NUR Exam2 F2018 prepU

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?

hypokalemia

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

rapid respirations

The nurse is caring for a client who was had a percutaneous tracheostomy (PCT) following a motor vehicle accident, and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

"This is a gauge used to regulate the amount of oxygen that a client receives."

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

"This test detects heme, a type of iron compound in blood in the stool."

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

Ambu bag

29s The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 20 bpm

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence.

A hypertonic enema is classified as which type of enema?

Cleansing enema

31s Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat.

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?

If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

Nasal cannula

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm

For which conditions would the nurse assess a client to determine the ability to adequately receive the data necessary to experience the world? Select all that apply.

a stimulus a receptor or sense organ an intact nerve pathway a functioning brain

When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk?

cholesterol level lipoprotein level triglyceride level

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

crepitus