Skills Test 5
A client with a history of emphysema has been admitted to the hospital with an exacerbation of her symptoms. The nurse is teaching the client to perform pursed-lip breathing in an effort to alleviate hypercarbia and shortness of breath. When performing pursed-lip breathing correctly, the client will do which of the following?
Exhale more slowly than she normally does.
The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply.
Mucous membranes are pink and moist. The client is able to state the date, time, and location. Heart rate is 64 beats/min.
Which is a sign of dyspnea specific to infants?
Nasal flaring
The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem?
PaCO2 of 55 mmHg
A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client?
Pneumococcal 13-valent conjugate
The nurse is assessing a client who was hospitalized due to a fall with a brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply.
The client has dark-colored urine with a noticeable odor. The client reports dizziness when standing up from a chair. The client has been working outside in warm temperatures.
A 55-year-old male client with emphysema worked with photography chemicals and smoked cigarettes for 30 years. Which symptom(s) will the nurse expects to find? Select all that apply.
Wheezing Chronic cough Shortness of breath Loss of appetite
A client is experiencing hypoxia. Which nursing concern is appropriate to address when planning care?
anxiety
A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited?
conduct a focused assessment
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
confusion
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?
distilled water
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan?
encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?
face tent
A 56-year-old male client has been diagnosed with liver cirrhosis and recent laboratory testing reveals significant hypoalbuminemia. The nurse should anticipate that an assessment of the client may reveal:
fluid accumulation in the client's abdominal space.
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:
hemoglobin level.
Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group?
infants
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?
nonrebreather mask
The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding?
pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?
pursed-lip breathing
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?
reads 0.21 when checking oxygen in room air
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?
thrombus
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"An electric stove may be a safer choice for you."
Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.
"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
"Is your mask causing discomfort?"
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?
"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."
A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?
"Make each breath deep enough to move the bottom ribs."
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute.
A client reports rarely leaving the house since starting use of home oxygen. What education should the nurse provide to the client? Select all that apply.
A portable oxygen device may be helpful. The client likely needs time to adjust. Friends and family can be invited to visit the client at home.
A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?
"Nasal strips may reduce or eliminate snoring."
A nurse is preparing to start an intravenous infusion for a client. Which preprocedural assessment is essential before inserting the cannula?
The nurse should assess the preferred site: at least 2 inches (5 cm) above the crease of the wrist.
Which is not a primary intracellular electrolyte?
chloride
Which is a major organ of the upper respiratory tract?
pharynx
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate?
"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions."
The nurse is caring for a client who is being discharged with total parenteral nutrition (TPN) to be delivered via a peripherally inserted central catheter (PICC). When teaching the client about care and management of the PICC line at home, what point(s) will the nurse include? Select all that apply.
"Contact your health care provider if you see yellow or greenish drainage at the PICC site." "If you have a cold or flu-like symptoms, wear a mask when you are preparing to give yourself TPN." "Ensure that you have washed your hands thoroughly before handling the PICC line."
A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?
"Have you tried nasal strips?"
A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching?
"I will be sure to change the TPN tubing every other day."
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
A client has been admitted to the post-surgical unit after a metatarsal (foot) amputation and has been provided with an incentive spirometer in order to prevent respiratory complications after surgery. What client education should the nurse provide about the correct use of incentive spirometry?
"Sit up as straight as you can when you're performing incentive spirometry."
A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond?
"There is no way you can contract a disease by giving blood."
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?
"Watery plasma, or serum, portion of blood."
A client who is Jehovah's Witness is having surgery and is concerned about the potential need for blood products. Which statement by the nurse is most appropriate?
"Would you consider the use of artificial blood products?"
A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"You should never smoke when oxygen is in use."
What is the average adult fluid intake and loss in each 24 hours?
1,500 to 3,500 mL
A hospital client has been experiencing nausea and has a standing order for the administration of an intravenous antiemetic. The nurse knows that the antiemetic must be diluted in 50 mL of IV fluid before being administered and should be given over a period of 20 minutes. The nurse will administer the drug using secondary tubing that has a drop factor of 10 gtts/ml. At what rate should the nurse program the infusion pump?
150 mL/hour
The client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.
167
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
2,600 mL
The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment?
21% (0.21)
A nurse is calculating the output of a client with acute kidney injury and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount does the nurse anticipate as the usual average?
300 mL/day
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?
42 gtt/min
A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
50 gtt/min
The nurse is caring for a client with severe edema who has crackles in the lungs. Which nursing intervention is the priority for this client?
Administer furosemide as ordered.
The nurse is caring for a client with chronic obstructive pulmonary disease who has been admitted to the hospital unit for pneumonia. The nurse notes that the client has a nonproductive cough and has a SpO2 of 92%. Before attempting to obtain a sputum specimen, which action will the nurse take first?
Administer inhalation therapy using a nebulized mixture of oxygen and humidification.
While in the dining room at the hospital, the nurse notes a visitor eating lunch. The visitor begins coughing forcefully. Which action(s) will the nurse take to assist this visitor? Select all that apply.
Allow the visitor to cough. Assess for a weak, ineffective cough.
The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.
Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.
The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?
Change the site every three to four days.
Chapter 16
Chapter 16
Chapter 21
Chapter 21
The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply.
Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation.
The nurse is working with a colleague and observes the colleague changing the bag of a client's IV solution as pictured above. What is the nurse's most appropriate response?
Encourage the colleague to hang the bag on the IV pole before spiking it.
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.
Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.
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.
The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate?
It decreases dry mucous membranes by delivering small water droplets.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It determines whether the client is getting enough oxygen.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.
Offer the client fluids in small containers. Provide a moisturizer for the lips and mouth. Remove the water pitcher from the client's bedside.
The nurse is inserting a medication lock for a client receiving intermittent intravenous antibiotics. To prevent the locked intravenous catheter from becoming obstructed between uses, which action will the nurse take during this procedure?
Slowly remove the syringe before the fluid is completely instilled.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Sodium is regulated by the renin-angiotensin-aldosterone system.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?
Stop the transfusion.
A client has been prescribed a blood test. When taking a venous blood sample, which intervention should the nurse perform?
Tap the skin over the vein several times.
The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply.
The client reports using laxative substances daily. The client has been vomiting for several days. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). The client has severe iron-deficiency anemia.
A woman had a left mastectomy with axillary node dissection due to cancer. How would this affect placement of an intravenous line?
The left arm should not be used.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
The nurse is preparing to access an implanted port when administering intravenous fluids and medications. What best practice should be used when accessing this port?
The system is accessed with a noncoring needle and patency is maintained by periodic flushing.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True
The nurse is caring for a client who will be receiving multiple antibiotics. When choosing a site for intravenous insertion, which guideline will the nurse follow?
Use distal parts of larger veins where accessible.
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
The nurse would expect to recommend an oxygen tent for which client?
a child who will not leave a facemask or cannula in place
What prevents air from reentering the pleural space when chest tubes are inserted?
a closed water-seal drainage system
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.
blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm
A nurse is choosing a vein to start an intravenous (IV) infusion in an adult client. What veins will the nurse attempt to use when initiating an IV infusion? Select all that apply.
cephalic vein metacarpal vein basilic vein the vein on dorsal aspect of the hand
Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply.
client who has full-thickness (third-degree) burns over 40% of the body client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa
The nurse is caring for a client who was in a motor vehicle accident and requires treatment for internal bleeding from the trauma. Which solution does the nurse anticipate infusing?
colloidal
A nurse is caring for a client who is to be provided nutrition intravenously for a short duration following a tracheotomy. Which intravenous solution does the nurse anticipate the health care provider will prescribed for this client?
crystalloid solution
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights
A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?
decreased fluid volume risk
Cross-matching of blood is ordered for a client before major surgery. What does this process do?
determines compatibility between blood specimens
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.
facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
high respiratory rate
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
hypertonic
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic solution
The nurse is caring for a client who has had severe diarrhea for 24 hours. Which fluid does the nurse anticipate infusing?
hypotonic
A post-surgical client has been ordered an infusion of normal saline (0.9% NaCl) at 125 mL/hour until such time as the client begins drinking adequately. The infusion of this intravenous fluid will cause:
increased fluid volume with no significant redistribution of body fluids.
In which fluid compartment is most of the body's fluid is located?
intracellular
The nurse is caring for a client who ran an outdoor marathon during peak heat in the summer. The client's baseline weight is reported as 125 lb (56.7 kg); however, on admission today, the client weighs 115 lb (52.2 kg). Based on the percentage of weight lost, the nurse will document the client's fluid volume status using which describing term?
moderately dehydrated
A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?
nonrebreather mask
A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?
oral hygiene
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.
osmosis filtration diffusion active transport
Which location might the nurse use to assess the condition of an insertion site for a central venous access device?
over the jugular vein
A client with renal disease requires IV fluids. It is important for the nurse to:
place the fluids on an electronic device.
The nurse has completed a respiratory assessment of an older adult client with numerous health problems. The results of the assessment include a respiratory rate of 24 breaths per minute and pulse oximetry of 90%. The nurse's next action should be to:
position the client in a high Fowler position.
The nurse is preparing to hang a nitroglycerin drip in a glass bottle for a client with chest pain. Which tubing selection by the nurse is appropriate?
primary vented tubing
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
prolongs expiration to reduce airway resistance
A client has been admitted to the hospital with a diagnosis of acute kidney injury, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the mostaccurate way that the care team can achieve this assessment goal?
weighing the client once per day
A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client?
yogurt broccoli tofu
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:
"He is using his chest muscles to help him breathe."
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. Which action should the nurse take?
Encourage the intake of salty liquids like broth and tomato juice.
The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply.
Obtain baseline vital signs prior to beginning the transfusion. Verify client identification and blood product information with a second nurse. Wear clean gloves when spiking the blood container with the administration set. Check that informed consent has been obtained from the client.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.
crackles in the lungs distended neck veins
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
pulse oximetry
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?
sleep apnea
