Silvestri (F&E, Resp, CV)

Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse would plan to administer this medication by which route?

By intravenous infusion

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem?

Metabolic alkalosis4

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

Monitor the client for dysrhythmias.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation

The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse would interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

urine specific gravity 1.043

The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN?

Monitoring the temperature

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

"Blocked nasal passages impair the sense of smell."

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement?

"I need to restrict my activity while this catheter is in place."

The nurse is teaching a client diagnosed with acute bacterial rhinosinusitis about supportive measures to increase client comfort. Which client statement would indicate a need for further teaching?

"I would run a dehumidifier in my bedroom at night while I'm sleeping."

The nursing instructor is reviewing the pathophysiology of influenza. The nursing instructor determines there is a need for further teaching if the nursing student makes which statement regarding influenza?

"Influenza A infects only humans."2

The nurse is caring for a client with no significant medical history who tested positive for COVID-19 and is experiencing moderate symptoms of cough, shortness of breath, and loss of sense of smell. The client asks the nurse when the infectious stage of the virus will end and the transmission-based precautions can be safely discontinued. Which is the appropriate nursing response? Select all that apply.

"Your symptoms need to have started to improve." "At least 5 days will need to have passed since your symptoms first appeared." "You need to be fever-free for at least 24 hours without using fever-reducing medications."

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Pco2 50 mm Hg 2. pH 7.35, Pco2 40 mm Hg 3.pH 7.50, Pco2 52 mm Hg 4.pH 7.52, Pco2 28 mm Hg

1. pH 7.25, Pco2 50 mm Hg

The nurse is caring for a client who underwent a pleurodesis procedure to treat a recurrent pleural effusion. The medication was instilled into the chest tube at 1600 and subsequently clamped. At what time will the nurse unclamp the chest tube?

2400

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1. Initiate and maintain supplemental oxygen as prescribed. 2. Plan activities with rest periods to conserve oxygen needs. 3. Provide nasotracheal suctioning as needed to remove secretions. 4. Monitor oxygenation (the oxygen saturation [SaO2]) during activity

3. Provide nasotracheal suctioning as needed to remove secretions.

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner?

30-90 minutes

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism?

A 73-year-old client who has just had pinning of a hip fracture

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3-

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs during suctioning.

The nurse is assessing a client complaining of fatigue and facial pain. Upon assessment, the nurse notes tenderness to percussion above the bilateral eyebrows and bilateral cheeks. The client also complains of facial pressure that is worse when bending forward; thick, greenish-yellow nasal discharge; sore throat; and fever at home. Which condition would the nurse suspect?

Bacterial rhinosinusitis

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

Bounding pulse Difficulty breathing Presence of dependent edema Neck vein distention in the upright position

The nurse is caring for a client with metabolic alkalosis. The nurse plans care, knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply.

Cardiac Nervous Neuromuscular

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid which action?

Encouraging the client to breathe slowly and shallowly

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action would the nurse take first?

Contact the primary health care provider (PHCP)

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client would expect to note which signs/symptoms?

Decreased respiratory rate and depth

The nurse is creating a plan of care for a client with hypokalemia. Which interventions would be included in the plan of care? Select all that apply.

Ensure adequate fluid intake. Implement safety measures to prevent falls. Instruct the client about foods that contain potassium. Encourage the client to obtain assistance to ambulate

The nurse is reviewing the risk factors for severe COVID-19 illness. The nurse would determine that which criteria increase the risk of a severe COVID-19 illness? Select all that apply.

Heart Failure Hypertension Diabetes Mellitus CKD COPD

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which finding documented in the client's record is an expected finding with this client?

Hyperinflation of lungs

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder would the nurse monitor for that could accompany the acid-base imbalance?

Hypokalemia

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning?

Lying on the back in a low-Fowler's position

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse would ask the client about which manifestations of the disorder? Select all that apply.

Malaise Anorexia Fatigue

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion Tachycardia Light-headedness

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

Pain, especially with inspiration

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?

Place the client on the left side in Trendelenburg's position.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value would the nurse expect to note?

Potassium level of 5.2 mEq/L (5.2 mmol/L)

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

Pour the aspirate into the NG tube and reinstill through a syringe with the plunger removed

The nurse is caring for a client w/ Crohn's disease who has a calcium level of 8mg/dL (2mmol/L). Which patterns would the nurse watch for on the electrocardiogram? (select all that apply) 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

Prolonged QT interval Prolonged ST segment

The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination.

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

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

A client complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse would take which actions in the care of this client? Select all that apply.

Remove the IV catheter at that site. Apply warm, moist packs to the site. Notify the primary health care provider (PHCP). Document the occurrence, actions taken, and the client's response.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

hypotension

The nurse is monitoring the respiratory status of a client with laryngeal cancer after creation of a tracheostomy. Which coexisting condition in the client may cause an inaccurate pulse oximetry reading?

hypotension

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that three enemas have been administered and the client is still passing brown, liquid stool. What would the RN instruct the AP to do?

Stop administering the enemas until the primary health care provider (PHCP) is notified.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves. widened QRS complexes

The nurse instructs a client with chronic obstructive pulmonary disease on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly?

The client breathes out slowly through the mouth.

The nurse is reviewing the pathophysiology of influenza and the various strains of the disease. The nurse would correctly identify H3N2 as which type of influenza?

influenza A

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation would the nurse make?

The client's test result will be positive, and a chest x-ray study will be required for evaluation.

The nurse is caring for a client diagnosed with COVID-19 experiencing hypercoagulability. Which laboratory result trends would the nurse anticipate? Select all that apply.

Thrombocytopenia Increased D-dimer level Prolonged prothrombin time (PT) Prolonged activated partial thromboplastin time (aPPT)

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

U waves Inverted T waves Depressed ST segment

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032

Urine specific gravity of 1.032

The nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

a shunt unit exists

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note?

complaints of night sweats

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.

dehydration stress decreased blood volume

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level?

depressed ST segment

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?

disconnection of ventilator tubing

The nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion?

integumentary output

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care, knowing that what reaction is the most powerful regulator of acid-base balance?

kidney

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care, knowing that the client is at risk for the development of which type of acid-base imbalance?

metabolic acidosis

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

metabolic acidosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

metabolic alkalosis

The nurse is assessing a client diagnosed with COVID-19. Objective data include a respiratory rate of 20 breaths per minute, oxygen saturation of 95% on room air, temperature of 101.6° F (38.6° C), lungs clear to auscultation bilaterally, and a chest x-ray (CXR) negative for an acute pulmonary process. Subjective findings include fatigue, malaise, and muscle aches, but the client denies shortness of breath. How would the nurse classify the client's illness severity?

mild illness

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How would the nurse interpret the result?

negative

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over which area?

over the trachea and larynx

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg2

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

potassium

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

prolonged bed rest

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

requires nasogastric suctioning

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg, and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

respiratory alkalosis, compensated

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse would select which solution to use for the nasogastric tube irrigation?

sodium chloride

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action would the nurse plan to take?

take no action

A client who is experiencing respiratory difficulty asks the nurse, "Why is it so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

the respiratory muscles relax

A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse would assess for which condition?

ventricular ectopy