1175 Exam 2 Ch18,24,27,28

A physician has ordered "Clear liquids, advance as tolerated." Which factors indicate to the nurse the advancement of the clients diet should be delayed?

Hypoactive bowel sounds Nausea and vomiting Reports of indigestion

The nurse is providing discharge teaching to a client with COPD who is being discharged on supplemental oxygen for one use. Which information should the nurse exclude from the client teaching?

Turn up the oxygen flow rate at night to avoid shortness of breath during sleep.

The nurse is preparing to apply a warm pack to a client experiencing back spasms. Which should the nurse do before application?

Asses the skin for edema and color

A client tells the nurse of experiencing rash and hives as food allergy. Which foods would be a likely concern?

Eggs

While caring for a client with pneumonia, the nurse notes that the client is having difficulty expectorating thick, rust-colored sputum. Which nursing intervention is the priority?

Encourage increase fluid intake

The nurse is caring for a client admitted with a diagnosis of bulimia nervosa. Which assessment finding will the nurse expect? Select all that apply.

Evidence of dental caries. Verbal reports of indigestion and nausea. Frequent bouts of sore throat. Poor skin turgor and sunken eyes.

The nurse is providing care for a client with an external fixation frame. Which entry will the nurse document in the clients medical record?

Rod, wires, and ring intact

The RN provides teaching a client with newly diagnosed diabetes mellitus. Which method will the LPN reinforce as the best indicator of long-term glycemic control?

Glycosylated hemoglobin or A1c

The LPN is obtaining a blood glucose level on a client receiving total parenteral nutrition, and notes that the blood glucose level is 220mg/dL. Knowledge of which condition prompts the LPN to report the finding to the RN?

Hyperglycemia

A client is prescribed warm moist heat application four times a day. Which should the nurse apply directly to the skin area?

Warm moist towel

A client who was lost in the woods hiking has a body temperature of 95`F and now is weak and confused. Which treatment should the nurse anticipate providing to improve the clients body temperature?

Warming blanket

The nurse is providing care for client after an above-the-knee amputation one day ago. Which nursing care is most important during the initial postoperative period?

Wrapping the stump with an elastic bandage.

The LPN is reinforcing instructions to a client for the use of an incentive spirometer. Which statement by the client will prompt the LPN to notify the RN that additional teaching Is necessary?

"I blow into the mouthpiece 10 timesavers day just as instructed."

The nurse assessed a client admitted from the emergency department reporting pain in the lower right quadrant of the abdomen with surgery planned within 3 hours. Intravenous fluids are already infusing. The nurse notes there is no diet restriction and plans to call doctor. Which is the most appropriate question?

"Should the client be NPO due to the probability of surgery?"

Match the respiratory diagnostic test or procedure with their purpose. 1. Peak flow 2. ABGs 3. Bronchoscopy 4. Chest physical therapy

1. Measures the amount of air that can exhaled with force; used in people with asthma. 2. Measures the acid-base balance of the blood. 3. Can obtain biopsies and visualize the trachea and bronchi; often done to diagnose cancer 4. Positioning client to drain mucus from lung lobes by using percussion

Match the oxygen devices with the description 1. Nasaal cannula 2. Venturimask 3. Non-rebreathing mask 4. Simple mask

1. Nasal prongs curved inward in the nares, oxygen flow a max of 4L/min. 4. Allows patient to breath through mouth and nose; may feel claustrophobic; set flow rate 5-10 L/min. 3. Set flow meter rate at 15 L/min to deliver 100% oxygen; bag must be inflated. 2. Contains a valve that delivers a specific percentage of oxygen.

A client is prescribed a heating pad to be placed on the lower back. when should the nurse teach the client to remove the heating pad to prevent rebound phenomenon.

25 t0 30 minutes

The nurse is caring for clients on an orthopedic unit. Which client will be he nurses immediate concern after receiving report?

A client with redness and purulent drainage at an external pin site.

The client is experiencing nausea, anorexia, and is vomiting foul-smelling emesis 2 days after surgery. Physical assessment reveals an extended abdomen and hypoactive bowel sounds. Which order does the nurse expect from the clients physician?

A nasogastric tube inserted for gastric decompression

The nurse is caring for a client in the hospital. On assessment, the nurse discovers the clients hand and feet are swollen. A review of the clients past medical history reveals a history of cardiac problems. Which diet does the nurse expect the physician to order for this client?

A sodium-restricted diet

While bathing a client, the nurse finds that the clients previous IV site is tender, and the vein feels hard upon palpation, indicating inflammation. Which should the nurse apple to the site?

A warm moist compress

The nurse Is caring for a client after total hip replacement surgery. The nurse knows it is important that the client not move the affected leg or beyond the midline of the body. Which important piece of equipment for this purpose dose the nurse identify?

Abductor pillow

The nurse is completing the placement of a nasogastric (NG) tube. Which is the most reliable way for the nurse to initially confirm the placement of the tube?

After placement of a radiopaque tube confirm the location of the tube by x-ray

The nurse is caring for a high school football player who is diagnosed with a serious sprain to the ankle that is swollen. Which is the most appropriate action of the nurse?

Apply cold pack to affected area

The nurse is admitting a client for a diagnosis unrelated to nutrition; however, the client states "I don't tolerate foods with gluten." Which meal will the nurse expect the client to order?

Baked chicken breast, mashed potatoes with butter and ice cream

The home-care nurse is visiting a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is routinely cared for by the clients spouse, who states, "it takes forever to do all the morning care." Which suggestion will the nurse make to the spouse?

Decide if some care activities can be done later in the day?

The nurse notes a new order for collection of a sputum specimen for culture from an older adult client. Which is the most appropriate action by the nurse to get the best sample?

Explain the order to the client and plan sputum can be more readily collected.

The nurse knows the tracheostomy tube

Is necessary for long-term airway and ventilation support.

The nurse is preparing a client for a diagnostic procedure on an injured shoulder. The client reports extreme pain with shoulder movement. The clients medical history indicates no significant health issues and no previous surgeries. Which diagnostic testing will the nurse anticipate?

Magnetic resonance imaging (MRI)

A client is prescribed site baths after hemorrhoid surgery. The client reports feeling light-headed, with this information, what should the nurse do before providing the client with this bath?

Measure orthostatic blood pressure

The nurse I scaring for a client with a chest drainage system. The nurse knows the water-seal chamber is monitored for healing of the pleural leak within the chest The nurse will monitor for which change?

Observe for decreased in bubbling.

The nurse is caring for a client recently admitted to the unit after a right knee replacement. Which assessment finding is most concerning to the nurse?

Pedal pulses on the operative foot are weak compared to the non-operative side.

The nurse is caring for a client admitted after a cast placement for a comminuted fracture of the lower leg. Which nursing intervention is most important for the nurse to perform?

Perform neurovasular checks every 2 hours for the first 24 hours.

The nurse assesses the skin of a client receiving a heat pack and decides to remove the pack. What skin color did the nurse assess to make this clinical determination?

Red

When the nurse inserts a nasogastric (NG) tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. Which action should the nurse take immediately?

Remove the tube completely

The nurse is providing care for a client skeletal traction of the femur following a skiing accident. Which action is contraindicated when caring for this client?

Remove weights when turning the client and then replace.

The nurse removes an ice pack that was placed on the clients skin 10 min ago. For which reason did the nurse remove the pack?

Skin was mottled

The RN is observing a LPN perform open tracheostomy suctioning. The RN would stop the LPN if which behavior is observed?

The LPN suctions the clients mouth and then the tracheostomy with he same catheter

The nurse enters the room of a client who is taking a nebulizer treatment set up by the respiratory therapist. Which observation by the nurse would be cause for intervening with the treatment?

The client is breathing in and out through the nose

The nurse is inserting a nasogastric (NG) tube. Which conclusion does the nurse make if a client coughs continually?

The clients airway is compromised

A client is connected to a chest tube drainage system. The physician has ordered chest drainage system to be set at - 18cm suction. Which chamber is the order related to?

The suction control chamber

The nurse is caring for a client with mild left-sided weakness who is using a walker for the first time. Which assessments indicate to the nurse that the client is using the walker correctly? Select all that apply.

The walker is the height of the clients hip joint. The hand brakes are set before the clients sit in the seat if provided. The client moves the affected leg forward with the walker.

Which assessment activities should the nurse include when performing a focused respiratory assessment on a client admitted with a diagnosis of bilateral pneumonia? Select all that apply.

Use of accessory muscles. Skin color. Respiratory rate. Cough.

The LPN approaches and asks the RN to check and make sure the continuous passive motion (CPM) machine is set up correctly before it is turned on. Which assessment by the RN is most important?

Verify the knee joint is properly positioned in the CPM.