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A nurse is collecting data from a chent who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect! 1 Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia
2) Hyperventilation
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because or cold reel. dio orre orowig nursing actions should the nurse take to promote the client's comfort? 1) Rub the chent's feet brisklv for several minutes 2) Obtain a pair of slipper socks for the client. 3 increase the clients oral no таке 4) Place a moist heating pad under the client's feet.
2) Obtain a pair of slipper socks for the client.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an annemenc
3) Check the client's vital signs
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine
3) Thick, red-colored urine
A nurse is reinforcing teaching about exercise with a chent who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1 "I will carry a complex carbohydrate snack with me when I exercise 2) "I should exercise first thing in the morning before eating breakfast. 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones."
4) "I will not exercise if my urine is positive for ketones."
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the clients troponins levels, the client ask what this blood test will show. The nurse should explain that troponins is
A heart muscle protein that appears in the bloodstream when there is damage to the heart
The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all that apply A. Assess the client's level of consciousness B. Monitor clients urine output C. Perform passive range of motion exercise D. maintain intravenous fluids as ordered E. Place the client with the HOB flat
A. Assess the client's level of consciousness B. Monitor clients urine output C. Perform passive range of motion exercise D. maintain intravenous fluids as ordered
An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action? A. Obtain an order for an EKG and serum potassium and digitalis levels B. Perform a neurological assessment to determine whether he has one side weakness. C. Assess lungs for decreased breath sounds and/or adventitious breath sounds. d. Obtain an order for an EKG
A. Obtain an order for an EKG and serum potassium and digitalis levels
The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Pulse rate has increased to 70 beats/min B. systolic BP has increased by 20 C. pupils are dilated D. oral secretions have decreased
A. Pulse rate has increased to 70 beats/min
A client arrives at the emergency department with deep partial thickness and burns over 15% of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate for this client? Select all that apply A. Starting an IV infusion of lactated Ringers solution B. Administering 6mg of morphine IV C. Administering tetanus prophylaxis as ordered
A. Starting an IV infusion of lactated Ringers solution B. Administering 6mg of morphine IV C. Administering tetanus prophylaxis as ordered
The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first? A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent. B. A client who is in heart failure and has gained 2 pounds in the last 24 hours. C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min
A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent.
The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include? A. use a condom for sexual intercourse B. Report any clay- colored stools. C. Eat a high protein diet D. Perform daily urine bilirubin checks
A. use a condom for sexual intercourse
A nurse in the ICU is caring for a client who has acute respiratory distress syndrome, ARDS, and is receiving mechanical ventilation via an endotracheal tube. The provider plans to excavate her within the next 24 hours. Which of the following is an important criterion for extubating the client?
Adequate tidal volume without manually assisted breaths
A nurse is caring for a female patient who came into the ED, reporting SOB and pain in the lung area. Her heart rate is 110/min, RR 40/min, and BP 140/80. Her arterial blood gases are: pH 7.5, CO2 29, PaO2 60, HCO3 20, and SaO2 86%. Which of the following is the priority intervention?
Administer oxygen via face mask
The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply A. presence of a thrill on palpation over the fistula B. Absence of a bruit on auscultation over the fistula C. Presence of a pulse in the extremity below the fistula D. Complaints of tingling or discomfort in the extremity E. Warm hand and fingers in the extremity in which the fistula is located
B. Absence of a bruit on auscultation over the fistula D. Complaints of tingling or discomfort in the extremity
The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax? A. Bronchovesicular lung sounds and friction rub B. Absent breath sounds and tachypnea C. Nasal flaring and lung consolidation D. Symmetrical chest expansion and bradypnea.
B. Absent breath sounds and tachypnea
A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mmhg. Which drugs does the nurse expect the physician to order for this client? A. Lidocaine (Xylocaine) B. Atropine sulfate C. Isoproterenol hydrochloride (Isuprel) D. Epinephrine
B. Atropine sulfate
A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply A. Clamping the chest tube intermittently B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates. E Taping the connection between the chest tube and the drainage system
B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates. E Taping the connection between the chest tube and the drainage system
A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock? A. Spastically, neuromuscular irritability, hyperreflexia B. Flaccidity and lack of sensation below the level of spinal cord lesion. C. Automatic dysreflexia with neurogenic bladder symptoms D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion.
B. Flaccidity and lack of sensation below the level of spinal cord lesion
A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don't know how I will tolerate pregnancy because I have lupus. Which response is best? A. Most women find that they feel better when they are pregnant B. How long have you been in remission? C. Women with lupus frequently have slightly longer gestation D. Its best to become pregnant within the first 6 months of diagnosis
B. How long have you been in remission?
When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome? A. Increased blood pressure B. Increased urine output C. Decreased pain D. Decreased PVCs
B. Increased urine output
Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? A. It is used to lower your blood pressure B. It is used to treat anemia C. It will help to increase the potassium levels in your body D. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity.
B. It is used to treat anemia
A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all that apply A. Constipation B. Muscle twitches C. Hypoactive bowel sounds D. Hyperactive deep tendon reflexes E. Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG
B. Muscle twitches D. Hyperactive deep tendon reflexes E. Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG
the nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication? A. Monitor the ECG for dysrthymias B. Place the client on bleeding precautions C. monitor urine output hourly D. Monitor for activity tolerance
B. Place the client on bleeding precautions
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A. Confirm that the ventilator settings are correct B. Verify that the ventilator alarms are functioning properly C. Assess the respiratory status and pulse oximeter reading. D. Monitor the clients arterial blood gas results
C. Assess the respiratory status and pulse oximeter reading.
A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings? A. Stroke B. Epileptic Seizure C. Decorticate posturing D. Decerebrate posturing
C. Decorticate posturing
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin. B. Obtain a STAT electrocardiogram C. Have the client sit down immediately D. Assess the client's vital signs.
C. Have the client sit down immediately
A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization? A. I need to get 6 shots of hep C B. Once I receive the Hep vaccine I will always been immune C. I will receive 3 injections over a period of months, which should protect me from hep B D. Hep vaccine is an oral vaccine with live attenuated Virus
C. I will receive 3 injections over a period of months, which should protect me from hep B
While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition? A. Hyperglycemia B. Increased Bile production C. Increased blood ammonia levels D. Hypocalcaemia
C. Increased blood ammonia levels
The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time? A. Measure urinary output hourly and maintain continuous cardiac monitoring B. Encourage client to perform slow pressure exercise of the affected side to promote circulation. C. Maintain pressure over catheter insertion site and determine distal circulation status. D. Evaluate apical pulse and determine presence of pulse deficit.
C. Maintain pressure over catheter insertion site and determine distal circulation status.
What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? A. Prolonged PR interval B. Wide QRS complex C. ST- Segment elevation or depression D. Tall, peak T-waves
C. ST- Segment elevation or depression
A client begins complains of chills and discomfort after about 50ml of blood has packed red blood cells. The best nursing action at this time is to A. Discontinue the transfusion and move the IV and restart IV transfusion at another site. B. compare the VS now and what they were before the transfusion begin C. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL SALINE solution and new tubing D. slow down the transfusion blood and dilute with normal saline solution
C. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL SALINE solution and new tubing
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Administer oxygen B. Checks the client's vital signs C. Ventilates the client manually D. Starts cardiopulmonary resuscitation
C. Ventilates the client manually
A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority, when assessing the severity of the burn?
Cause of the burn
Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed? A. Nitroglycerin B Nifedipine (Procardia) C Lidocaine (Xylocaine) D. Amiodarone (Cordarone)
D. Amiodarone (Cordarone)
A client comes into the ER with complains of midsternal chest pain radiating to the neck and left arm which is unrelieved by sublingual nitroglycerin. An electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician? A. PR impulse 0.20 sec B. Tachycardia rate of 125 beat of premature C. premature ventricle beat D. An ST segment elevation from the isoelectric baseline
D. An ST segment elevation from the isoelectric baseline
A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following: A. Dialited pupils B. Sudden vomiting and diarrhea C. drop in BP and pulse D. Diaphoresis above the level of the lesion
D. Diaphoresis above the level of the lesion
A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect?
Elevated central venous pressure, CVP
A client comes into the ED reporting nausea and vomiting that worsens when lying down and without relief from antacids. The provider suspects acute pancreatitis. Which of the following lab results should the nurse expect to see if the client has acute pancreatitis?
Increase serum amylase
A nurse is assessing a client who has disseminated intravascular coagulation DIC. Which of the following should the nurse expect in the findings?
Increased clotting factors
A nurse is about to administer warfarin to a client who has atrial fibrillation. When the client asks what his medication will do, which of the following actions is an appropriate nursing response?
It prevent strokes in clients who have atrial fibrillation
A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury?
Lactated ringers
A client arrives at the emergency department following an explosion at the chemical plant. He has deep partial and full thickness. Chemical burns over more than 25% of his body surface area. What is the nurses priority intervention?
Maintain a patent airway
A nurse is caring for a client who has full thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system?
Obtain a central venous pressure
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the tve of drainage found?
Purulent
A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response?
Stridor
After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain. d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hr
a. A patient with smoke inhalation who has wheezes and altered mental status
A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first? a. Administer acetaminophen (Tylenol) PO. b. Administer ibuprofen (Motrin) PO. c. Draw coagulation study blood work in the AM d. Give morphine sulfate IV
a. Administer acetaminophen (Tylenol) PO.
The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? a. CVP of 3 cm H20 and urine output of 20 mL/hr b. Jugular vein distention with the head elevated 45 degrees c. Chest tube drainage of 50 mL/hr in the first 2 hours d. Persistent increased BP and increased pulse pressure
a. CVP of 3 cm H20 and urine output of 20 mL/hr
The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea? a. Decreased breath sounds are heard over the left side of the chest b. Increased rhonchi are present at the lung bases bilaterally c. Ventilator pressure alarm continues to sound d. Client is able to speak and coughs excessively
a. Decreased breath sounds are heard over the left side of the chest
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV b. increase normal saline infusion to 150 mL/hr c. Administer hydrocortisone (SoluCortef) 100 mg IV d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
a. Give furosemide (Lasix) 40 mg IV
What is the desired action of dopamine (Intropin) when administered in the treatment of shock? a. It increases myocardial contractility b. It is associated with fewer severe allergic reactions c. It causes rapid vasodilation of the vascular bed d. It supports renal perfusion by dilation of the renal arteries
a. It increases myocardial contractility
The nurse is caring for a client who is receiving a blood transfusion. The transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution b. Slow the infusion and evaluate the vital signs and the client's history of tranfusion reactions c. Slow the infusion of blood and begin infusion of normal saline solution from the Y connector. d. Recheck the unit of blood for correct identification numbers and crossmatch information
a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution
The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The nurse uses latex gloves when applying antibacterial cream to a burn wound b. The float nurse obtains burn cultures when the patient has a temp of 101* F c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing change d. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an elevated serum glucose
a. The nurse uses latex gloves when applying antibacterial cream to a burn wound
The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication? a. Tremors and central nervous system stimulation b. Tachycardia and chest discomfort c. Development of oral candidiasis d. An increase in blood pressure
a. Tremors and central nervous system stimulation
The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the desired effect? a. Chest pain is completely relieved b. Client performs activities of daily living without chest pain c. Pain is controlled with frequent changes of patch d. Client tolerates increased activity without pain
b. Client performs activities of daily living without chest pain
The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client's BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action? a. Recheck the BP and call the doctor b. Decrease the infusion rate and recheck the blood pressure in 5 minutes c. Stop the medication and keep the IV open with D5W. d. Assess the client's tolerance of the current level of BP
b. Decrease the infusion rate and recheck the blood pressure in 5 minutes
A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What is the best action for the nurse to take? a. encourage the patient to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the patient's resp. rate d. Reposition pt in high-Fowler's position and reassess breath sounds
b. Notify the HCP and prepare for endotracheal intubation
When caring for the patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? (TB ch.67 Q.17) a. BP 92/56 mm Hg b. Skin cool and clammy c. apical pulse 118 beats/min d. Arterial oxygen saturation 91%
b. Skin cool and clammy
Which of these findings is the best indicators that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. hemoglobin is within normal limits b. Urine output is 60 mL over the last hour c. Pulmonary artery wedge pressure (PAWP) is 10 mmHg d. Mean arterial pressure (MAP) is 55 mm Hg
b. Urine output is 60 mL over the last hour
A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED? a. cover the burned area with sterile gauze b. inspect mouth for signs of inhalation c. administer intravenous pain medication d. draw blood for a CBC
b. inspect mouth for signs of inhalation
A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicate a complication that requires notifying the provider immediately? a. Serosanguineous drainage from the puncture site b. Discomfort at the puncture site c. Increased heart rate d. Decreased temperature
c. Increased heart rate
Which interventions will the nurse include in the plan of the care for a patient who has cardiogenic shock? a. Avoid elevating head of bed b. Check temperature every 2 hours c. Monitor breath sounds frequently d. Assess skin for flushing and itching
c. Monitor breath sounds frequently
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. cool clammy skin b. inspiratory crackles c. apical heart rate of 48 beats/min d. temperature 101.2* F
c. apical heart rate of 48 beats/min
A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. Raise the foot of the bed to a 90 degree angle b. Remove the dressing to inspect the wound c. Prepare to insert a central line d. Administer oxygen via nasal cannula
d. Administer oxygen via nasal cannula
Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has: a. A heart rate of less than 120 beats/min b. Urine output of at least 30 mL/hr. c. Received adequate anticoagulation d. Been receiving adequate IV fluid replacement
d. Been receiving adequate IV fluid replacement
The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology? a. Reduction of circulation to the coronary arteries, this increasing the preload b. Decreased glomeruli filtration rate, resulting in volume overload c. Stimulation of the sympathetic nervous system, causing severe vasoconstriction d. Decrease in the cardiac output and inadequate tissue perfusion
d. Decrease in the cardiac output and inadequate tissue perfusion
During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor b. Monitor daily weight c. Assess mucous membranes d. Measures hourly urine output
d. Measures hourly urine output
During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which findings is most important for the nurse to report to the HCP? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation
d. New onset of confusion and agitation
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mmHg. The nurse will anticipate the administration of which of the following? a. Nitroglycerin (Tridil) b. Sodium nitroprusside (Nipride) c. Drotrecogin alpha (Xigris) d. Norepinephrine (Levophed)
d. Norepinephrine (Levophed)
Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation
d. Oxygen saturation
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following? a. A cardiology consult b. Less frequent suctioning c. An antidysrhythmic medication d. Pre-oxygenation prior to suctioning
d. Pre-oxygenation prior to suctioning
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escarotomy. The clients spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
" large incisions will be made in the eschar to improve circulation"
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed.
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction.
1) Avoid bending at the waist
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the chent lie sunine with knees flexed 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery.
1) Cover the client's wound with a moist, sterile dressing.
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery.
1) Cover the client's wound with a moist, sterile dressing.
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)
1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this clients secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway..
1) Provide humidified oxygen.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 3) Burns 4) lIvpervolemia
1) Shivering
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a dav. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water.
1) Take temperature once a dav.
