Module 2- Prep U's

A nurse is caring for a client with a tracheostomy tube in place who has rhonchi bilaterally and a SaO2 of 94%. If the client is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction.

The nurse has completed a respiratory assessment of an elderly client with numerous health problems. The results of the assessment include a respiratory rate of 24 breaths per minute and pulse oximetry of 90%. The nurse's next action should be to:

Put the client in high fowlers position

A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure?

Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously

The nurse administered 10 units of a short-acting insulin to a client. Forty-five minutes after administration, the client reported weakness and had cold and clammy skin. The nurse failed to act appropriately when the nurse:

delayed evaluating response to the medication until now.

The nurse is to administer an intramuscular injection of 1.2 mL of an antiemetic from a 5-mL multiuse vial. To prepare the medication for administration, the nurse:

injects 1.2 mL of air into the vial.

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing?

intradermal

A nurse is performing a sensitivity test on a client. What would be the best type of injection to use for this procedure?

intradermal

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

intradermal

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?"

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe."

The nurse is teaching a client with chronic bronchitis about a new prescription for salmeterol. Which statement made by the client would indicate that the teaching about medication has been successful?

"I will take this medication everyday"

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

"Let me tell you what I will be doing. It should not be painful."

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

"Put away the salt shaker and eat low-salt foods."

The nurse performs a respiratory assessment on a client and deems the findings normal. How will the nurse best document this assessment?

"Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; oxygen saturation 98%."

A client has been admitted to the post-surgical unit after a metatarsal (foot) amputation and has been provided with an incentive spirometer in order to prevent respiratory complications after surgery. What client education should the nurse provide about the correct use of incentive spirometry?

"Sit up as straight as you can when you're performing incentive spirometry."

A nurse is obtaining an oral temperature on a client, using an electronic thermometer. The client notes having an electronic thermometer at home and asks how to care for it. Which response is appropriate?

"When not in use, keep the probe in the storage place within the unit."

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

"Wounds heal because HBOT helps to regenerate new tissue quickly."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use"

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

"Your white blood cells have increased in the area."

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

-Exposure to the pathogen -Nonspecific symptoms -Positive laboratory tests -Return of appetite

The nurse is to administer levothyroxine 0.125 mg PO at 0600. The package is labeled levothyroxine 125 mcg. Calculate the number of tablets the nurse will administer. Record your answer as a whole number.

1 tab

A nurse is collecting a sputum specimen from a client. The nurse will need to collect a minimum of how many milliliters of sputum to be sufficient for analysis?

1.5 to 3 ml

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

10-15 degrees

A nurse needs to administer an intradermal tuberculin skin test injection to a client. What is the most suitable angle when administering an intradermal injection?

10-degree angle

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?

100 to 120 mm Hg

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

15 degree needle

When assessing an infant's axillary temperature, it will be

1°F (0.5°C) lower than an oral temperature

The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment?

21%

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:

An older adult can have an infection without a fever

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?

As the gauge number becomes larger, the diameter of the needle and the lumen become smaller.

The nurse is auscultating the anterior chest of a client and hears gurgles. What is the nurse's appropriate action?

Ask the client to cough and auscultate the anterior Chest again.

An ultrasonic Doppler is used for:

Auscultating a pulse that is difficult to palpate.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

Auscultation

The client has a chest incision under the left arm from cardiac surgery 1 week ago. The client now has pneumonia and has percussion during postural drainage prescribed. The nurse:

Avoids striking the area under the left arm

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:

Bacterial infection

The nurse is teaching the client about a balanced and nutritious diet. Which dietary choices selected by the client indicate an understanding of dietary needs?

Baked potato, salad with olive oil dressing, and lean steak

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

Check temperature

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

Clear mucus

The following clients are being seen in the emergency department. Which client will be prioritizedto have a mental status assessment performed by the nurse?

Client who overdosed on prescribed oxycontin

The nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse do first?

Complete a comprehensive exam

When performing suctioning to remove the liquid secretion from a client with chest congestion, what nursing action will the nurse perform to prevent hypoxemia in the client?

Complete the process in no more than 15 seconds.

The nurse is taking a client's vital signs and finds the blood pressure is 99/60 mm Hg. The client states, "That is strange, I have hypertension and my blood pressure has never been lower than 130/90 mm Hg." The nurse confirms the client's report in the recent vital signs trend. What is the nurse's next action?

Determine if the cuff size is appropriate for the client's arm circumference.

The process of phagocytosis involves:

Digestion of microbes by white blood cells.

A nurse's finger was accidentally injured while administering a parenteral injection. In which order does the nurse understand the steps to be taken after having an accidental injury?

Document the injury in writing. Identify the client, if possible, and obtain HIV and hepatitis B virus status results. Obtain counseling on the potential for infection. Obtain the most appropriate postexposure drug treatment prophylaxis. Get tested for the presence of antibodies at approved intervals. Observe for potential symptoms and get medical follow-up care.

When percussing the liver, the sound should be:

Dull

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels

A nurse is caring for a middle-age client who looks worried. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition?

Dyspnea

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing

Dyspnea

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection

A sputum specimen is to be collected from a client. What would the nurse do?

Encourage a forceful cough to expectorate sputum.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

Encouraging the client to consume at least 1.5-2 L of fluids daily of clear fluids daily

The nurse is educating a client about ways to increase their cardiac output. Which does the nurse include in the teaching?

Exercise

The nurse is teaching a client about the combination drug dextroamphetamine saccharate-amphetamine aspartate monohydrate-dextroamphetamine sulfate-amphetamine sulfate XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response?

Extended release

A nurse is preparing to complete an assessment on a client with a history of heart disease. Which technique will the nurse use to begin the assessment?

Inspection

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

Intradermal

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen

A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:

It is a vaccine given to booster antibodies towards the tetanus pathogen.

Which contains all the components of a valid order?

John Smith, atenolol 50 mg, twice a day, by mouth

A nurse practitioner is preparing to examine a child with a suspected otitis media. Which instrument will be required?

Otoscope

A nurse is preparing to assess the integumentary system for texture, temperature, moisture, and edema. Which assessment technique will the nurse use?

Palpation

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand.

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?

Postural hypotension

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?

Prodromal period

A nurse is using inhalation therapy with a client. Which would not be administered through this method?

Protein therapy

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

Pulse oximetry

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?

Pumping the blood pressure cuff up to 200 mm Hg routinely

The most common infection in children is:

Respiratory

When the nurse administers the client's amlodipine, the client states that usually only one pill is taken instead of three pills. Which right of medication should now be triple checked before allowing the client to take the medication?

Right dose

A nurse working in a clinic is planning to conduct vision screenings for adults. What equipment would be needed to test vision?

Snellen chart

The nurse has completed a focused respiratory assessment of a client and is documenting the assessment findings in the client's medical record. How should the nurse document the results of pulse oximetry testing?

SpO2 = 96%

A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection?

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.

A 70-year-old client with chronic obstructive pulmonary disease (COPD) has a respiratory infection being treated with antibiotics. He is also taking oral corticosteroids to assist in decreasing the inflammation in the lungs. The client is prone to:

Superinfection

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

Symmetry (comparison of bilateral body parts)

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases.

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate?

The client will state how to safely take the prescribed antibiotic.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature?

The dorsum

A parent brings a child into the pediatric office with reports of an itchy red rash with fluid filled blisters. Two siblings at home are reported to have the same rash.

The nurse knows that since the parent had the same virus during childhood they will have cellular immunity in the form of antibodies

Regarding medication administration, what must occur at the change of shifts?

The opioids for the division are counted.

A nurse has assessed a client's respiratory system and made the following entry in the client's medical record: "Crackles auscultated to lower lungs fields bilaterally." This abnormal assessment finding indicates:

The presence of fluid in the alveoli.

A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture?

The shoulder and upper back curves forward.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record

There is an auscultatory gap

A nurse is caring for a client who underwent a tracheostomy (trach) following throat surgery. What is the rationale for swabbing the area around the outside of the trach tube with hydrogen peroxide?

To remove encrusted secretions

A client has suffered a spinal cord injury that has impaired the ability to breathe independently. Which intervention is the client most likely to require in order to facilitate long-term mechanical ventilation?

Tracheostomy

A group of nursing students is reviewing information about artificial airways in preparation for a class discussion the next day. The students demonstrate understanding of the information when they identify what as an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea?

Tracheostomy

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

Tracheostomy collar

A client with a head injury will require long-term airway support. Which device will be required for this client?

Tracheostomy tube

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

The nurse is caring for a client with a chest tube in situ. When performing a focused respiratory assessment, which action is important to take before auscultating the lungs?

Turn off the suction regulator attached to the tube.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope.

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?

Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding.

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

a dysrhythmia.

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection?

checking for documented allergies to food or drugs

The nurse receives a change-of-shift report on the following clients with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?

client with a respiratory rate of 36 breaths/minute

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate

What is an average normal temperature in Celsius for a healthy adult?

oral: 37°C

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

prolongs expiration to reduce airway resistance

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?

pumping the blood pressure cuff up to 200 mm Hg routinely

An alert client cannot cough up secretions and has gurgling sounds from the mouth. The bestaction of the nurse is to:

suction the mouth with a Yankauer-tip catheter.

What is an example of drug diversion? The nurse:

takes a medication from one client's container to use for another person

Which of the following can a nurse assess by palpation?

temperature, turgor, moisture

A nurse needs to administer a prescribed injection to a toddler. Which injection site is mostsuitable for the client?

vastus lateralis site

The client is a 9-month-old infant who is to receive an intramuscular injection. Which muscle is best for administration of this medication?

vastus laterlis

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?

ventrogluteal

The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment?

21% (0.21)

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's right lower quadrant. How long should the nurse listen before documenting absent bowel sounds?

5 minutes

The nurse on a geriatric care unit is completing assessments of four clients. Which client is mostlikely to exhibit edema?

81 year old women with heart failure

Before assessing a client's respiratory rate, the nurse should remind the client to breathe normally.

False

A nurse is preparing an injection by withdrawing the solution from a multidose vial. What is necessary to facilitate withdrawing a medication from the vial?

First, inject an equal amount of air into the vial.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

Flow meter

A client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess the client's temperature using an oral thermometer, but the client is unable to follow directions to close the mouth and secure the thermometer sublingually. Additionally, the client repeatedly withdraws their head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?

Assess the client's temperature by axilla

The nurse is performing the positions test on a client following a head injury. Which assessment would the nurse interpret as a normal finding?

Coordinated movement of both eyes

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

Decrease the apical pulse

The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Decreased level of consciousness

A nurse is preparing to suction a client. Place the suction procedure in the correct order.

Gather equipment. Adjust the suction to 120 to 150 mm Hg with tubing occluded. Provide preoxygenation. Set up a sterile field and apply gloves. Insert the catheter without suction approximately 5 to 6 inches. Withdraw the catheter, applying intermittent suction, and oxygenate the client.

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization?

Gently pull the pinna down and back.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature

Give the client a bath in tepid water.

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?

Healthcare-associated infection (HAI)

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

Hemoglobin level

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

Immediately assist the client back to bed

A nurse is withdrawing a dose of heparin from a vial and notices that a significant volume of air is mixed with the medication that is now in the syringe. How can the nurse increase the pressure in the vial to reduce the chance of bubbles in the syringe?

Inject air into the vial equal in volume to the medication that will be withdrawn

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received

The nurse is preparing to auscultate the lung sounds of a client with asthma. How should the nurse complete the assessment?

Listen to at least one full respiration in each location.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Listen with the stethoscope at the fifth intercostal space left mid-clavicular line

While assessing breath sounds, a nurse hears crackles. The nurse interprets this finding as indicating which condition?

Moisture in the air lungs

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

Nasal cannula

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

Sleep apnea

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

Systolic pressure

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Tachycardia

A nurse is performing a general survey of a client admitted to the hospital. Which action is an element of this procedure?

Taking vital signs

During a physical assessment, a client reports a desire to reduce snoring because it interferes with the spouse's ability to sleep properly. What suggestion could the nurse make to improve the client's condition?

Tell the client to use nasal strips when sleeping.

Which of the following can a nurse assess by palpation?

Temperature, trugor, moisture

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?

Temporal temperature 100.8º F (38.2º C)

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

The abilities for the arteries to stretch

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.