Unit 4 *****

A nurse is teaching a client with osteoporosis about dietary selections. What client statement indicates the teaching was effective?

"I will eat more dairy products to increase my calcium intake."

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen"

A child has an order for an erythrocyte sedimentation rate (ESR). The child's mother asks what the purpose of the test is. What is the best response by the nurse?

"This test will tell if your child has an infection or inflammation somewhere in their body."

The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient?

A barrel chest

The nurse is teaching a group of adult clients about health promotion. What should the nurse recommend in order to minimize the clients' risk for COPD?

Avoid smoking

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.)

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 client's most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend?

Bananas

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?

Increased serum creatinine level

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive?

Influenza

A client is experiencing an increase in blood glucose levels. The nurse understands that which of the following hormones would be important in lowering the client's blood glucose level?

Insulin

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining a patent airway

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?

Raise the head of the bed

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?

Remove all metal necklaces

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breathe deeply and cough

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

A nurse is caring for a pregnant client with asthma. Which intervention will the nurse perform?

assess oxygen saturation

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in?

high Fowler's position

A nurse is caring for an 80-year-old client with pneumonia. What would be most appropriate for the nurse to assess this client for?

impaired gas exchange

In what age group would a nurse expect to assess the most rapid respiratory rate?

infants

Which of the following diagnostic findings is indicative of a protein deficiency in adults?

low serum albumin.

An older adult client with heart failure and 2+ pitting edema is prescribed furosemide. Due to the effects of furosemide, which additional medication should the nurse recommend to the client to supplement when taking furosemide?

potassium

The nurse administers a loop diuretic to the client. In addition to sodium and water, what other electrolyte would the nurse expect to be excreted in significant amounts?

potassium

The nurse would assess respirations in a 9-month-old infant when the client is:

quiet in the parent's lap.

A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

shake the inhaler for 3 to 5 seconds

Which laboratory test result would be most important for the nurse to assess in a child who is suspected of having a urinary tract infection?

urinalysis

A client is admitted to a skilled health facility after total hip replacement. The client asks if the nurse would explain the types of cells that circulate in the blood. The nurse would include which information?

"There are three distinct cells that circulate in the blood: red blood cells, white blood cells, and platelets."

A client who utilizes a portable oxygen device reports planning to attend an upcoming bonfire on the beach. What is the appropriate nursing response?

"When using portable oxygen, you should avoid any fire."

A nurse is caring for a 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?

28%

The nurse knows which is the normal serum value for potassium?

3.5-5.0 mEq/L (3.5-5.0 mmol/L).

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk of aspiration?

A client receiving continuous enteral feeding through NG tube

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.)

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

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation?

Clubbing of the fingers

The nurse's review of a client's laboratory results indicates that inflammation is absent and platelet levels are low. Which test was performed to provide the platelet count?

Complete blood count

Which of the following urine characteristics would the nurse anticipate when caring for a client whose lab work reveals a high urine specific gravity related to dehydration?

Dark amber urine

The nurse should anticipate that a client who collapsed while running his or her first marathon and has a urine specific gravity of 1.035 is experiencing:

Dehydration

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to a client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which or the following locations?

Earlobe

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

Elevated erythrocyte sedimentation rate

The nurse is caring for a client with suspected dehydration. Which results does the nurse recognize will help confirm this diagnosis?

Elevated urine specific gravity

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake.

A nurse diabetes educator is planning an initial visit to a home care client who was recently diagnosed with diabetes mellitus. Which skills would the nurse help the client learn?

For most patients, the goal of diabetes education is self-care in terms of diet, exercise, medication administration, and blood glucose monitoring, as well as prevention, recognition, and treatment of complications. The nurse plays a significant role in patient education and training.

A nurse is assessing a client who displays pale skin and nail beds. Which laboratory data should the nurse evaluate?

Hemoglobin level

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality?

Hyperkalemia

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?

Hypokalemia

A client is admitted with an alteration in arterial blood gases. Cellular injury is most likely to result from which aspect of this abnormality?

Hypoxia

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?

Perform the Heimlich maneuver.

The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan?

Performing chest physiotherapy as ordered

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported.

Potassium of 2.8 mEq/L

The health care provider needs to assess a client for protein-calorie malnutrition. The best diagnostic measure would be:

Prealbumin

The nurse is caring for a very ill client. When evaluating this client's protein status, the nurse should look at which lab/diagnostic test results?

Prealbumin and albumin

A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care?

Setting realistic short- and long-term goals

A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position?

Sitting upright, leaning forward slightly

The effective circulating volume is the major regulator of water balance in the body. What else does it regulate?

Sodium

A nurse is assessing a client who has hypoxia. which of the following findings should the nurse expect?

Tachycardia

A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?

The client is not making any sounds

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?

The spacer increases the amount of medication delivered to the lungs

A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which is the following techniques should the nurse use?

Vibration

A high school teenager comes to the emergency room with symptoms that include the abrupt onset of severe pharyngitis and a high fever. The teenager reports that in the previous 4 days he has "just not felt well." The nurse anticipates orders to include which of the following?

White blood cell count

A 2-year-old child arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. What is the priority nursing intervention?

assessing respirations and administering oxygen

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

atelectasis

The nurse is caring for a child admitted with suspected leukemia. The nurse has taken the child's history and performed an assessment. The nurse will plan to prepare the child for which additional diagnostic test first?

complete blood cell count (CBC)

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?

conjunctivae