Think tank for quiz 6

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? A. Apply a new transdermal patch once a week B. Apply the transdermal patch in the AM C. Apply the transdermal patch in the same location as the previous patch D. Apply a new transdermal patch when chest pain is experienced

B. Apply the transdermal patch in the AM

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? A. Dilated pupils B. Dysrhythmias C. Diarrhea D. Gastric ulcer

B. Dysrhythmias

A nurse is admitting a client who reports flue-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that that the client is experiencing which of the following conditions ? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A nurse is administering nasal decongestant drop for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation B. Assist the client to a side lying position C. Hold the dropper 2 cm ( 1 in ) above the marks D. Instruct the client to stay in the same position for 2 min

A. Tell the client to blow her nose gently before the instillation

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take ? A. Observe the client before taking further action B. Perform the Heinrich maneuver C. Assist the client to the floor begin mouth to mouth D. Slap the client on the back several times

B. Perform the Heimlich Maneuver The question states the patient cannot talk letting you know they are choking

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D. Tachycardia

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increases risk of aspiration while eating? (Select all that apply.) A. A client has lactose intolerance B. A client who has had a cerebrovascular accident C. A client who is 4 hr postoperative following a leg amputation with general anesthesia D. A client who has had prolonged diarrhea E. A client who has had radiation therapy for head and neck cancer

B. A client who has had a cerebrovascular accident C. A client who is 4 hr postoperative following a leg amputation with general anesthesia E. A client who has had radiation therapy for head and neck cancer

A nurse is providing discharge teaching to a client who has a new prescription for home ox therapy via a nasal cannula. Which of the following should the nurse include in the teaching? Select all that apply A. Verify the o2 rate every other day B. Check the cannula position on a regular basis C. Check the tops of the ears for skin breakdown D. Post "no smoking" signs in a prominent location in the home E. Apply petroleum ointment to nares if they become dry and irritated

B. Check the cannula position on a regular basis C. Check the tops of the ears for skin breakdown D. Post "no smoking" signs in a prominent location in the home

A nurse is auscultation get a client's lung and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breath deeply and cough B. Instruct the client to limit fluid intake to less than 2000 ml/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-Fowler's position

A. Repeat auscultation after asking the client to breath deeply and cough

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration? A. A client who has a chest tube following a fall from a ladder B. A client who had hemi-colectomy and placement of colostomy C. A client receiving continuous enteral feeding through NG tube D. A client who Chron's disease has an ileostomy

C. A client receiving continuous enteral feeding through NG tube

A nurse is caring for a client who had splenectomy and has been on bed-rest for several days, because of complications. The nurse auscultation decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

C. Atelectasis

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings while the client is sitting in a chair B. Remove stockings once a each day C. Check the stockings for wrinkles D. Measure the size of the clients foot

C. Check the stockings for wrinkles

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnate of the ears B. Dorsal surface of the hand C. Conjunctivae D. Doral surface of the foot

C. Conjunctivae

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. A client who has pertussis C. A client who has streptococcal pharyngitis D. A client who has measles

D. A client who has measles

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack ? A. Beclomethasone B. Salmeterol C. Formoterol D. Albuterol

D. Albuterol

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygen ? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D. Clubbing of the fingers

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first ? A. Administer o2 at 2L/min B. Administer prescribed analgesic med C. Encourage coughing and deep breathing D. Raise the head of the bed

D. Raise the head of the bed

A nurse is assessing a client who is 2 days postoperative and auscultation bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A. Atelectasis

A nurse is caring for client who is receiving oxygen at 2 L/min via a nasal cannula. The Nurse recognizes the client is receiving which of the following inspired oxygen concentration? A. 28 % B. 36 % C. 50 % D. 70 %

A. 28 %

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another non surgical client C. A room in the ICU D. A room that is within view of the nurses' station

A. A room with air exhaust directly to the outdoor environment

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A systolic murmur B. A third heart sound ( S3 ) C. An expected heart sound D. A fourth heart sound ( S4 )

A. A systolic murmur ( Erbs point )

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute B. Assess the apical pulse with a Doppler device C. Assess the pedal pulse for a full min D. Assess the pedal pulses with a Doppler device

A. Assess the apical pulse for a full minute

A nurse is caring for a client who has Han and ask the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who has a history of which of the following conditions? A. Asthma B. Glaucoma C. Depression D. Migraines

A. Asthma

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr B. Perform ROM exercises at least 2-3 times daily C. Make sure the client has an intake of 2K-3K ml of fluid per day D. Apply anti embolic stockings.

A. Auscultate breath sounds at least every 2 hr

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaint of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs B. Request a dietitian consult C. Suggest that the client rests before eating the meal D. Request an order for an antiemetic

A. Check the client's vital signs

A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching ? A. I have started taking ginger root to treat my joint stiffness B. I take this med at the same time each day C. I eat a green salad every night with dinner D. I had my INR checked three weeks ago

A. I have started taking ginger root to treat my joint stiffness

A nurse is caring for a client who receives furosemide. Which of the follow labs do you check? A. Potassium B. Albumin C. Cortisol D. Bicarbonate

A. Potassium

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure? A. Remove all metal necklaces B. Take several shallow breaths during the procedure C. come NPO D. Expect minor discomfort after the procedure

A. Remove all metal necklaces

A nurse is providing discharge teaching to a client has a new prescription for a meted dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhalor for 3 to 5 seconds B. Rinse the mouth with mouthwash after inhaling the medication C. Wait 2 min between inhalation's D. Press down twice on the MDI canister

A. Shake the inhaler for 3 - 5 seconds

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? A. The client holds his breath for 10 seconds after inhaling the med B. The client takes a quick inhalation while releasing the med from the inhaler C. The client exhales as the med is released from the inhaler D. The client waits 10 mins between inhalation

A. The client holds his breath for 10 seconds after inhaling the med

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching. A. "The spacer increases the amount of medication delivered to the oropharynx" B. "The spacer increases the amount of medication delivered to the lungs" C. "Inhale rapidly using the spacer with the MDI" D. "Cover exhalation slots of the spacer with lips when inhaling"

B. The spacer increases the amount of medication delivered to the lungs

A nurse is performing a cardiac assessment on client and auscultation an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? A. Atrial gallop B. Ventricular gallop C. Closure of the mitral valve D. Closure of pulmonic valve

B. Ventricular gallop

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of the rest. Secretions? A. Encourage the client to ambulated frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer

C. Encourage the client to increase fluid intake