Nurs 472 Exam 2 Question Collection

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client A.) who has lost blood during birth. B.) who has had an overdose of opioids. C.) who has had severe allergic reaction to a bee sting. D.) with an overwhelming bacterial infection.

D.) with an overwhelming bacterial infection.

Which blood pressure (BP) reading would result in a pulse pressure indicative of shock? A.) 90/70 mm Hg B.) 100/60 mm Hg C.) 130/90 mm Hg D.) 120/90 mm Hg

A.) 90/70 mm Hg

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? A.) Arterial blood gas (ABG) findings B.) White blood cell count findings C.) Serum thyroid level findings D.) Red blood cells (RBCs) and hemoglobin count findings

A.) Arterial blood gas (ABG) findings

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: A.) Assess pulse and blood pressure. B.) Lay the client's head to a flat position. C.) Notify the physician. D.) Administer prescribed pain medication.

A.) Assess pulse and blood pressure.

The nurse is preparing to suction a client with an endotracheal tube. What should be the nurse's first step in the suctioning process? A.) Assess the client's lung sounds and SaO2 via pulse oximeter. B.) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask. C.) Explain the suctioning procedure to the client and reposition the client. D.) Turn on suction source at a pressure not exceeding 120 mm Hg.

A.) Assess the client's lung sounds and SaO2 via pulse oximeter.

Which of the following clinical manifestations occur in cardiogenic shock? A.) Blood pressure falls B.) Urine output increases C.) Quick capillary refill D.) Skin is dry

A.) Blood pressure falls

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the client has what diagnosis? A.) COPD B.) Pneumonia C.) Lung cancer D.) Asthma

A.) COPD

The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client? A.) Correct and safe use of oxygen therapy equipment B.) Technique for performing postural drainage C.) How to provide safe and effective tracheostomy care D.) Safe technique for self-suctioning of secretions

A.) Correct and safe use of oxygen therapy equipment

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? A.) Decreased peristalsis B.) Hematemesis C.) Fecal occult blood D.) Hyperactive bowel sounds

A.) Decreased peristalsis

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? A) Effective breathing at a rate of 16 breaths/minute through the established airway B) Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds C) Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds D) A respiratory rate of 28 breaths/minute with accessory muscle use

A.) Effective breathing at a rate of 16 breaths/minute through the established airway

Which of the following types of shock will a nurse observe in a client with extensive burns? A.) Hypovolemic shock B.) Neurogenic shock C.) Septic shock D.) Anaphylactic shock

A.) Hypovolemic shock

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A.) Kinking of the ventilator tubing B.) A change in the oxygen concentration without resetting the oxygen level alarm C.) An ET cuff leak D.) A disconnected ventilator circuit

A.) Kinking of the ventilator tubing

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? A.) Maintaining a patent airway B.) Preventing the need for suctioning C.) Increasing the client's lung compliance D.) Maintaining the sterility of the client's airway

A.) Maintaining a patent airway

Which type of burn is similar to a sunburn? A.) Superficial partial-thickness B.) Deep partial-thickness C.) Full-thickness D.) Electrical

A.) Superficial partial-thickness

The nurse has explained to the client that after his thoracotomy, it will be important to adhere to a coughing schedule. The client is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? A.) Teach him how to perform huffing. B.) Teach him postural drainage. C.) Teach him how to use a metered dose inhaler. D.) Teach him to use a mini-nebulizer.

A.) Teach him how to perform huffing.

The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? A.) Removal of the tube, oxygen, and then ventilator B.) Removal from the ventilator, tube, and then oxygen C.) Removal from oxygen, tube, and then ventilator D.) Removal from oxygen, ventilator, and then tube

B.) Removal from the ventilator, tube, and then oxygen

The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the parent. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child? A.) The child is having an allergic reaction and going into anaphylactic shock. B.) The child is having an allergic reaction and going into cardiogenic shock. C.) The child is having an allergic reaction and going into neurogenic shock. D.) The child is having an allergic reaction and going into obstructive shock.

A.) The child is having an allergic reaction and going into anaphylactic shock.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? A.) Water-seal chamber B.) Suction control chamber C.) Air-leak chamber D.) Collection chamber

A.) Water-seal chamber

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: A.) cough as the cuff is being deflated. B.) exhale deeply as the nurse reinflates the cuff. C.) take a deep breath as the nurse deflates the cuff. D.) hold the breath as the cuff is being reinflated.

A.) cough as the cuff is being deflated.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A.) maintaining the client's fluid, electrolyte, and acid-base balance. B.) providing emotional support to the client and family. C.) preserving full range of motion in all affected joints. D.) planning for the client's rehabilitation and discharge.

A.) maintaining the client's fluid, electrolyte, and acid-base balance.

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? A.)Arterial blood gas (ABG) findings B.) Serum thyroid level findings C.) White blood cell count findings D.) Red blood cells (RBCs) and hemoglobin count findings

A.)Arterial blood gas (ABG) findings

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? A.) Limited gas exchange B.) Multiple organ failure C.) Brain death D.) Endotoxins in the system

B.) Multiple organ failure

The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge? A.) Walk 1 mile (1.6 km) 3 to 4 times a week. B.) Perform shoulder exercises five times daily. C.) Use weights daily to increase arm strength. D.) Walk on a treadmill 30 minutes daily.

B.) Perform shoulder exercises five times daily.

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? A.) 4 B.) 1 C.) 2 D.) 3

B.) 1

Which of the following is a common complication of an electrical burn injury? A.) Absent bowel sounds B.) Cardiac dysrhythmias C.) Loss of mobility D.) Localized edema

B.) Cardiac dysrhythmias

The nurse is to make a room assignment for a client diagnosed with an upper respiratory infection. The other clients with empty beds in the room are listed in the accompanying chart. The best room assignment for the new client would be with Client A.) Client A who is HIV positive and has acute pharyngitis B.) Client B who is receiving an IV infusion of crystalloid solution following epistaxis C.) Client C who has primary bleeding following a tonsillectomy D.) Client D who had a total laryngectomy and is receiving enteral feedings

B.) Client B who is receiving an IV infusion of crystalloid solution following epistaxis

What quick assessment technique should the nurse use to assess the percentage of burn injury? A.) Observe the color of the client's wound B.) Compare the client's palm with the size of the burn wound C.) Observe the client's level of consciousness D.) Check the client's vital signs

B.) Compare the client's palm with the size of the burn wound

A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first? A.) Diphenhydramine IV B.) Epinephrine intramuscularly C.) IV infusion of normal saline D.) Albuterol nebulizer

B.) Epinephrine intramuscularly

A client recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the client? A.) Ask a family member to interpret what the client is trying to communicate. B.) Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board. C.) Assure the client that everything will be all right and that remaining calm is the best strategy. D.) Ask the physician to wean the client off the mechanical ventilator to allow the patient to speak freely.

B.) Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board.

You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child? A.) She is having an allergic reaction and going into cardiogenic shock. B.) She is having an allergic reaction and going into anaphylactic shock. C.) She is having an allergic reaction and going into neurogenic shock. D.) She is having an allergic reaction and going into obstructive shock.

B.) She is having an allergic reaction and going into anaphylactic shock.

The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A.) Nutritional status and fluid balance B.) Signs and symptoms of respiratory complications C.) The family's willingness to care for the client D.) Resumption of the client's ADLs

B.) Signs and symptoms of respiratory complications

The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A.) Pulse oximetry above 80% and stable vital signs B.) Stable vital signs and arterial blood gases (ABGs) C.) Normal level of consciousness D.) Stable nutritional status and ABGs

B.) Stable vital signs and arterial blood gases (ABGs)

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? A.) They help prevent subcutaneous emphysema. B.) They help prevent cardiac arrhythmias. C.) They help prevent pulmonary edema. D.) They help prevent pneumothorax.

B.) They help prevent cardiac arrhythmias.

The health care provider prescribes esmolol for a client with supraventricular tachycardia. During esmolol therapy, what should the nurse monitor? A.) ocular pressure. B.) heart rate and blood pressure. C.) body temperature. D.) cerebral perfusion pressure.

B.) heart rate and blood pressure.

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: A.) assist-control (AC) ventilation. B.) synchronized intermittent mandatory ventilation (SIMV). C.) continuous positive airway pressure (CPAP). D.) pressure support ventilation (PSV).

B.) synchronized intermittent mandatory ventilation (SIMV).

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client? A.) Ask the physician to wean the client off the mechanical ventilator to allow the client to talk. B.) Assure the client that everything will be all right and that he shouldn't become upset. C.) Ask the client to write, use a picture board, or spell words with an alphabet board. D.) Ask a family member to interpret what the client is trying to communicate.

C.) Ask the client to write, use a picture board, or spell words with an alphabet board.

The nurse is caring for a 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? A.) Neurogenic shock B.) Septic shock C.) Cardiogenic shock D.) Anaphylactic shock

C.) Cardiogenic shock

postural drainage has been ordered for a client who is having difficulty mobilizing bronchial secretions. Before repositioning the client and beginning treatment, the nurse should perform what health assessment? A.) Pulmonary function testing B.) Thoracic palpation C.) Chest auscultation D.) Chest percussion

C.) Chest auscultation

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation? A.) Client use of tweezers to remove encrustations. B.) Use of non-sterile tissues to wipe secretions from the airway. C.) Initial washing of hands after cleaning inner cannula. D.) Wearing a loose-fitting cloth over the stoma.

C.) Initial washing of hands after cleaning inner cannula.

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs? A.) Nonrebreathing mask B.) Partial-rebreathing mask C.) Nasal cannula D.) Venturi mask

C.) Nasal cannula

A client who has an altered level of consciousness is receiving tube feedings. Clients receiving tube feeding should be placed in which position? A.) Trendelenburg B.) Supine C.) Semi-Fowler's or higher D.) Side-lying

C.) Semi-Fowler's or higher

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? A.) Add more air to the cuff. B.) Remove the malfunctioning cuff. C.) Suction the client, withdraw residual air from the cuff, and reinflate it. D.) Call the physician.

C.) Suction the client, withdraw residual air from the cuff, and reinflate it.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family? A.) The client has lost too much blood. B.) The client is brain dead. C.) The client is not responding to medical interventions. D.) The client has given up.

C.) The client is not responding to medical interventions.

A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? A.) Face tent B.) Nonrebreathing mask C.) Venturi mask D.) Tracheostomy collar

C.) Venturi mask

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: A.) decrease circulation to the fingers. B.) increase edema in the arms. C.) dislodge the autografts. D.) increase the amount of scarring.

C.) dislodge the autografts.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? A.) perineal B.) legs C.) face, neck, chest D.) hands, major joints

C.) face, neck, chest

A client scheduled for a catheter ablation procedure confides to the nurse that he is worried about having some of his heart cells destroyed. The best response by the nurse is which of the following? A.) "The doctor knows best; just let her worry about which heart cells to destroy." B.) "Everything will turn out fine; do not worry about your heart cells." C.) "Don't worry. All resuscitation equipment is kept nearby when these procedures are being done." D.) "Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."

D.) "Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best? A.) "Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia." B.) "It's just a coincidence; most clients with atrial fibrillation don't receive warfarin." C.) "Warfarin controls heart rate in the client with atrial fibrillation." D.) "Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

D.) "Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

he palm represents which percentage of a person's TBSA? A.) 10% B.) 15% C.) 5% D.) 1%

D.) 1%

Constant bubbling in the water seal of a chest drainage system indicates which problem? A.) Tension pneumothorax B.) Increased drainage C.) Tidaling D.) Air leak

D.) Air leak

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? A.) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B.) Inform the physician promptly that there is in imminent leak in the drainage system. C.) Encourage the client to do deep breathing and coughing exercises. D.) Document that the chest drainage system is operating as it is intended.

D.) Document that the chest drainage system is operating as it is intended.

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? A.) Insert an indwelling catheter. B.) Replace fluids. C.) Administer pain medication. D.) Establish a patent airway.

D.) Establish a patent airway.

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient? A.) Subcutaneous B.) Intramuscular C.) Oral D.) Intravenous

D.) Intravenous

Which of the following is the preferred IV fluid for burn resuscitation? A.) Normal saline (NS) B.) D5W C.) Total parenteral nutrition (TPN) D.) Lactated Ringer's (LR)

D.) Lactated Ringer's (LR)

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? A.) Dextrose 5% in water (D5W) B.) Albumin C.) Normal saline solution with 20 mEq of potassium per 1,000 ml D.) Lactated Ringer's solution

D.) Lactated Ringer's solution

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock? A.) Anaphylactic B.) Obstructive C.) Septic D.) Neurogenic

D.) Neurogenic

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock? A.) Neurogenic B.) Anaphylactic C.) Cardiogenic D.) Septic

D.) Septic

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of a client who has A.) overdosed on opioids. B.) had severe allergic reaction to a bee sting. C.) lost blood during birth. D.) an overwhelming bacterial infection.

D.) an overwhelming bacterial infection.

A client who has been brought to the ED is unresponsive, and has an elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. The client's labs show an elevated white blood cell count; cultures are forthcoming. What does the nurse suspect may be the cause of the client's present condition? A.) cardiogenic shock B.) neurogenic shock C.) anaphylactic shock D.) septic shock

D.) septic shock

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

Semi-fowlers

A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system.

Suction control is determined by the height of instilled water in that chamber. The suction control chamber is on the left side. In the middle of the closed drainage system is the water-seal chamber. The drainage chamber is on the right side of the closed drainage system