do which of the following. select all that apply monitor serum creatine and BUN levels administer a sedative keep the head of the bed flat administer humidified oxygen auscultate the lungs

monitor serum creatine and BUN levels administer humidified oxygen auscultate the lungs

What is the rationale that supports multidrug treatment for clients with tuberculosis: • multiple drugs potentiate the drugs' actions • multiple drugs reduce undesirable drug adverse effects • multiple drugs allow reduced drug dosages to be given • multiple drugs reduce development of resistant strains of the bacteria

multiple drugs reduce development of resistant strains of the bacteria

an adult is receiving oxygen by nasal prongs. which statement by the client idnicates that client teaching regarding oxygen therapy has been effective i was feeling fine so i removed my nasal prongs it will be good to rest from taking deep breaths now that my oxygen is on dont' forget to come back quickly when you get me out of bed; i don't like to be without my oxygen for too long my family was angry when i told them they could not smoke in my room

my family was angry when i told them they could not smoke in my room

which of the following can cause a low pulse ox reading. select all that apply nail polish inadequate peripheral circulation hyperthermia increased hgb level edema

nail polish inadequate peripheral circulation edema

delivers an FiO2 of 24% to 55% to 44% at a flow rate of 1 to 6L/min via tubing with two small prongs for insertion into the nares nasal cannula simple face mask nonrebreather mask venturi mask face tent

nasal cannula

the client with COPD is taking theophylline. the nurse should instruct the client to report which of the following signs of theophylline toxicity. select all that apply nausea vomiting seizures insomnia vision changes

nausea vomiting seizures insomnia

delivers an FiO2 of 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration nasal cannula simple face mask nonrebreather mask venturi mask face tent

nonrebreather mask

the nurse is caring for a client who has just had a chest tube attached to a portable water seal drainage system observe for intermittent bubbling in the water-seal chamber flush the chest tube with 30 to 60 ml of NSS q4 to6 hours maintain the client in an extreme lateral position strip the chest tubes in the direction of the client

observe for intermittent bubbling in the water-seal chamber

a client who underwent a left lower lobectomy has been out of surgery for 48 hours. the client is receiving morphine sulfate via a PCA system and reports having pain in the left thorax that worsens when coughing. the nurse should let the client rest, so that the client is not stimulated to cough encourage the client to take deep breaths to help control the pain check that the PCA device is functioning properly then reassure the client that the machine is working and will relieve the pain obtain a more detailed assessment of the client's pain using a pain scale

obtain a more detailed assessment of the client's pain using a pain scale

a nurse is caring for a 76 year old female client brought in to a clinic by her husband. the husband states that his wife woke up this morning and did not recognnize him or know where she was. the client reports chills and chest pain that worsens with inspiration. which of the following is the highet priority nursing task obtain baseline vital signs and oxygen saturation obtain a sputum culture obtain a complete history from the client provide a pneumococcal vaccination

obtain baseline vital signs and oxygen saturation

a nurse is training a newly licensed nurse who is caring for a client who is receiving mechanical ventilation. the ventilator has been placed on presure support ventilation PSV mode. the newly licensed nurse demonstrates an understanding of PSV by stating that pressure support maintains the amount of pressure in the lungs to open alveoli and prevent ateectasis on spontaneous ventilation to decrease the work of breathing on spontaneous ventilation to increase the work of breathing on continuous ventilation to decrease the work of breathing

on spontaneous ventilation to decrease the work of breathing

while making rounds, the nurse finds a client with COPD sitting in a wheelchair slumpted over a lunch tray. after determining the client is unresponsive and calling for help, the nurse's first action should be to push the code blue button call the rapid response team open the client's airway call for a defibrillator

open the client's airway

which of the following items should the nurse have placed in the client with a chest tube's room select all that apply oxygen sterile water enclosed hemostat clamps indwelling urinary catheter occlusive dressing suction source bladder scan machine

oxygen sterile water enclosed hemostat clamps occlusive dressing suction source

a nurse is caring for a client who is scheduled for a thoracentesis at the bedsie. which of the following items should the nurse ensure is in the client's room . select all that apply oxygen equpiment incentive spirometer pulse oximeter thoracentesis tray suture removal kit

oxygen equpiment pulse oximeter thoracentesis tray

for a client with rib fractures and a pneumothorax, the physician prescribes morphine sufate 1 to 2 mg/h given IV as needed for pain. the nursing care goal is to provide adequate pain control so that the client can breath effectively. which of the following outcomes would indicate successful achievement of this goal pain rating of 0/10 by the client decreased client anxiety respiratory rate of 26 breaths/min PaO2 of 70 mg Hg

pain rating of 0/10 by the client

the nurse will be performing chest physiotherapy (CPT) on a client every 4 hours. what is the appropriate action by the nurse gently slap the chest wall use vibration techniques to move secretions from affected lung areas during the inspiratoin phase perform CPT at least 2 hours after meals plan apical drainage at the beginning of the CPT session

perform CPT at least 2 hours after meals

A client is being discharged with nasal packing n place. the nurse should instruct the client to • perform frequent mouth care • use normal saline nose drops daily • sneeze and cough with mouth closed • gargle every 4 hours with salt water

perform frequent mouth care

a nurse is assisting a provider with the removal of a chest tube. which of the following should the nurse instruct the client to do lie on his left side during removal hold his breath inhale deeply during removal perform the valsalva maneuver during removal

perform the valsalva maneuver during removal

the nurse teaches a client with COPD to assess for signs and symptoms of right sided heart failure. which of the following signs and symptoms should be included in the teaching plan clubbing of the nail beds hypertension peripheral edema increased appetite

peripheral edema

the nurse is preparing to assist with the removal of a chest tube. which of the following is appropriate at the site fro which the chest tube is removed adhesive strip (steri-strips) petroleum gauze 4 x 4 gauze with antibioitic ointment no dressing is necessary

petroleum gauze

Clients who have had active tuberculosis are at risk for recurrence. which of the following conditions increases that risk: • cool and damp weather • active exercise and exertion • physical and emotional stress • rest and inactivity

physical and emotional stress

an adult is being admitted to the nursing unit with a diagnosis of pneumonia. she has a history of arrested TB. what will the nurse's initial action place the client in respiratory isolation encourage cough and deep breathing force fluids administer O2

place the client in respiratory isolation

a nurse is assessing lung sounds on a client with pneumonia who is having pain during inspiration and expiration. the nurse hears loud grating sounds over the lung fields. the nurse should document the client's pain level and should document that • lung sounds were clear upon auscultation • fine crackles were heard upon auscultation • wheezing was heard upon auscultation • pleural friction rub was heard upon auscultation

pleural friction rub was heard upon auscultation

a client has been admitted to the hospital. lung assessment reveals the following: bronchial breath sounds over L lower lobe, diminished breath sounds L lower lobe, tactile fremitus present, percussion dulled in this area. based on the assessment findings, what condition does the nurse suspect pneumonia asthma emphysema early left-sided heart failure

pneumonia

a client is undergoing a thoracentesis the nurse should monitor the client during and immediately after the procedure for which of the following. select all that apply pneumothorax subcutaneous emphysema tension pneumothorax pulmonary edema infection

pneumothorax subcutaneous emphysema tension pneumothorax pulmonary edema

a man is injured in an industrial accident. the industrual nurse assesses him and observes use of accessory muscles, severe chest pain, agitation, shortness of breath. the nurse also notices one side of his chest moving differntly than the other. the nurse suspects flail chest. what will be the nurse's inital action apply a sandbag to the flail side of his chest prepare for intubation and mechanical ventilation prepare for chest tube placement administer pain medication

prepare for intubation and mechanical ventilation

A client with asthma has pronounced wheezing upon auscultation. Suspecting an impending asthma attack, a nurse should: a. have the client cough and deep breath b. prepare to intubate the client c. prepare to administer a nebulized beta-2 adrenergic agonist d. have the client lay on his or her right side

prepare to administer a nebulized beta-2 adrenergic agonist

a nurse is helping a client with obstructive sleep apnea to apply a CPAP mask before going to sleep. the nurse knows that the CPAP is intended to • breath for the client during sleep • reduce intrathoracic pressure • deliver high concentrations of oxygen • prevent alveolar collapse

prevent alveolar collapse

on the first postoperative day following right-sided thoracotomy, a nurse is assiting a client with arm and shoulder exercises. the client reports pain with the exercises and why they must be performed. the nurse should explain that the exercises promote respiratory function increase blood flow back to the heart and venous system improve muscle mass to compensate for muslce removed during the procedure prevent stiffening and loss of function

prevent stiffening and loss of function

the nurse has calculated a low PaO2/FIO2 ratio less than 150 for a client with ARDS. the nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions supine semi flowlers lateral side prone

prone

Which of the following home care instructions would be appropriate for a client with a laryngectomy • perform mouth care every morning and evening • provide adequate humidity in the home • maintain a soft bland diet • limit physical activity to shoulder and neck exercises

provide adequate humidity in the home

an adult is receiving oxygen per face mask at 40%. the nurse should include which of the following in her plan of care provide good skin care making sure the mask fits well keep all visitors out of the room turn off the CPAP during the day keep the bag inflated at all times

provide good skin care making sure the mask fits well

the nurse prepares to perfrom endotracheal suctioning. which of the following are appropriate guidelines. select all that apply set wall suction at 150 mm Hg to ensure adequate suction apply intermittent suction while inserting and withdrawing the catheter provide hyperoxygenation to the client with 100% FiO2 before suctioning clear the catheter and tubing and save for later use maintain surgical aseptic technique

provide hyperoxygenation to the client with 100% FiO2 before suctioning maintain surgical aseptic technique

a nurse is caring for a client who has a tracheotomy. which of the following interventions should the nurse include. select all that apply use medical aseptic technique when performing tracheostomy care change the tracheostomy ties each time tracheostomy care is given provide the client with materials for nonverbal communication keep pressure greater than 30 mm Hg clean the stoma site with half-strength hydrogen peroxide followed by 0.9% sodium chloride

provide the client with materials for nonverbal communication clean the stoma site with half-strength hydrogen peroxide followed by 0.9% sodium chloride

a client has the following arterial blood gas values: pH 7.52, PaO2 50 mm Hg; PaCO2 28 mm Hg; HCO3 24.the nurse determines that which of the following is a possible cause for these findings COPD diabetic ketoacidosis with Kussmaul's respirations myocardial infarction pulmonary embolus

pulmonary embolus

which of the following are significant data to gather form a client who has been diagnosed with pneumonia. select all that apply • quality of breath sounds • presence of bowel sounds • occurence of chest pain • amount of perpheral edema • color of nail beds

quality of breath sounds occurrance of chest pain colour of nail beds

which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis turn from side to side raise and lower the head raise the arm on the affected side over the head flex and extend the elbow on the affected side

raise the arm on the affected side over the head

following thoracotomy the client has severe pain. which of the following strategies for pain management will be most effective for this client repositioning the client immediately after administering pain medication reassessing the client 30 minutes after administering pain medication verbally reassuring the client after administering pain medication readjusting the pain medication dosage as needed according to the cleitn's condition

reassessing the client 30 minutes after administering pain medication

A nurse who is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. the client is rating pain at 9 out of 10. for which pain management modality should the nurse advocate: • nsaids • oral analgesics • regional/local analgesia (epidural or intercostal injection) • IV bolus meperidine (Demerol)

regional/local analgesia (epidural or intercostal injection)

a nurse is setting up oxygen for an adult male. he is to receive oxygen at 2 L per nasal cannula. what should be included for this treatment adjust the flow rate to keep the reservoir bag inflated 2/3 full during inspiration monitor the client carefully for risk of aspiration make sure the valves and rubber flaps are patent, functional, and not stuck remind the client not to use vaseline lip balm

remind the client not to use vaseline lip balm

a client is on a ventilator. the ventilator alarm goes off. the nurse assesses the client and observes increased respiratory rate, use of accessory muscles and agitaiton. what should be the nurse's first action remove the client from the ventilator and ambubag the client while continuing to assess to determine the cause of the client's distress call respiratory therapy to check the ventilator notify the physician turn off the alarm

remove the client from the ventilator and ambubag the client while continuing to assess to determine the cause of the client's distress

a client has had surgery for a deviated nasal septum. which of the following would indicate that bleeding was occuring even if the nasal drip pad remained dry and intact • nausea • repeated swallowing • increased respiratory rate • increased pulse

repeated swallowing

which of the following interventions would be most likely to prevent the development of ARDS teaching cigarette smoking cessartion maintaining adequate serum potassium monitoring clients for signs of hypercapniaa replacing fluids adequately during hypovolemic states

replacing fluids adequately during hypovolemic states

a 68 year old male is being admitted to the hospital for an exacerbation of his COPD. what will most likely be included in the plan of care placed on 10 L of oxygen per NC placed in repiratory isolation require frequent rest periods throughout the day placed on fluid restriction

require frequent rest periods throughout the day

a nurse shold interpret which of the following as an early sign of a tension pneumothroax in a client with chest trauma diministed bilateral breath sounds muffled heart sounds respiratory distress tracheal deviation

respiratory distress

A nurse is working at a telephone health service. which advice should the nurse give to a client who has had 3 days of symptoms that strongly suggest influenza: • return to work after another day of rest • rest and increase fluid intake to 3 litres of fluid per day • use over the counter antihistamines • make an appointment to get the flu shot

rest and increase fluid intake to 3 liters of fluid per day

pseudoephedrine (Sudafed) has been prescribed as a nasal decongestant. which of the following is a possible adverse effect of this drug • constipation • bradycardia • diplopia • restlessness

restlessness

the nurse may expect a client with suspected early ARDS to exhibit which of the following PaO2 of 90, PaCO2 of 45, Xray showing enlarged heart, bradycardia thick green sputum production, PaO2 of 75, pH 7.45 restlessness, suprasternal retractions PaO2 of 65 wheezes, slow deep respirations, PaCO2 of 55, pH of 7.25

restlessness, suprasternal retractions PaO2 of 65

what is the rationale for this intervention for pulmonary embolism: administer cyrstalloids improves cardiac contractility restores intravascular volume assesses for thrombocytopenia

restores intravascular volume

supplemental low flow oxygen therapy is prescribed for a man with emphysema. which is the most essential action for the nurse to initiate anticipate the need for humidification notify the physician that this order is contraindicated place the client in an upright position schedule frequent pulse oximeter checks

schedule frequent pulse oximeter checks

which of the following conditions can place a client at risk for ARDS septic shock COPD asthma heart failure

septic shock

when caring for the client who is receiving an aminoglycoside antibiotic the nurse shold monitor which of the following values • serum sodium • serum potassium • serum creatinine • serum calcium

serum creatinine

delivers an FiO2 of 40% to 60% at flow rates of 5 to 8 L/min for short term oxygen therapy nasal cannula simple face mask nonrebreather mask venturi mask face tent

simple face mask

The nurse is teaching a client how to manage a nosebleed. which of the following instruction would be appropriate to give the client: • tilt your head backward and pinch your nose • lie down flat and place an ice compress over the bridge of the nose • blow your nose gently with your neck flexed • sit down, lean forward, and pinch the soft portion of your nose

sit down, lean forward, and pinch the soft portion of your nose

when discharging a client home who is on oxygen, which of the following is most important for the nurse to teach smoking cessation equipment maintenance incorporating rest into ADLs anger management

smoking cessation

the client with pneumonia develops mild constipation and the nurse administers docusate sodium (Colace) as prescribed. this drug works by • softening the stool • lubricating the stool • increasing stool bulk • stimulating peristalsis

softening the stool

a client with bacterial pneumonia is to be started on iv antibiotics. which of the following diagnostic test must be completed before antibiotic therapy begins • urinalysis • sputum culture • chest radiograph • red blood cell count

sputum culture

an adult has undergone a bronchoscopy. which assessment finding indicate to the nurse that he is ready for discharge use of accessory muscles for breathing, decreaed lung sounds stable vital signs, return of gag and cough reflex hemoptysis, rhonchi development of tachycaria with occasional PVCs able to eat and drink

stable vital signs, return of gag and cough reflex

What areas of education should the nurse provide employees in a factory making products that cause respiratory irritation to reduce the risk of laryngeal cancer. select all that apply: • stopping smoking • using a HEPA filter in the home • limiting alcohol intake • brushing teeth after every meal • avoid raising the voice to be heard over the noise in the factory

stopping smoking limiting alcohol intake

a client learning about COPD self care at a community health class aska a nurse why the participants are being taught about the lip breathing. the nurse should respond by explaining that pursed lip breathing can help to • reduce upper airway inflammation • reduce anxiety through humor • strengthen respiratory muscles • increase effectiveness of inhaled medication

strengthen respiratory muscles

approximately 10 minutes after a client returns from surgery with a tracheostomy tube the nurse assesses increaing norisy respiratory and an increased pulse. what action should be taken immediately take the client's blood pressure suction the tracheostomy tube drain water from the O2 tubing change the tracheostomy tube

suction the tracheostomy tube

which of the following nursing interventions would promote effective airway clearance in a client with ARDS administering oxygen every 2 hours turning the client every 4 hours administering sedatives to promote rest suctioning if cough is ineffective

suctioning if cough is ineffective

a client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. the nurse should assess the client for sudden sharp chest pain wheezing breath sounds over affected side hemoptysis cyanosis

sudden sharp chest pain

a nurse in an ED is caring or a client who has advanced lung cancer. the client reports dyspnea on exertion and at rest, and her family states that she has become disoriented over the last 72 hr a chest xray reveals a baseball sized mediastinal tumor. vital signs are as follows: HR 104, BP 88/42, RR 38, T 100.2 F, SaO2 89% on RA. which of the following do these findings indicate cardiac tamponade sick sinus syndrome superior vena cava syndrome right heart block

superior vena cava syndrome

a client with tuberculosis is taking isoniazin. to help prevent development of peripheral neuropathies the nurse should instruct the client to • adhere to a low cholesterol diet • supplement the diet with pyridoxine (vitamin B6) • get extra rest • avoid excessive sun exposure

supplement the diet with pyridoxine (vitamin B6)

a nurse is caring for a client who has severe acute respiratory syndrome. treatment for this client may include. select all that apply antibiotics supplemental oxygen antiviral medications bronchodilators intubation

supplemental oxygen antiviral medications intubation

which of the following modes of ventilation can increase conditioning of the respiratory muscles. select all that apply assist-control syncrhonized intermittent mandatory ventilation continuous positive airway pressure pressure support ventilation independent lung ventilation

syncrhonized intermittent mandatory ventilation continuous positive airway pressure pressure support ventilation

the nurse is planning to teach a client with COPD how to cough effectively. which of the following instructions should be included take a deep abdominal breath, bend forward and cough three or four times on exhalation lie flat on the back, splint the thorax, take two deep breaths, and cough take several rapid, shallow breaths and then cough forcefully assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing

take a deep abdominal breath, bend forward and cough three or four times on exhalation

the nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis • avoid the use of caffeinated beverages • perform postural drainage every day • take hot showers twice daily • report a temperature of 38.9 or higher

take hot showers twice daily

which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia • encourage the client to breathe shallowly • have the client practice abdominal breathing • offer the client incentive spirometry • teach the client to splint the rib cage when coughing

teach the client to splint the rib cage when coughing

The client with tuberculosis is to be discharged home with community health nursing follow-up. of the following nursing interventions, which should have the highest priority: • offering the client emotional support • teaching the client about the disease and its treatment • coordinating various agency services • assessing the client's environment for sanitation

teaching the client about the disease and its treatment

the nurse has placed the intubated client with ARDS in prone position for 30 minutes. which of the following would require the nurse to discontinue prone positioning and return the client to the supine position. select all that apply the family is coming in to visit the client has increased secrtions requiring frequent suctioning the SpO2 and PO2 have decreased the client is tachycardic with drop in blood presssure the face has increased skin breakdown and edema

the SpO2 and PO2 have decreased the client is tachycardic with drop in blood presssure the face has increased skin breakdown and edema

Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia • a respiratory rate of 25 to 30 bpm • the ability to perform activities of daily living without dyspnea • a maximum loss of 5 to 10 lb of body weight • chest pain that is minimized by splinting the rib cage

the ability to perform activities of daily living without dyspnea

a client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. the nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. what is the significance of this fluctuation an obstruction is present in the chest tube the client is developing subcutaneous emphysema the chest tube system is functioning properly there is a leak in the chest tube system

the chest tube system is functioning properly

which of the following indicates that the client with COPD who has been charged to home understands the care plan the client promises to do pursed lip breathing at home the client states actions to reduce pain the client will use oxygen via a nasal cannula at 5 L/min the client agrees to call the physician if dyspnea on exertion increases

the client agrees to call the physician if dyspnea on exertion increases

The nurse teaches the client how to instil nose drops. which of the following techniques is correct: • the client uses sterile technique when handling the dropper • the client blows the nose gently before instilling drops • the client uses a new dropper for each instillation • the client sits in a semi folwer's position with the head tilted forward after administration of the drops

the client blows the nose gently before instilling drops

a client has the following arterial blood gas values: pH 7.52, PaO2 50 mm Hg; PaCO2 28 mm Hg; HCO3 24. based upon the client's PaO2 which of the following conclusions would be accurate the client is severely hypoxic the oxygen level is low but poses no risk for the client the client's PaO2 level is within normal range the client requires oxygen therapy with very low oxygen concentrations

the client is severely hypoxic

a nurse is partnered with a PCA on a med-surg floor. the PCA provides information about the clients for whom the PCA has been caring. based on the information from the PCA which client should the nurse attend to first the client with a pulmonary embolus who has not had a bowel movement in 2 days the client who underwent a video thoracoscopy with oxygen saturation readings from 88% to 90% on oxygen at 4 L/NC the client who underwent a wedge resection of right lung and has a blood pressure of 100/65 mm Hg the client who has rib fractures and has not voided for 6 hours after the urinary catheter was removed

the client who underwent a video thoracoscopy with oxygen saturation readings from 88% to 90% on oxygen at 4 L/NC

the nurse is a member of a team that is planning a client centered approach to care of clients with COPD using the chronic care model. the teach should focus on improving quality of care and delivery in which of the following areas. welect all that apply the community clinical information systems devliery system design administrative leadership emphasis on the acute care setting

the community clinical information systems devliery system design

Following an unrestrained motor vehicle crash a client presents to an emergency department with multiple injuries including chest trauma. a physician notifies the care team that the client has progressed to ARDS and requests that the family be updated on the client's condition. the nurse should plan to discuss with the family that: • the condition generally stabilizes with positive prognosis • the client can be discharged with home oxygen • the condition is always fatal • the condition is highly life-threatening and that end-of-life concerns should be addressed

the condition is highly life-threatening and that end-of-life concerns should be addressed

the nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a corticosteroid. which of the following indicates that the client is using the MDI correctly. select all that apply the inhaler is held upright the head is tilted down while inhaling the medicine the client waits 5 minutes between puffs the client rinses the mouth with water following administration the client lies supine for 15 minutes following administration

the inhaler is held upright the client rinses the mouth with water following administration

a client has a chest tube attached to a water seal drainage system and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. the nurse should determine that the lung has fully expanded the lung has collapsed the chest tube is in the pleural space the mediastinal space has decreased

the lung has fully expanded

which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer the support available to assist the client at home the distance the client lives from the hopital the client's ability to do home blood pressure monitoring the client's knowledge of the causes of lung cancer

the support available to assist the client at home

a nurse is caing for a client who has COPD. upon discharge the client is concerned that he will never be able to leave his house now that he has been placed on continuous oxygen. which of the following statements should the nurse make there are portable oxygen delivery systems that you can take with you when you go out you can remove the oxygen and then reapply it when you get home you probably will not be able to go out as much as you used to home health services will come to you so you will not need to get out

there are portable oxygen delivery systems that you can take with you

A nurse is completing the health history for a client who has been taking echinacea for a head cold. the client asks "why isn't this helping me feel better" which of the following responses by the nurse would be the most accurate: • there is limited information as to the effectiveness of herbal products • antibiotics are the agents needed to treat a head cold • the head cold should be gone within the month • combining herbal products with prescription antiviral medications is sure to help you

there is limited information as to the efectiveness of herbal products

the nurse is checking tuberculin skin test results at a health clinic. one client has an area of induration measuring 12 mm in diameter, what does this finding indicate this finding is a normal reading this finding indicates active TB this is positive reaction and an indicate exposure to TB this client needs to come back in two more days and let the nurse look at the area of induration again

this is positive reaction and an indicate exposure to TB

after a radical neck dissection, the client reports that he is having difficulty raising his right arm above his head when dressing. which of the following responses is appropriate i wil call your provider and let her know that your right arm is weak this sometimes occurs as a complication after a radical neck dissection it is normal for you to be weak after this type of surgery you may need to wear your arm in a sling the rest of your life

this sometimes occurs as a complication after a radical neck dissection

which of the following is an expected outcome of pursed lip breathing for clients with emphysema to promote oxygen intake to strengthen the diaphragm to strengthen the intercostal muscles to promote carbon dioxide elimination

to promote carbon dioxide elimination

the physician has inserted a chest tube in a client with a pneumothorax. the nurse should evaluate the effectiveness of the chest tube for administration of oxygen to promote formation of lung scar tissue to insert antibiotics into the pleural space to remove air and fluid

to remove air and fluid

the client had a removal of the larynx and a permanent opening made into the trachea. what is the correct name of this procedure total laryngectomy tracheostomy radical neck dissection partial laryngectomy

total laryngectomy

When suctioning a tracheostomy tube 3 days following insertion the nurse should follow which of the following procedures: • use a sterile catheter each time the client is suctioned • clean the catheter in sterile water after each use and reuse for no longer than 8 hours • protect the catheter in sterile packaging between suctioning episodes • use a clean catheter with each suctioning and disinfect it in hydrogen peroxide between uses

use a sterile catheter each time the client is suctioned

an adult has had a total larngectomy. the nurse is discussing options for verbal communication with the client. which statement indicatse the client understands the statement indicates the client understand the available options for verbal communication because of the arthritis in my hands, i think the voice button method would be easiest to use by the time i leave the hospital i will be able to talk if i use the esophageal speech, my voice will be high pitched and soft using an artifical larynx will make me sound sort of monotone

using an artifical larynx will make me sound sort of monotone

which of the following oxygen delivery devices is used when a prcise amount of oxygen must be delivered nonrebreather mask ventrui mask nasal cannula simple face mask

venturi

delivers an FiO2 of 24% to 55% at flow rates of 2 to 10 L/min via different sized adaptors nasal cannula simple face mask nonrebreather mask venturi mask face tent

venturi mask

a client has developed a hospital acquired pneumonia. when preparing to administer cephalexin (Keflex) 500 mg, the nurse notices that the pharmacy sent cefazolin (Kefzol). what should the nurse do. select all that apply administer the cefazolin (Kefzol) verify the medication prescription as written by the physician contact the pharmacy and speak to a pharmacist request that cephalexin (Keflex) be sent promptly return the cefazolin (Kefzol) to the pharmacy

verify the medication prescription as written by the physician contact the pharmacy and speak to a pharmacist request that cephalexin (Keflex) be sent promptly return the cefazolin (Kefzol) to the pharmacy

a client is receiving streptomycin for the treatment of tuberculosis. the nurse should assess the client for eight cranial nerve damage by observing the client for • vertigo • facial paralysis • impaired vision • difficulty swallowing

vertigo

when auscultating the lung fields a sound describes as rustling, like wind in the trees is heaerd. what is the correct term for this occurence crackles rhonchi wheeze vesicular

vesicular

the nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack occupational exposure to toxins viral respiratory infections exposure to cigarette smoke exercising in cold temperatures

viral respiratory infections

a client recently diagnosed with tuberculosis is placed on a multi-medication regimen. which of the following instructions should the nurse give the client in regard to ethambutol your urine may turn a dark orange watch for a change in the color of your sclera watch for any changes in vision take viatmin B6 daily

watch for any changes in vision

On the third postoperative day following a total laryngectomy a client's family asks a nurse when the client will be able to eat. which response by the nurse is best: • we are going to start with a feeding tube but eventually he should be able to eat normally • we are going to start with a feeding tube but eventually he will have to learn a different way of swallowing to prevent aspiratoin • because of his surgery it will be several more days before his gastrointestinal tract bbegins functioning again • he will probalby always have to be fed through a gastrostomy tube in his stomach

we are going to start with a feeding tube but eventually he should be able to eat normally

which of the following symptoms is common in clients with active tuberculosis • weight loss • increased appetite • dyspnea on exertion • mental status changes

weight loss

which of the following parameters indicate deterioration in the client's respiratory status. select all that apply SaO2 95% wheezing retraction of sternal muscles warm and pink extremities and mucous membranes premature ventricular complexes respiratory rate of 34/min anxiety

wheezing retraction of sternal muscles premature ventricular complexes respiratory rate of 34/min anxiety

when teaching a client with COPD to conserve energy the nurse should teach the client to lift objects while inhaling through an open mouth while exhaing through pursed lips after exhaling but before inhaling while taking a deep breath and holding it

while exhaing through pursed lips

a nurse is caring for a client who has a tension pneumothorax. the nurse knows that as a result of the tension pneumothorax, air continues to accumulate and the intraplueral pressure rises which causes small blebs to develop in the lung on the affected side allows air to flow freel through the chest wall during inspiration and expriation causes less air to enter on inspiration and exceed the barometric pressure will cause the mediastinum to shift away from the affected side and decrease venous return

will cause the mediastinum to shift away from the affected side and decrease venous return

an adult will undergo a total laryngectomy tomorrow. she is concerned about communicating post op. the nurse should plan for her to communicate by which method the first 24 - 48 hours after surgery. using the artificial larynx writing or pointing on communication board using esophageal speech using a voice button

writing or pointing on communication board

a client who has been taking flunisolide nasal spray (Nasalide) two inhalations a day for treatment of asthma has painful, white paatches in the mouth. which response by the nurse would be most appropriate this is an aticipated adverse efect of your medication. it should go away in a couple of weeks you are using your ihaler too much an it has irritated your mouth you have developed a fungal infection from your medication. it will need to be treated with an antifungal agent be sure to brush your teeth and floss daily. good oral hygiene will treat this problem

you have developed a fungal infection from your medication. it will need to be treated with an antifungal agent

the nurse is caring for a client diagnosed with laryngeal cancer and is admitted for a total laryngectomy with a right radical neck dissection. the client asks the nurse if he will be able to speak after the surgery. which of the following is an appropriate response by the nurse there is a good chane that you will be able to speak in your natural voice you will have to use a written form of communication for the rest of your life you will not be able to speak again with your natural voice, but there are options for re-establishing speech the primary concern at this time is to remove the cancer, so you shouldn't worry about your voice at this time

you will not be able to speak again with your natural voice, but there are options for re-establishing speech

A nurse is teaching a client about taking antihistamines. which of the following instructions should the nurse include in the teaching plan. select all that apply: • operating machinery and driving may be dangerous while taking antihistamines • continue taking antihistamines even if nasal infection develops • the effect of antihistamines is not felt until a day later • do not use alcohol with antihistamines • increase fluid intake to 2000 ml/day

• operating machinery and driving may be dangerous while taking antihistamines • do not use alcohol with antihistamines • increase fluid intake to 2000 ml/day

a public health nurse is planning a flu shot clinic. the nurse is working on advertising. which groups should be the highest priority to target when advertising the flu shot clinic. select all that apply • pregnant women • grade school children • nursing assistants at a nursing home • a hypertension clinic population • outpatient psychiatric population • spinal cord-injured population at an assisted living facility

• pregnant women • nursing assistants at a nursing home • spinal cord-injured population at an assisted living facility