Unit 3, 4 and 5
The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement by the client should prompt the nurse to refer the client for further assessment? "Lately, I have this cough that just never seems to go away." "I find that I don't have nearly the stamina that I used to." "I seem to get nearly every cold and flu that goes around my workplace." "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."
"Lately, I have this cough that just never seems to go away."
A 17-year-old client who is married wishes to have a breast reduction. She has insurance through her job as a cashier. Which information will the nurse provide to the client? "You can sign the consent form on this line." "I am able to give informed consent for you to have this procedure." "Your parent or legal guardian must sign the consent form." "Because you are a minor, no consent form is needed."
"You can sign the consent form on this line."
As an OR nurse, you are required to assess the client continuously and protect them from developing potential complications, as much as humanly possible. To protect a client from malignant hyperthermia, you need to know the symptoms—what are the symptoms of malignant hyperthermia? All of the options are correct Cyanosis Hypotension Decreased urine output
All of the options are correct
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Positioning the client in a supine position Assessing breath sounds at least every 2 hours
Ambulating the client as soon as possible
Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process? Atelectasis Consolidation Bronchiectasis Empyema
Consolidation
A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply. Do not smoke, or quit smoking if currently smoking. Wear appropriate protective equipment when around airborne irritants and dusts. Try to find another occupation as soon as possible. Schedule an annual lung x-ray to monitor health.
Do not smoke, or quit smoking if currently smoking. Wear appropriate protective equipment when around airborne irritants and dusts.
The nurse has been injured with a needlestick while caring for a newly admitted client, and she goes to tell the charge nurse. What is the next thing the injured nurse should do? Document the injury in writing. Obtain the client's HIV status. Get instructions on monitoring potential symptoms. Report the injury to the supervisor.
Document the injury in writing.
Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply. Discussing and reviewing the advanced directive document Establishing an intravenous line Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed Beginning discharge planning
Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis? Gram-negative Klebsiella Pseudomonas aeruginosa Group A, beta-hemolytic streptococcus Staphylococcus aureus
Group A, beta-hemolytic streptococcus
The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? Difficulty ambulating Hemorrhage Infrequent swallowing Bradycardia
Hemorrhage
The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Incentive spirometry Intermittent positive-pressure breathing (IPPB) Positive end-expiratory pressure (PEEP) Bronchoscopy
Incentive spirometry
The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action? Teach the client deep-breathing and coughing exercises Contact the respiratory therapist promptly Teach the client to splint the rib cage Teach the client pursed lip breathing
Teach the client to splint the rib cage
A 22-year-old male patient developed a pulmonary embolism (PE) several days ago and has undergone a course of treatment in the hospital. Discharge has been delayed indefinitely, however, because the patient has developed pleurisy as a complication of his PE. When planning this patient's care, what outcome should the nurse prioritize? The patient will successfully demonstrate breathing retraining. The patient will adhere to his prescribed treatment regimen. The patient will demonstrate appropriate use of metered-dose inhalers (MDIs) with a spacer. The patient will experience acceptable control of his pain.
The patient will experience acceptable control of his pain.
Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following? Time between exposure and onset of symptoms Presence of microorganisms without the host interacting with them State in which the host displays a decrease in wellness Process of the host shedding the microorganisms to another
Time between exposure and onset of symptoms
A client has had a laryngectomy as treatment for laryngeal cancer. Which nutritional interventions should be implemented for the client? Use enteral feedings after the procedure. Offer plenty of thin liquids when intake resumes. Season food to suit increased sense of taste and smell. Recommend a long-term use of zinc lozenges.
Use enteral feedings after the procedure.
When caring for a client with a respiratory infection, the nurse washes her hands frequently and thoroughly. What are the other precautionary steps the nurse should take in order to prevent infection? Get monthly immunizations against infections. Wear a mask when talking to the client. Receive vaccination after every visit. Avoid contact with the client.
Wear a mask when talking to the client.
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed? When the patient has less than 30 mL for 2 consecutive days When the patient states that there is discomfort and requests removal When the drainage tube comes out In 1 week when the patient no longer has serous drainage
When the patient has less than 30 mL for 2 consecutive days
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. administering inhalation anesthetics positioning the client on the operating table administering regional nerve blocks counting sponges before and after surgery monitoring the client's vital signs
positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs
What does a positive Mantoux test indicate? active immunity to tuberculosis production of an immune response development of full-blown tuberculosis an active case of tuberculosis
production of an immune response
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? 3 months 3 to 5 months 6 to 12 months 13 to 18 months
6 to 12 months
A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment? A 1.5 L/day fluid restriction A high-potassium, low-sodium diet A liquid or soft diet A high-protein diet
A liquid or soft diet
A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Pneumoconiosis Pleural effusion Acute respiratory failure Pneumonia
Acute respiratory failure
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments
Coordinating the surgical team
The nurse recognizes what groups of people are at an increased risk for infection? Select all that apply. Debilitated clients Older adults Adolescents Clients with impaired skin Clients with pancreatic disease
Debilitated clients Older adults Clients with impaired skin
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Passive range of motion exercises for the upper and lower extremities Early ambulation and the use of compression stockings Incentive spirometry and deep breathing and coughing exercises Maintenance of SpO2 levels ≥90% using supplementary oxygen
Early ambulation and the use of compression stockings
The surgeon's preoperative assessment of a client has identified that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? Maintain the head of the bed at 45 degrees or higher. Encourage early ambulation. Encourage oral fluid intake. Perform passive range-of-motion exercises every 8 hours.
Encourage early ambulation.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention
First intention
The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? Food and liquids will be held in the immediate postoperative period. You will receive a diet high in vitamin B. In the immediate postoperative period, you will receive a soft diet high in carbohydrates. You may eat anything you want following surgery.
Food and liquids will be held in the immediate postoperative period.
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? "Gargle with a warm salt solution." "You may have a sore throat for 1 week." "You are allowed to have hot tea or coffee." "Decrease oral intake if increased swallowing occurs."
Gargle with a warm salt solution."
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hypotension, hyperoxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia
Hypercapnia, hypoventilation, and hypoxemia
The nurse is caring for a client in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The client has become hypotensive. What is the cause of this complication to the ARDS treatment? Pulmonary hypotension due to decreased cardiac output Severe and progressive pulmonary hypertension Hypovolemia secondary to leakage of fluid into the interstitial spaces Increased cardiac output from high levels of PEEP therapy
Hypovolemia secondary to leakage of fluid into the interstitial spaces
The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrom
If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.
A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action? Apply a cold pack to the affected area. Apply heat to the forehead. Perform postural drainage. Increase fluid intake.
Increase fluid intake.
A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? Obtain serial ABG samples. Monitor pulse oximetry readings. Perform chest auscultation. Monitor incentive spirometry volumes.
Monitor pulse oximetry readings.
During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? Assist the client to the bathroom. Offer the client a bedpan or urinal. Wait until the client gets to the operating room and is catheterized. Have the client go to the bathroom.
Offer the client a bedpan or urinal.
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? Older adults have less compliant lung tissue than younger adults. Older adults are not normally candidates for pneumococcal vaccination. Older adults often lack the classic signs and symptoms of pneumonia. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.
Older adults often lack the classic signs and symptoms of pneumonia.`
A cleansing enema is prescribed for a client who is scheduled to have colon surgery. What is the rationale for this procedure? Surgical clients routinely are given a cleansing enema. Cleansing enemas are given before surgery at the client's request. There will be less flatus and discomfort postoperatively. Peristalsis does not return for 24 to 48 hours after surgery.
Peristalsis does not return for 24 to 48 hours after surgery.
The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client? Signs and symptoms of pulmonary infection Swallowing ability and signs of aspiration Activity level and role performance Residual effects of compromised oxygenation
Residual effects of compromised oxygenation
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing First-intention healing Second-intention healing Third-intention healing
Second-intention healing
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Dullness or flatness on percussion over areas of collected fluid Dyspnea and coughing Fever and chills Stabbing pain during respiratory movement
Stabbing pain during respiratory movement
A health care provider schedules an emergency surgery for a client with intestinal perforation. Which action should the nurse take to prepare the client for immediate surgery? Start an intravenous line Discuss discharge planning with the family Obtain informed consent Administer pain medication
Start an intravenous line
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Staphylococcus aureus Mycobacterium tuberculosis Pseudomonas aeruginosa Streptococcus pneumoniae
Streptococcus pneumoniae
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Unresponsive arterial hypoxemia Diminished alveolar dilation Tachypnea Increased PaO2
Unresponsive arterial hypoxemia
A nurse is aware that the diagnostic feature of ARDS is sudden: Unresponsive arterial hypoxemia. Diminished alveolar dilation. Tachypnea Increased PaO2
Unresponsive arterial hypoxemia.
A client with a pleural effusion was "tapped" to drain the fluid to reduce mediastinal pressure. Which primary condition would most likely have caused the pleural effusion? heart failure emphysema sleep apnea asthma
heart failure
A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? Negative Positive Borderline Uncertain
negative
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: area of redness is measured in 3 days and determines whether tuberculosis is present. skin test doesn't differentiate between active and dormant tuberculosis infection. presence of a wheal at the injection site in 2 days indicates active tuberculosis. test stimulates a reddened response in some clients and requires a second test in 3 months.
skin test doesn't differentiate between active and dormant tuberculosis infection.
During the winter, increased instances of acute bronchitis cause a backlog of physician appointments that spill over into ED visits. What is the most common cause of acute bronchitis infections? viral infections bacterial infections chemical irritation bronchial asthma
viral infections
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? No fluid is normally present 20 mL or less 20-40 mL More than 40 mL
20 mL or less
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of prophylactic antibiotics Administration of pneumococcal vaccine to vulnerable individuals Obtaining culture and sensitivity swabs from all newly admitted clients Administration of antiretroviral medications to clients over age 65
Administration of pneumococcal vaccine to vulnerable individuals
What is the most commonly prescribed treatment for the common cold? Antihistamines Decongestants Antitussives Expectorants
Antihistamines
A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Acute respiratory distress syndrome (ARDS) Atelectasis Aspiration Pulmonary embolism
Atelectasis
While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care? Avoid actions that will cause the client to breathe deeply. Ambulate the client at least three times daily. Arrange for a soft-textured diet and increased fluid intake. Encourage the client to speak as little as possible
Avoid actions that will cause the client to breathe deeply.
The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? Carboxyhemoglobin level Brain natriuretic peptide (BNP) level C-reactive protein (CRP) level Complete blood count
Brain natriuretic peptide (BNP) level
An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? Nasogastric intubation Administration of probiotic supplements Bed rest Cautious hydration
Cautious hydration
A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem? Encouraging the patient to adopt a later bedtime and earlier rising hour Encouraging the patient to avoid alcohol and hypnotic medications Teaching the patient deep breathing and coughing exercises to perform before going to bed Teaching the patient strategies for waking himself up when he experiences an apneic spell
Encouraging the patient to avoid alcohol and hypnotic medications
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound? Count the sponges. Label the tissue specimen. Prepare the necessary sutures. Hand equipment to the surgeon as needed.
Count the sponges.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin B6 Vitamin C Vitamin D Vitamin E
Vitamin B6
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? Facilitate total parenteral nutrition (TPN). Keep a complete suction setup at the bedside. Feed the client several small meals daily. Refer the client for occupational therapy.
Keep a complete suction setup at the bedside.
A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures should be initiated in this client? Psychological counseling Nutritional support High-protein oral diet Occupational therapy
Nutritional support
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Mobilizing early Using incentive spirometry Receiving vaccinations Using prescribed opioids
Receiving vaccinations
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to Stay in bed when experiencing a fever Properly dispose of used tissues Seek medical help if he experiences inability to swallow Place an ice collar on the throat to relieve soreness
Seek medical help if he experiences inability to swallow
The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? A social worker should temporarily sign the informed consent. Consent should be obtained from the hospital's ethics committee. Surgery should be done without informed consent. Surgery should be delayed until the parents arrive.
Surgery should be done without informed consent.
A mediastinal shift occurs in which type of chest disorder? Tension pneumothorax Traumatic pneumothorax Simple pneumothorax Cardiac tamponade
Tension pneumothorax
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? Turn onto the affected side. Use a prescribed analgesic. Avoid using a pillow while splinting. Use a heat or cold application.
Turn onto the affected side.
Preventing falls in older adults directly correlates to preventing bone fractures. If an older adult falls and fractures one or more ribs, what is a possible complication that could develop after the fracture? pneumonia confusion osteoporosis bronchospasm
pneumonia
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue
Pink to red and soft, bleeding easily
The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? Pneumothorax Cardiac ischemia Acute bronchitis Aspiration
Pneumothorax
The nurse is conducting a preoperative assessment with a client who is having abdominal surgery on the same day. When reviewing the client's medication list, the nurse recognizes the client has a higher risk of bleeding during the intra- and postoperative periods if which medication was taken? metoprolol acetylsalicylic acid furosemide morphine
acetylsalicylic acid this aspirin anti inflammatory drug and blood thinner
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? corticosteroids diuretics insulin anticoagulants
diuretics
A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? emergency surgery elective surgery palliative surgery diagnostic surgery
emergency surgery
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Position the client in the side-lying position. Administer an anti-emetic. Obtain an emesis basin. Ask the client for more clarification.
Position the client in the side-lying position.
The nurse is performing wound care on a 68-year-old postsurgical client. Which of the following practices violates the principles of surgical asepsis? Holding sterile objects above the level of the nurse's waist Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated Pouring solution onto a sterile field cloth Opening the outermost flap of a sterile package away from the body
Pouring solution onto a sterile field cloth
he scrub nurse is responsible for: Calling the "time-out" to verify the surgical site and procedure Monitoring the administration of the anesthesia Monitoring the operating-room personnel for breaks in sterile technique Preparing the sterile instruments for the surgical procedure
Preparing the sterile instruments for the surgical procedure
An obese client is scheduled for open abdominal surgery. What priority education should the nurse provide to this client? Prevention of wound dehiscence Wound care and infection prevention Prevention of venous thromboembolism Prevention of respiratory complications
Prevention of respiratory complications
A client in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter should the nurse monitor most closely on a client who is postoperative following an embolectomy? Lung function testing Pressure in the vena cava White blood cell differential Pulmonary arterial pressure
Pulmonary arterial pressure
A nurse is caring for a female client who will undergo a curative surgery for cholecystectomy. Which precaution should the nurse take before surgery to prevent venous stasis? Recommend that the client wear antiembolism stockings. Ask the client to wiggle the toes at regular intervals. Enclose the client's leg in a pneumatic splint. Ask the client to remove her dentures.
Recommend that the client wear antiembolism stockings.
The perioperative nurse knows that the National Patient Safety Goals have the potential to improve client outcomes in a wide variety of health care settings. Which of these goals has the most direct relevance to the OR? Improve safety related to medication use Reduce the risk of client harm resulting from falls Reduce the incidence of health care-associated infections Reduce the risk of fires
Reduce the risk of fires
There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: beginning anesthesia Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression
Stage II: excitement
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first Stands behind the worker, who has hands across the neck Places both arms around the worker's waist Makes a fist with one hand with the thumb outside the fist Exerts pressure against the worker's abdomen
Stands behind the worker, who has hands across the neck
A 58-year-old male patient with a 60 pack-year history of cigarette smoking and a history of heavy alcohol use has been diagnosed with laryngeal cancer following a physical examination and endoscopy. The patient has been scheduled for a partial laryngectomy and is highly anxious about the consequences of this surgery. What patient education should the nurse provide for this man? "Most people who have a partial laryngectomy find that their breathing, swallowing, and speech are unchanged." "After a partial laryngectomy, most patients work with a speech therapist and regain some of their ability to speak." "A partial laryngectomy has the advantage of having only a minimal effect on your speech." "Unfortunately, the nature of a partial laryngectomy means that you can no longer use your vocal cords."
"A partial laryngectomy has the advantage of having only a minimal effect on your speech."
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states "Do not smoke and avoid being around others who are smoking." "It is fine to speak in a whisper. This does not strain your voice." "Do not use a humidifier; it will make your problem worse." "The 'tickle' in your throat will improve with cold liquids."
"Do not smoke and avoid being around others who are smoking."
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? "The ET tube will maintain your airway while you're under anesthesia." "The ET tube will be inserted through an opening in your trachea." "The ET tube will remain in place for at least a day postsurgery." "The ET tube will be connected to a negative-pressure ventilator."
"The ET tube will maintain your airway while you're under anesthesia."
A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response? "The type of treatment depends on the patient's age and health status." "The type of treatment depends on what the patient wants when given the options." "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." "The type of treatment depends on the discussion between the patient and the health care provider over which treatment is best."
"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."
The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? "The younger you are when you start smoking, the higher your risk of lung cancer." "The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays." "The risk for lung cancer is determined mostly by what type of cigarettes you smoke." "The risk for lung cancer depends primarily on the other risk factors for cancer that you have."
"The younger you are when you start smoking, the higher your risk of lung cancer."
The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? "Which medications do you take daily?" "When was the last time you had anything to eat or drink?" "Can you tell me why you are here this morning?" "Do you want me to call the hospital chaplain before you have anesthesia?"
"When was the last time you had anything to eat or drink?"
A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia? "You will be asleep and won't be aware of the procedure." "You will be asleep but may feel some pain during the procedure." "You will be awake but will not be aware of the procedure." "You will be awake and will not have sensation of the procedure."
"You will be awake and will not have sensation of the procedure.
4. The nurse is educating the parents of a child with otitis media. Which statement made by the parents indicates a need for further teaching? a) "I will avoid exposing my child to smoke in the future." b) "I will be certain to never prop my child's bottle." c) "I will avoid exposing my child to others with upper respiratory infections. "d) "I will be certain to dry the outer ear well after each time we go swimming."
"d) "I will be certain to dry the outer ear well after each time we go swimming."
An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 4 seconds with 2 episodes/hour. 6 seconds with 3 episodes/hour. 8 seconds with 4 episodes/hour. 10 seconds with 5 episodes/hour.
10 seconds with 5 episodes/hour.
Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 60; 50 60; 40 75; 50 75; 40
60; 50
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client who ambulates in the hallway every 4 hours A client with a nasogastric tube A client who is receiving acetaminophen (Tylenol) for pain
A client with a nasogastric tube
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: One vocal cord was removed along with a portion of the larynx. The voice was spared and a tracheostomy would be in place until the airway was established. A permanent tracheal stoma would be necessary. A portion of the vocal cord was removed.
A permanent tracheal stoma would be necessary.
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? Administer intradermal injections into each child's inner forearm. Administer intramuscular injections into each child's vastus lateralis. Administer a subcutaneous injection into each child's umbilical area. Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.
Administer intradermal injections into each child's inner forearm.
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? Administer one intramuscular injection of penicillin. Provide the client with oral penicillin that will last for 5 days. Provide emphatic oral instructions for the client. Ask an accompanying homeless friend to monitor the client's follow-up.
Administer one intramuscular injection of penicillin.
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection? An antiviral agent such as acyclovir An antibiotic such as amoxicillin An antihistamine such as Benadryl An ointment such as bacitracin
An antiviral agent such as acyclovir
The nurse is creating a plan of care for a client diagnosed with acute laryngitis. What intervention should be included in the client's plan of care? Place warm washcloths on the client's throat, as needed. Have the client inhale warm steam three times daily. Encourage the client to limit speech whenever possible. Limit the client's fluid intake to 1.5 L/day.
Encourage the client to limit speech whenever possible
While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of what? Bowel functioning is significantly decreased. Bowel functioning ceases due to becoming permanently paralyzed. The bowel shrinks and appears deflated. The bowel makes loud sounds constantly.
Bowel functioning is significantly decreased.
The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? Have the client sign the informed consent and place it in the chart. Call the physician to review the procedure with the client. Explain the procedure clearly to the client and her family. Provide the client with a pamphlet explaining the procedure.
Call the physician to review the procedure with the client.
The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? Copious sputum production Coughing Dyspnea Severe pain
Coughing
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? Pneumothorax Flail chest ARDS Tension pneumothorax
Flail chest
The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? Anxiety related to diagnosis of cancer Altered nutrition related to swallowing difficulties Ineffective airway clearance related to airway alterations Impaired verbal communication related to removal of the larynx
Ineffective airway clearance related to airway alterations
The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? Rejection of the kidney Rejection of the implanted lens Infection Adrenal storm
Infection
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery
Intubate the client and control breathing with mechanical ventilation
The nurse is preparing to send a client to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the client to surgery? Select all that apply. Laboratory reports Nurses' notes Verification form Social work assessment Dietitian's assessment
Laboratory reports Nurses' notes Verification form
A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply. Coping Level of consciousness Oral intake Arterial blood gases Vital signs
Level of consciousness Arterial blood gases Vital signs
A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? Teaching focuses on safe and effective use of antibiotics. The client should be preliminarily screened for surgery. Symptom management is the main focus of medical and nursing care. The focus of care is resting the voice to prevent chronic hoarseness.
Symptom management is the main focus of medical and nursing care.
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? Cough Hemoptysis Syncope Tachypnea
Tachypnea
A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? Malignant hyperthermia occurs in the operating room only. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. The client can develop malignant hyperthermia up to 24 hours after surgery. The client will need to be discharged with special instructions.
The client can develop malignant hyperthermia up to 24 hours after surgery.
A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. The client explains the procedure should be completed first thing in the morning before rising from the bed. The client repeats the explanation and instructions in one's own words to demonstrate understanding.
The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.
The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? The client may be experiencing presurgical anxiety. The client may be at risk for malignant hyperthermia. The grandmother's surgery has minimal relevance to the client's surgery. The client may be at risk for a sudden onset of postsurgical infecti
The client may be at risk for malignant hyperthermia.
The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? The client's swallowing ability The client's airway patency The client's carotid pulses Signs and symptoms of infection
The client's airway patency
The nurse is caring for a client who has been in a motor vehicle accident and the care team suspects that the client has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis? The client is experiencing painless hemoptysis. The client's arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing. The client's oxygen saturation level is below 88%, but he denies shortness of breath. The client's pain intensifies when he coughs or takes a deep breath.
The client's pain intensifies when he coughs or takes a deep breath.
A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize? The rationale and technique for using incentive spirometry The correct use of a metered-dose inhaler (MDI) for bronchodilators The need to maintain good nutrition and adequate hydration The importance of adhering to the prescribed treatment regimen
The importance of adhering to the prescribed treatment regimen
A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP The importance of participating in daily physical exercise when using CPAP on a regular basis The need to have continuous pulse oximetry in place while the CPAP machine is in use The importance of complying with CPAP despite the inconvenience associated with its use
The importance of complying with CPAP despite the inconvenience associated with its use
A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? The procedural physician should be notified immediately of client findings. This is an expected finding in the immediate postoperative period. The client should be returned to the operating room for further evaluation. The client needs to have the neurologic status fully evaluated.
This is an expected finding in the immediate postoperative period.
Which client would a nurse monitor most closely for postoperative respiratory complications? a 75-year-old client with a history of hypertension who had a colonoscopy an 8-year-old client with no medical problems who had a tonsillectomy a 55-year-old client with a history of asthma who had a colon resection a 31-year-old client with no medical problems who had an appendectomy
a 55-year-old client with a history of asthma who had a colon resection
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen? a woman who takes daily anticoagulants to treat atrial fibrillation a woman who takes daily thyroid supplements to treat her longstanding hypothyroidism a man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension a man who regularly treats his rheumatoid arthritis with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)
a woman who takes daily anticoagulants to treat atrial fibrillation
2. You've been invited to speak to the Hospital Guild of the hospital where you practice nursing. You've been asked to address "Communicable Diseases of Winter" and are speaking to a large group of volunteer women, most of whom are older than 60 years. What practices should you encourage in these women, who are at the risk of pneumococcal and influenza infections? Select all that apply a) Receiving vaccination b) Using prescribed opioids c) Hand antisepsis d) Technique for incentive spirometry
a) Receiving vaccination c) Hand antisepsis
A client is brought to the ED after aspirating large amounts of water and nearly drowning. This client is at risk for which complication as a result of this recent trauma? acute respiratory distress syndrome (ARDS) empyema pulmonary tuberculosis bronchiectasis
acute respiratory distress syndrome (ARDS)
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is ampicillin. amoxicillin-clavulanic acid. cefprozil. cefuroxime.
amoxicillin-clavulanic acid.
Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require: larger doses of anesthetic agents and larger doses of postoperative analgesics. larger doses of anesthetic agents and lower doses of postoperative analgesics. lower doses of anesthetic agents and lower doses of postoperative analgesics. lower doses of anesthetic agents and larger doses of postoperative analgesics.
arger doses of anesthetic agents and larger doses of postoperative analgesics.
1. During a community health fair, a nurse is teaching a group of seniors about health promotion and infection prevention. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? a) Take all prescribed medications b) Receive vaccinations c) Exercise daily d) Drink six glasses of water daily
b) Receive vaccinations
The nurse is caring for a client who has been admitted to an acute care unit after surgery. When reviewing the client chart, what information will the nurse expect to find in the intraoperative record? performance of incentive spirometry completion of skin preparation vital signs assessment every hour initial assessment by anesthesiologist
completion of skin preparation
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: continuously monitors the sedated client. performs a complete assessment of the client. obtains a surgical consent from the client's mother. assesses how well the client is recovering from anesthesi
continuously monitors the sedated client.
3. A 5-year-old is diagnosed with acute otitis media. Which nursing intervention below would be a primary one? a) Cautioning the child not to pull on the ear b) Administration of a mydriatic c) Cautioning the child not to blow the nose d) Relief of pain
d) Relief of pain
The nurse is preparing a client for a surgical procedure that is scheduled for the next morning. What nursing action(s) is important to limit the risk of intraoperative and postoperative complications? Select all that apply. educating client about postoperative care measuring baseline vital signs shaving the operative area the night before the operation having the client void immediately before surgery maintaining strict NPO (nothing by mouth) status for at least 6 hours checking that all diagnostic tests are completed
educating client about postoperative care measuring baseline vital signs having the client void immediately before surgery checking that all diagnostic tests are completed
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? pH 7.87, PaCO2 38, HCO3 28 pH 7.47, PaCO2 28, HCO3 30 pH 7.49, PaCO2 34, HCO3 25 pH 7.25, PaCO2 48, HCO3 24
pH 7.25, PaCO2 48, HCO3 24
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.
pleural effusion.
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? operative site marking preoperative checklist procedural pause (time-out) informed consent
procedural pause (time-out)
A client is in the post anesthesia care unit following abdominal surgery. The client is showing frank, increased bleeding, and the client's blood pressure is plummeting. Which intervention will the nurse perform to manage and minimize hemorrhage and shock? reinforce dressing and apply pressure elevate the head of bed provide back rub encourage deep breathing
reinforce dressing and apply pressure
Who is legally responsible for obtaining the client's informed consent for a surgical procedure? the surgeon the registered nurse the admissions clerk any licensed person
the surgeon
The nurse recognizes that palliative surgery is performed for what purpose? to remove a part of the body that is diseased to lessen the intensity of an illness to make or confirm a diagnosis to restore function to tissue that is traumatized
to lessen the intensity of an illness
A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. vaccinations hand antisepsis incentive spirometry prescribed opioids
vaccinations hand antisepsis
