NCLEX 175-342

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates the best understanding of this stress reduction measure?

"The best thing about this is that I can use it anywhere, anytime."

A nursing student is caring for a hospitalized client with a diagnosis of lung cancer. The health care provider has prescribed a partial rebreathing face mask for the client, and the nursing instructor asks the student about its purpose. The student correctly responds by stating that:

"The device conserves oxygen by having the client rebreathe her own exhaled air."

A client has undergone fluoroscopy-assisted aspiration biopsy of a chest lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse notes which of the following?

Absence of breath sounds in the right upper lobe

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

Accumulation of secretions in the client's lungs

A client undergoing computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?

Anaphylactic

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the nurse stands and begins to walk, the client begins to complain of chest pain. The nurse should initially take which action?

Assist the client to get back into bed.

The nurse notes this dysrhythmia on the client's cardiac monitor (refer to figure).The nurse next reports that the client is experiencing which of the following?

Atrial fibrillation

A nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?

Breath sounds are now clear.

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes:

Breath sounds greater on the right than the left

A sublingual nitroglycerin (Nitrostat) tablet administered to a client for chest pain has relieved the pain. The nurse ensures that the client has which important item within easy reach before leaving the room?

Call bell

A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to:

Cardiac arrest

A nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?

Chills and night sweats

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:

Decrease the client's oxygen-based respiratory drive.

A nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. The nurse interprets that this is likely a result of:

Decreased inflammatory reaction at the site

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse plans to tell the client that this is:

Expected and the client should very gradually increase activity as tolerated

A nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems?

Hypotension

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:

Just under the left clavicle

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which of the following?

Lung crackles, peripheral edema, and weight gain

A nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which of the following positions because it will aggravate breathing?

Lying on his or her back in low Fowler's position

A nurse is preparing a plan of care for the client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse should avoid positioning this client:

On the right side

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Click on the sound button.)The nurse determines that these breath sounds usually are caused by which of the following?

Opening of small airways that contain fluid

A health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the health care provider asks the client to:

Perform the Valsalva maneuver.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

Pericardial friction rub

A nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which of the following? (Click on the sound button.)

Pericardial friction rub

A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?

Places the stethoscope on the client's gown

A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen test will be performed. In performing the Allen test, the nurse assists to occlude the:

Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should do which of the following after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the specimen.

A nurse is monitoring a client for bradypnea. Which is characteristic of this respiratory pattern?

Regular but abnormally slow

A nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?

Residents of a long-term care facility

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral

A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should:

Stop the procedure and oxygenate the client.

A nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which of the following signs experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. The nurse interprets that:

The tube may be occluded.

A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring?

There is an air leak somewhere in the system.

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which of the following signs or symptoms observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Tracheal deviation to the right

A client is diagnosed with nasal polyps, asthma, and an acetylsalicylic acid (aspirin) allergy. The nurse provides home care instructions, based on the knowledge that the client has:

Triad disease

A nurse reads a client's Mantoux skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that the client has:

Exposure to tuberculosis

A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage and expects to note that it is:

Bloody

A nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

The client complains of leg edema, and skin breakdown has started.

A nurse teaches a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?

The client is breathing through the nose.

A nurse is assisting a client who underwent radical neck surgery to get out of bed. The nurse provides the support to the client, who is afraid to move the head by doing which of the following?

Placing a hand behind the client's head

A client reports the chronic use of nasal sprays. The nurse provides instructions to this client about which piece of information related to chronic use of nasal sprays?

The protective mechanism of the nose may be damaged.

A nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Arterial PaO2 of 48

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which of the following typical characteristics?

Deep and painful

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs or symptoms?

Fever and sore throat

A nurse is providing discharge teaching for a post myocardial infarction (MI) client who will be taking one baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?

"I will take this medication every day."

A nurse determines that a client with coronary artery disease (CAD) has the necessary understanding of disease management if the client makes which statement?

"I will walk for one-half hour daily."

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." The appropriate nursing response is which of the following?

"You are concerned about losing your leg?"

A nurse determines that which of the following clients is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

A nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which of the following data will not be needed by the laboratory for adequate evaluation of the specimen?

A list of client allergies

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin grains 1/150 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next?

Administer another nitroglycerin tablet.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The nurse is told that the client's prothrombin time is 18 seconds with a control of 11 seconds. The nurse plans to:

Administer the next dose of warfarin sodium.

A nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Choose the instructions that the nurse should place on the list. Select all that apply.

Avoid hot fluids. Avoid rough foods. Eat ice cream to soothe the throat.

A nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which of the following food items from the dietary menu?

Baked haddock, steamed broccoli, herbed rice, sliced strawberries

A nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which of the following would be the best dinner choice from the daily menu?

Baked pollack, mashed potatoes, and carrot-raisin salad

A client has a history of left-sided heart failure. The nurse would look for the presence of which of the following to determine whether the problem is currently active?

Bilateral lung crackles

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check the client's:

Blood pressure

A nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Click on the sound button.)The nurse would interpret this breath sound to be which of the following?

Bronchial breath sounds

A nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Click on the sound button.)The nurse determines that this finding is characteristic of which disorder?

Bronchitis

A client seeks treatment for a complaint of hoarseness that has lasted for 6 weeks. Based on this symptom, the nurse interprets that the client is at risk of having:

Laryngeal cancer

A nurse is providing dietary instructions to a client with congestive heart failure (CHF). The nurse determines that the client understands the instructions if the client states that which of the following food items will be avoided?

Catsup

A nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on these data, the nurse determines that the priority would be to:

Check the vital signs and level of consciousness.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which of the following positions for the reading?

Flat

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which of the following items?

Chest pain

A nurse determines that which of the following clients is most likely to be a candidate for cardioversion?

Client with unstable rapid atrial fibrillation

A nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

Cough

A nurse is discussing signs of severe airway obstruction with a group of nursing students. Which one of the following signs would the nurse emphasize is one that indicates severe airway obstruction?

Cyanosis

A nurse is assisting a health care provider with the insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?

Document the accurate functioning of the tube.

A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which of the following should be instituted immediately by the nurse?

Droplet precautions

A client who has undergone a left heart catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse immediately because these symptoms are consistent with:

Femoral artery thrombus or hematoma

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). The nurse determines that the client indicates an initial understanding of lifestyle alterations if the client states an intention to:

Eat a diet that is low in fat and cholesterol.

A nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as:

Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse determines that which of the following items would be of most help to the client?

Elevating the head of the bed to at least 45 degrees

A nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention will be included in the post-procedure plan of care?

Encourage the client to increase fluid intake.

A client has the following laboratory values: pH of 7.55, HCO3 of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do?

Encourage the client to slow down his breathing.

The nurse observes the following rhythm on the cardiac monitor. (Refer to the figure.)Which action should the nurse take first?

Evaluate the client for hypotension and assess mental status.

A client is at risk for complications of heart failure. What is the nurse's priority for early detection of the most likely cause of complications with this client?

Evaluating total body fluid

A nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which of the following meals?

Fresh strawberries, steamed vegetables, and baked fish

A nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next?

Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions.

A nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which of the following actions to assist this client?

Gives the client a device holder to wear around the waist

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer, expecting to note that the ulcer:

Has a brownish or "brawny" appearance

A nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. The nurse provides medication instructions and tells the client that acetaminophen (Tylenol) is usually prescribed to be taken before the administration of the topical nitrate because:

Headache is a common side effect of nitrates.

A nurse is caring for the client diagnosed with tuberculosis (TB). Which of the following findings, if made by the nurse, would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

A nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action first?

Immerse the end of the tube in sterile saline.

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which of the following areas?

In the groove behind the medial malleolus and the Achilles tendon

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain. The nurse further collects data on the client to see whether these episodes occur with:

Ingestion of coffee or chocolate

A nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which of the following is important to include to ensure accurate monitoring of the client's oxygenation status?

Instruct the client not to move the sensor.

A male client with chronic obstructive pulmonary disease (COPD) on bedrest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, what is the priority client activity for the nurse to incorporate in the plan of care?

Instruct the client to reposition himself.

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which of the following positions for the procedure?

Left side-lying with the head of the bed elevated 45 degrees

A nurse positions a client for a surgical procedure. Which position can likely lead to the potential for decreased lung expansion in the client?

Lithotomy

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

Lowering the head of the bed to a flat position

A nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. What should the nurse do?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?

Nasal obstruction

A nurse is reading the results of the Mantoux skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:

Negative

A nurse is using a stethoscope to listen to the client's heart and hears this sound. (Click on the sound button.)To assist in identifying the sound, the nurse should take which initial best action?

Palpate the carotid pulse for a pulsation.

A nurse is auscultating a client's heart sounds and hears these sounds. (Click on the sound button.)The nurse identifies these as being produced during which phase of the cardiac cycle?

Passive filling phase of ventricles

A nurse is evaluating the effects of care for the client with deep vein thrombosis. Which of the following limb observations would the nurse note as indicating the least success in meeting the outcome criteria for this problem?

Pedal edema that is 3+

A nurse is preparing to assist a health care provider with the insertion of a chest tube. The nurse anticipates that which of the following supplies will be required for the chest tube insertion site?

Petrolatum (Vaseline) gauze

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action in the care of the client?

Place the client on a cardiac monitor.

A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if the client:

Planned to eat the largest meal of the day at a time when hungry

A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could:

Precipitate rebound hypertension

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation?

Semi-Fowler's

Acetylsalicylic acid (Aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. The nurse informs the client that the aspirin will:

Prevent the formation of clots.

A nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which of the following to effectively accomplish this goal?

Provide a quiet and low-stimulus environment.

A nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which of the following as the best strategy to assist the client in coping with the disease?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits:

Shortness of breath and tracheal deviation

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which of the following should the nurse institute when providing care for the client?

Take daily weights and monitor trends.

A nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse would incorporate which of the following in discussions with the client?

Take in adequate daily fiber to prevent straining during a bowel movement.

A client with angina pectoris who was given a first dose of newly prescribed nitroglycerin (Nitrostat) sublingual tablet complains of slight dizziness and headache. The nurse takes which action first?

Takes the client's blood pressure

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Teaches about the effects of cocaine on the heart and offers referral for further help

A nurse is assisting in the care of a client diagnosed with rheumatic heart disease. When teaching the client about self-management of this health problem, the nurse reminds the client to alert his dentist about the condition because:

The client requires prophylactic antibiotics before treatment.

A nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation.

A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets that:

The tube is patent.

A nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease. The nurse would determine the teaching as successful if the client stated that a safe weight loss goal is:

Two pounds per week

A client with a diagnosis of congestive heart failure is preparing for discharge to home from the hospital. The nurse determines that the client is ready for discharge to home if the client can:

Verbally describe the daily medications, doses, and times to be administered.

A nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which of the following is done as a final measure to determine correct tube placement?

Verify placement by a chest x-ray.

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign that indicates that the medications are not having the intended effect?

Weight gain of 2 to 3 pounds in a few day

A nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. The nurse interprets that this client has:

Wheezes

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and collecting initial data, the nurse places a sign above the bed stating that the client should remain on bedrest:

With the head of the bed elevated no more than 15 degrees

A nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which of the following?

The system is functioning as expected.

A nurse has given instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse would need to reinforce the teaching if a family member made which of the following statements?

"A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

A nurse has completed counseling about smoking cessation with a client with coronary artery disease. The nurse determines that the client has understood the material best if the client states that:

"A smoker has twice the risk of having a heart attack than a nonsmoker."

A nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which of the following statements?

"I will walk for one-half hour daily."

A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse responds to the client, using the knowledge that:

Denial is a common occurrence early after MI.

A nurse is caring for a client with Buerger's disease. Which finding would the nurse determine is a potential complication associated with this disease?

Numbness and tingling in the legs

A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on the understanding that:

Discomfort may occur with needle insertion, and there is minimal exposure to radiation.

A male client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?

Explore the specific concerns with the client.

A nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which of the following is available at the bedside?

Oxygen tubing and flowmeter

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which of the following results would the nurse expect to note?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a Pleur-Evac drainage system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines that:

There is a leak in the system, which requires immediate investigation and correction.

A client receiving parenteral nutrition through a central intravenous line is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position?

Left side in Trendelenburg's

A nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). The nurse should alter the environment to ensure that it is:

Low stimulus, low stress

A nurse working the 3:00 to 11:00 PM shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?

Fasting for 12 hours

A client who has laryngeal nodules is scheduled for outpatient surgery to have them removed. The nurse collects data on the client and expects the client to complain of which typical symptom associated with this condition?

Hoarseness

A client is admitted to the hospital with a diagnosis of pleurisy. The nurse checks the client for which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration

A nurse is providing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of doing which of the following?

Avoiding exposure to either very hot or very cold weather

A nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?

Blood pressure that increases from 114/82 to 118/86 mm Hg

A nurse has finished suctioning a client. The nurse would use which of the following parameters to best determine the effectiveness of suctioning?

Clear breath sounds

A nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which of the following breath sounds are noted?

Crackles in the lung bases

A client who is 36 hours post myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation was made?

Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.

Protect the stoma from water. Soaps should be avoided near the stoma. Wash the stoma daily using a washcloth. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

A nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?

Pulse rate of 58 beats per minute

A nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status?

Respiratory rate of 18 breaths per minute

A nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse interprets that:

The behavior is likely the result of hypoxia.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects that the health care provider wrote a prescription for the client to remain on bedrest:

With the head of bed elevated no more than 30 degrees

A nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which of the following statements?

"I should use disposable plates, forks, and knives."

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided?

"I will have the client take a shallow breath before coughing."

A nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from re-entering the pleural space? Refer to figure.

2

A nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. What is the proper compression-to-ventilation ratio for one-person CPR?

30:2

A nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Based on this finding, the nurse should:

Explore with the client the sources of stress in life.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse interprets that this result is:

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to:

Expel mucus from the airways.

A client presents to the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action first?

Have the client sit down, lean forward, and apply pressure to the nose.

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action first?

Have the client stop and lie back down in bed.

A nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should do which of the following to care for this client in a holistic manner?

Instruct the family member to dress the client warmly before going outside.

A nurse has given simple instructions on preventing some of the complications of bedrest to a client who experienced a myocardial infarction. The nurse would intervene if the client were performing which of these activities, which would be contraindicated?

Isometric exercises of the arms and legs

A nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse tells the client to do which of the following?

Keep the ankles uncrossed.

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which of the following medications to the client in the last hour?

Lorazepam (Ativan)

A client has had a set of arterial blood gases drawn. The results are pH 7.34, Paco2 of 37, Pao2 of 79, HCO of 19. The nurse interprets that the client is experiencing:

Metabolic acidosis

A nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer?

Nonproductive hacking cough

A nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Click on the sound button.) What intervention should the nurse take immediately?

Notify the registered nurse.

In what area of the chest would the nurse expect to auscultate this breath sound? (Click on the sound button.)

Over the peripheral lung fields

A nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). The nurse identifies that the priority problem during the acute phase would be:

The client's pain

A client with angina pectoris has just been started on medication therapy with nitroglycerin (Nitrostat). In planning care for this client, the nurse would place priority on measuring:

Vital signs

A nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse would reinforce with the client the importance of complying with which of the following measures to prevent a recurrence?

Weigh self every morning before breakfast.

A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, what interpretation should the nurse make?

The client should be repeating the sequence 10 to 20 times in each session.