PrepU: Exam II

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? A. Assess for medication prescription for breakthrough pain. B. Tell the client he or she will have to wait for 1 hour. C. Administer the next dose of the pain medication. D. Assess the client for signs of narcotic addiction.

A

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? A. Nasal cannula B. Simple oxygen mask C. Venturi mask D. Partial rebreather mask

A

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? A. Naloxone B. Diphenhydramine C. Atropine D. Epinephrine

A

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A. True B. False

A

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? A. Deep breathing B. Pursed-lip breathing C. Diaphragmatic breathing D. Incentive spirometry

A

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding? A. Crackles B. Vesicular C. Wheezes D. Rales

A

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? A. Crackles in the lower lobes B. Inspiratory stridor C. Expiratory stridor D. Wheezing in the upper lobes

A

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? A. Raising the height of the bed to the waist level prior to moving the client B. Turning the client as a complete unit to avoid twisting the spine C. Placing the client in good alignment with joints slightly flexed D. Replacing pillows and positioning devices

A

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? A. The 24-month-old child who is unable to walk unassisted B. he 3-month-old child who is unable to raise the head when prone C. The 6-month-old child who is unable to roll over D. he 18-month-old child who is unable to stack blocks

A

The nurse is preparing to educate a client on how to perform incentive spirometry. Which concepts should the nurse include? A. Incentive spirometry provides visual reinforcement of deep breathing. B. Proper, frequent use of incentive spirometry can improve pulmonary circulation. C. Decrease of oxygen saturation is expected during the first few minutes of incentive spirometry. D. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue.

A

The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client? A. Teaching a client range-of-motion exercises B. Transferring a client from the bed to a stretcher C. Transferring a client from the bed to a chair D. Applying graduated compression stockings

A

The nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system? A. Medicare B. Medicaid C. Capitation D. AmeriCare

A

What is an accurate step in the procedure for giving a client a back massage? A. Apply lotion to the client's shoulders, back, and sacral area using a light, gliding stroke. B. Start by placing hands beside each other at the top of the client's spine and stroke downward to the buttocks in slow, continuous strokes. C. Massage the client's shoulder, entire back, areas over iliac crests, and sacrum with deep, penetrating up-and-down motions. D. Knead the client's skin using effleurage (gently alternating grasping and compression motions).

A

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? A. Rapid respirations B. Weight loss C. Increased urine output D. Mental alertness

A

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) A. Encourage deep breathing. B. Play the client's favorite music. C. Promote a restful environment. D. Encourage increased protein. E. Encourage the use of a sitter.

A, B, & C

A nurse is giving change of shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply. A. Name of the client B. Intake and output prior to surgery C. Client discharge teaching needs D. Type of insurance E. personal feelings about the client F. current vital signs

A, B, C, & F

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? A. Decreased heart rate B. Guarding of the chest area C. Increased respiratory rate D. High blood pressure

B

A client reports a dull, aching pain to his right flank where he was struck during a football game one week ago. What is responsible for the transmission of such pain? A. A-delta fibers B. C-fibers C. Frontal lobe D. Spinal dorsal horn

B

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? A. Serotonin B. Endorphins C. Melatonin D. Dopamine

B

A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? A. PAINAD scale B. 0 to 10 numeric rating scale C. Payen behavioral pain scale D. FLACC scale

B

A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed? A. Hemoglobin 12 mg/dL B. Hematocrit 35% C. Transferrin 360 mg/dL D. Blood urea nitrogen (BUN) 17 mg/dL

B

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? A. Gentle cleansing B. Wound irrigation C. Debridement D. Apply moist dressing

B

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as A. "Your present pain is worse because you had your packing removed." B. "Acute pain tends to increase during the day and is called a routine pain response" C. "I will call your doctor because you may have loosened sutures when walking." D. "You will need more pain medication as the days progress."

B

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? A. Hyperventilation B. Hypoxia C. Perfusion D. Atelectasis

B

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? A. Remove the chest tube. B. Document the finding. C. Contact the Rapid Response Team. D. Remind the client to remain stationary in bed to stop the bubbling.

B

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? A. Simple mask B. Tracheostomy collar C. Nasal cannula D. Face tent

B

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? A. Inhale through the nose instead of the mouth. B. Be sure to shake the canister before using it. C. Inhale the medication rapidly. D. Inhale two sprays with one breath for faster action.

B

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Pasta salad B. Fish C. Banana D. Green beans

B

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? A. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." B. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." C. "If you breathe through the mouth first, you will swallow germs into your stomach." D. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."

B

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. Antihypertensive drugs B. Corticosteroids C. Potassium supplements D. Laxatives

B

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? A. Snack on high-carbohydrate foods frequently. B. Eat smaller meals that are high in protein. C. Contact the physician for nutrition shake. D. Eat one large meal at noon.

B

Which nursing action associated with successful tube feedings follows recommended guidelines? A. Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. B. Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. C. Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. D. Prevent contamination during enteral feedings by using an open system.

B

A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which health care service referral by the nurse is most appropriate? A. Respite Care B. Extended Care C. Hospice Care D. Palliative Care

C

A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation; however, he can be aroused. What would be the sedation score for this client? A. 1 B. 2 C. 3 D. 4

C

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? A. Contusion B. Incision C. Avulsion D. Puncture

C

Oxygen and carbon dioxide move between the alveoli and the blood by: A. Osmosis B. Hyperosmolar pressure C. Diffusion D. Negative pressure.

C

The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client: A. Uses the sides of the walker to rise up out of a chair. B. Places the walker far in front when walking. C. Steps into the walker when walking. D. Leans over the walker when walking.

C

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? A. Supine B. Prone C. Sims' D. Fowlers'

C

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? A. Supine B. Prone C. Sims' D. Fowler's

C

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? A. 10 L/min oxygen via Venturi mask B. 8 L/min oxygen via partial rebreather mask C. 8 L/min oxygen via nasal cannula D. 12 L/min oxygen via nonrebreather mask

C

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? A. "You will receive medication through this device." B. "This drain minimizes the chance for bacteria to enter the surgical site." C. "It provides a way to remove drainage and blood from the surgical wound." D. "The bulb-like system will stay in place permanently after your mastectomy."

C

The nurse is giving a back massage to a client who is having trouble sleeping. Which nursing actions are performed appropriately? Select all that apply. A. The nurse massages the client's shoulder, entire back, areas over iliac crests, and sacrum with light vertical stroking motions. B. The nurse kneads the client's skin using continuous grasping and pinching motions. C. The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. D. The nurse completes the massage with additional short, stroking movements that eventually become heavier in pressure. E. The nurse applies warmed lotion to client's shoulders, back, and sacral area. F. The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks.

C, E, & F

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: A. Pulmonary embolism. B. Myocardial infarction. C. Lung cancer. D. Congestive heart failure.

D

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? A. "The chest tube cannot be moved." B. "You will need to use a bedpan while the chest tube is in position." C. "Let me get the unlicensed assistive personnel (UAP) for you." D. "I can assist you to the bathroom and back to bed."

D

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of: A. Consulting. B. Conferring. C. Reporting D. Referring

D

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? A. Crackles B. Bronchovesicular C. Bronchial D. Vesicular

D

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she states that back injuries: A. Are related to sitting for long periods of time. B. Can be prevented by using a gait belt. C. Are a routine consequence of the job. D. Can occur when repositioning uncooperative clients.

D

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? A. Tidal volume (TV) B. Total lung capacity (TLC) C. Forced Expiratory Volume (FEV) D. Residual Volume (RV)

D

The spouse of a client in the early stages of dementia asks the nurse if the spouse is a candidate for "aging in place." The nurse understands that which of the following statements is the most accurate description of "aging in place"? A. Clients are required to move to an apartment or some similar living space while they are still able to care for themselves. B. Patients must remain in their own homes to be eligible for "aging in place." C. Clients will have access to the healthcare community associated with "aging in place" up until the time they need to be hospitalized. D. "Aging in place" communities are a form of extended care where community members meet each other's needs.

D

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? A. Friction B. Necrosis of tissue C. Ischemia D. Shearing force

D

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? A. Cardiovascular B. Peripheral Vascular C. Neuromuscular D. Respiratory

D

Which statements accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? A. This approach can only be used with oral analgesics. B. A PCA pump must be used and monitored in a health care facility. C. The PCA pump is not effective for chronic pain. D. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

D

What are examples of the use of guided imagery to promote client comfort? Select all that apply. A. A nurse plays a client's favorite music in the background. B. A nurse instructs a client how to breathe properly for relaxation. C. A nurse reads a book to a client who is postcataract surgery. D. A nurse asks a client to imagine sitting on the beach on a sunny day. E. A nurse asks a client to concentrate on the details of a pleasant image. F. A nurse asks a client to focus on tightening and relaxing a particular muscle group.

D & E