NU310 - Adult Health Prep U
Which term best describes a living will?
Medical directive
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?
Metabolic acidosis
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn't compressed; instead it's fully expanded.
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?
The edges of a sterile package, once opened, are considered unsterile.
An example of a curative surgical procedure is
Tumor excision
Which of the following is an inappropriate nursing action by the surgical nurse?
Wearing sterile gloves over artificial nails
A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline ABG levels
Which of the following is a leading cause of chronic obstructive pulmonary disease (COPD) exacerbation?
Bronchitis
A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned?
Calcium
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently
A client with a chronic lung disease is prescribed postural drainage. Place in order the nurse's actions to perform this procedure. Use all options.
Plan to do the procedure before a meal. Provide medication to loosen secretions before the procedure. Obtain an emesis basin, sputum cup, and paper tissues. Instruct client to breathe in through the nose and out through pursed lips. Place client in position to drain the lower lobes for 10 to 15 minutes and then cough. Place client in position to drain the middle lobe for 10 to 15 minutes and then cough. Place client in position to drain the upper lobes for 10 to 15 minutes and then cough.
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as
Pleural effusion
The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?
Pneumonia
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
Position the client to maintain a patent airway.
When is the ideal time to discuss preoperative teaching
Pre admission visit
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?
Cerebral edema
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
Circulatory hypoxia
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?
Classes at community centers to teach about smoking cessation strategies
Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services?
Clients and families view hospice care as giving up
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV)
A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?
Prevents early airway collapse
The nurse is preparing an older adult for a surgical procedure. Which action will the nurse take to protect the client from injury during the operative period?
Protect bony prominences with extra padding.
Which cardiovascular findings indicate to the nurse that the condition of the client who is dying is worsening?
Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?
Rapid onset of severe dyspnea
The nurse recognizes which symptom as a clinical manifestation of shock?
Rapid, weak, thready pulse
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis?
Red open sores on the oral mucosa
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing the dressing or applying pressure if bleeding is frank
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to:
Remove air from pleural space
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?
Remove the entire sterile field from use
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
Report early calf pain.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?
Report the infection to an immediate supervisor.
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come answer the questions
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
Respiratory alkalosis
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Routinely deflating the cuff
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?
Second intention healing
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
Serum potassium level of 2.6 mEq/L
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?
Shortness of breath
A client with a recent history of GI disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will:
Show movement of the GI tract
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
Significant
As the moment of death approaches, which of the following does the nurse encourage the family to do?
Speak to the client in a calm and soothing voice.
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel
The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia?
Stage IV
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stop the chemotherapy infusion
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
Synchronized intermittent mandatory ventilation (SIMV).
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
Tachycardia (heart rate >150 beats per minute)
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider?
Takes high doses of vitamin D
A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?
Tense and relax muscles in the lower extremities.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
The client and physician are focusing on symptom relief not a cure.
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?
The client can be discharged from the PACU.
A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?
The client can develop malignant hyperthermia up to 24 hours after surgery.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
The client had a liver transplant 2 years ago
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?
The client is displaying early signs of shock.
A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?
The lungs primarily eliminate the anesthesia.
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
The patient participates willingly in the preoperative preparation.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?
pH: 7.48
A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying?
"I just want to see my daughter graduate from college. That's all."
A client approaching end-of-life reports dyspnea as being 7 on a scale from 0 to 10. Which action will the nurse take to assist this client?
Coach to use pursed lip breathing.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
Strict hand hygiene
A client asks the nurse what is causing the fatigue following radiotherapy. What is the nurse's bestresponse?
Substances are released when tumor cells are destroyed.
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?
0-4 mm
Which solution is hypotonic?
0.45 NaCl
Which is considered an isotonic solution?
0.9% normal saline
The client vomits during the surgical procedure. The best action by the nurse is:
Suction the client to remove saliva and gastric secretions.
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?
Experiences pain within tolerable limits
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?
Furosemide
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of
Graft versus host disease
A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse?
Prednisone
The scrub nurse is responsible for:
Preparing the sterile instruments for the surgical procedure
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway.
Which of the following techniques least exhibits surgical asepsis?
Suctioning the nasopharyngeal cavity of a client
The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?
Sun safety/use of sunscreen
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?
Surgeon
The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?
Symptoms do not appear until the disease is well established
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?
Verify consent
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
Viruses like influenza are the most common cause of pneumonia
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
Which nutrient plays an important role in normal blood clotting?
Vitamin K
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
Volume cycled
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?
Presence of Trousseau sign
A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary?
"I do not need to rinse my mouth with this type of inhaler."
A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?
"Client is becoming agitated and complains of pleuritic pain."
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?
"I can resume my usual activities as soon as I get home."
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?
"I can use laxatives and enemas but only once a week"
The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction?
"I can't use a spacer or holding chamber with the MDI."
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor"
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?
"Remain supine for the time specified by the physician."
The nurse is caring for a client with a newly discovered tumor that may be benign or malignant. The client asks, "What makes a malignant tumor different from a benign one?" What should the nurse include in the response? Select all that apply.
"The cells of the tumor bear little resemblance to the cells in the tissue where the tumor started." "It grows by invasion and infiltrates the surrounding tissues."
A patient is scheduled for cryoablation for cervical cancer and tells the nurse, "I am not exactly sure what the surgeon is going to do." What is the best response by the nurse?
"The surgeon is going to use liquid nitrogen to freeze the area."
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?
15 mm induration
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6-12 months
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?
7-10 days
The lethal tumor dose is defined as the dose that will eradicate what percentage of the tumor yet preserve normal tissue?
95%
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30mL
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason?
Allows for the nurse to facilitate the grieving process
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate?
Adjuvant therapy is likely.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered
A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client?
Adrenal insufficiency
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
Anxiety
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?
Apply a warm air blanket, gradually increasing body temperature.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
Arterial blood gas (ABG) analysis
What assessment method would the nurse use to determine the areas of the lungs that need draining?
Auscultation
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?
Call the healthcare provider
When a client's ventilation is impaired, the body retains which substance?
Carbon dioxide
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
Which oncologic emergency involves the accumulation of fluid in the pericardial space?
Cardiac tamponade
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?
Cardiovascular system
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?
Central venous pressure
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:
Circulating nurse
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?
Confusion
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
Continue to take antibiotics for the entire 10 days.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
Dantrolene sodium
Why is assessment of dentition important in the patient preparing to have a surgical procedure with general anesthesia?
Decayed teeth or dental prosthesis can become dislodged during intubation.
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear?
Decreased breath sounds
The nurse recognizes that the older adult is at risk for surgical complications due to:
Decreased renal function
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?
Dehydration
Which is the initial stage of grief, according to Kübler-Ross?
Denial
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?
Developing a list of people with whom the client has had contact
The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?
Discontinue the intravenous lactated Ringer solution.
Which is also known as a proxy directive?
Durable Power of Attorney for Health Care
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate?
Handling instruments to the surgeon and assistants
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?
Headache
A nurse is teaching a client about the rationale for administering allopurinol with chemotherapy. Which example would be the best teaching by the nurse?
It lowers serum and uric acid levels
A laser is being used to excise tissue during a client's surgical procedure. Which item will the nurse apply to minimize personal risk due to the smoke from the device?
N95 respiratory mask
A client is transported from the postanesthesia care unit (PACU) to an inpatient care area after receiving intrapleural analgesia for pain control. The nurse knows that this type of anesthesia is used for which surgical procedure?
Nephrectomy
A client scheduled for surgery has a blood pressure of 186/90 mm Hg. After documenting this in the medical record, which action will the nurse take?
Notify the health care provider of the blood pressure
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?
Notify the surgeon
A type of comprehensive care for clients whose disease is not responsive to cure is
Palliative care
The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using?
Palliative care
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority?
Risk for infection
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?
Risk for perioperative positioning injury related to positioning in the OR
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
The mucous secreting glands are abnormal
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?
This must be very difficult for you
The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching.
Understanding - "I should get the PPSV23 this year because I got the PCV13 last year." - "Sleeping with a humidifier can help loosen secretions." - "I will seek medical attention if my cough worsens." - "I will rest and avoid overexertion." Requires Reinforcement of Teaching - "I will take the antibiotics until the secretions clear up." - "I will drink 1 liter of fluid each day." - "A persistent or recurring fever is normal after starting antibiotics." - "I will perform deep-breathing exercises once per day."
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
Urine retention
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing.
A client schedules to have total hip replacement surgery in 2 weeks. Which activities will the nurse complete during preadmission testing within the preoperative phase? Select all that apply.
Verify completion of diagnostic testing Complete initial assessment Begin client testing
The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:
First intention
ou are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?
Fit all employees with protective masks
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
Flail chest
The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?
Flush toilet twice after every use
Which domain of perioperative nursing practice focuses on clinical processes and outcomes?
Health care systems
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?
Hourly leg exercrises
A client diagnosed with cancer has his tumor staged and graded based on what factors?
How they tend to grow and cell type
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?
Hypercalcemia
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia
The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance. During the assessment, the nurse focuses on monitoring the client for:
Hypokalemia Cardiac arrhythmias
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
Hypoxia
A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 85% for a patient with COPD. What stage should the nurse document the patient is in?
I
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
I floss my teeth every morning
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
I will support my incision with my hands when I cough and do my deep breathing exercises."
There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements.
II: Excitement
A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention?
IV site is red and swollen
A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action?
If coughing occurs, repeat it
Asthma is cause by which type of response?
IgE mediated
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange
A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes
Implementing measures to clear pulmonary secretions
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
"I'll be sleepy to but I will be able to respond to your questions"
A client asks the nurse about possible ill effects from general anesthesia. What is the bestresponse by the nurse?
"Some possible negative effects include difficulty waking up and slow heart rate."
Which would be least likely to contribute to a case of hospital-acquired pneumonia?
A nurse washes her hands before beginning client care
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?
"You will be lying on your side with your knees to your chest."
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease.
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
The nurse would intervene when making which of the following observations in the surgical environment?
A staff member dressed in street clothes enters the semirestricted zone.
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?
Advice for the family to have fruit juices readily available at the client's bedside.
In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply.
Albuterol is a bronchodilator. Prednisone is a corticosteroid.
The nurse in the postanesthesia care unit (PACU) is preparing to receive a client from the operating room. The nurse knows that which information would need to be communicated?
Allergies Surgical procedure Estimated blood loss Medical comorbidities Anesthetic agents used
Which is the strongest predisposing factor for asthma?
Allergy
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
Aspiration pneumonia
The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first?
Assess for bleeding
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?
Assess for signs and symptoms of fluid volume deficit.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?
Assess the client's heart rhythm and nail beds.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
Assessing WBC count, temperature, and wound appearance
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?
Atelectasis
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
Auscultate bowel sounds
Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client?
Autologous
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods
A client is receiving external radiation to the left thorax to treat lung cancer. Which intervention should be part of this client's care plan?
Avoid using soap in the irritated area
A client returns to the surgeon's office for a report on a diagnostic procedure to determine the cell composition of the client's abdominal neoplasm. Which term is significant to indicate the likelihood of the tumor spreading?
Benign
The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery?
Blood pressure 80/50
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood tinged sputum
Which statement is true about both lung transplant and bullectomy?
Both procedures improve the overall quality of life of a client with COPD.
A client has just received stem cell transplantation as treatment for leukemia. What are the post procedural nursing interventions for clients receiving any form of stem cell transplantation?
Closely monitor the client for at least 3 months.
In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:
Increase the likelihood of a successful recovery
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cough or change in chronic cough
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
Which procedure uses liquid nitrogen to freeze tissue, thereby destroying cells?
Cryoablation
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?
Diuretics
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst
client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?
Elective
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?
Electrocardiogram (ECG) results
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
Elevated blood pressure
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
Emergency
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should:
Encourage fluid intake, to dilute the urine
A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
Encourage the client to ambulate as soon as possible after surgery.
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue?
Excisional biopsy
The nurse is assisting with the removal of an oral endotracheal tube. Place in order the actions the nurse will take to provide care to the client. Use all options.
Explain the procedure. Place a self-inflating bag and mask at the bedside. Suction the tracheobronchial tree and oropharynx. Remove tape. Deflate the cuff. Provide a few breaths of 100% oxygen. Insert a new sterile suction catheter inside the tube. Instruct the client to inhale. Remove the tube while suctioning the airway as it is removed
The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to clients who are dying and their families is to first do which of the following?
Explore own feelings on mortality and death and dying.
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme anxiety
A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following?
Faith and belief
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy?
It removes a wedge of tissue for diagnosis
As a circulating nurse, what task are you solely responsible for?
Keeping records
With which condition should the nurse expect that a decrease in serum osmolality will occur?
Kidney failure
A decrease in circulating white blood cells (WBCs) is referred to as
Leukopenia
A client is undergoing a perineal surgical procedure. The nurse should place the client in which position?
Lithotomy
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Localized calf tenderness
The nurse understands that the purpose of the "time out" is to:
Maintain the safety of the client
The primary objective in the immediate postoperative period is
Maintaining pulmonary ventilation.
Which is a growth-based classification of tumors?
Malignancy
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?
Malignant hyperthermia
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?
Mask is placed over nose and extends to bottom lip.
Corticosteroids have which effect on wound healing?
Mask the presence of infection
What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?
Mast cells
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis
Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors?
Mourning
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?
On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
Ondansetron
A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily?
One beef cube and 8 oz of tomato juice
A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is?
Optional
A hospice nurse is visiting the home of a client who was recently diagnosed with a terminal illness. The nurse is developing the client's plan of care and is assessing beliefs and preferences about end-of-life care. The nurse would expect to complete this assessment at which time?
Over the course of several visits
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?
Oxygen
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
Oxygen saturation (SaO2) of 85%
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
Which is a classic sign of hypovolemic shock?
Pallor
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following?
Participating in assisted suicide violates the Code of Ethics for Nurses.
The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan?
Performing chest physiotherapy as ordered
A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.
Performing guided imagery Putting on soothing music Changing the client's position
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?
Pink color
A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?
Tilt the head back and lift the lower jaw.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
To prevent cerebrospinal fluid (CSF) leakage
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?
Tolerance
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
The nurse is caring for a patient with liver disease who had a surgical procedure. When should the nurse alert the physician?
When the patient's blood ammonia concentration reaches 180 mg/dL
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?
Wound healing
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
You will need to practice birth control measures
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse?
calcium 12.9 mg/dL (3.2 mmol/L)
