142 Exam 1 Review

The nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk? a. history of foot surgery b. Parkinson's disease c. leukemia d. history of a total abdominal hysterectomy

b. Parkinson's disease Risk factor to develop dysphagia.

A nurse is reinforcing teaching provided to a client about postop complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia? a. diarrhea b. aspiration c. pain d. puritis

b. aspiration

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? a. jugular vein distension b. clubbing of the fingers c. heart murmur d. paradoxical breathing

b. clubbing of the fingers This is an expected finding for someone who has a chronic pulmonary disease, such as COPD.

A nurse is caring for a client who has type 1 DM and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? a. Kussmaul respirations b. diaphoresis c. decreased skin turgor d. ketonuria

b. diaphoresis a, c, d indicate hyperglycemia

A nurse is caring for a client who has type 2 DM and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? a. hunger b. increased urination c. cold, clammy skin d. tremors

b. increased urination

A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing? a. type 2 DM b. BMI 28 c. married d. current smoker e. corticosteroid use f. 68 years old

a, d, e, f

A nurse is providing teaching to a client who has type 2 DM about the pathophysiology of the disease. Which of the following statements by the client indicates an understanding of the teaching? a. "my cells are resistant to the effects of insulin" b. "my body breaks down sugars too efficiently" c. "my pancreas does not produce insulin" d. "my body produces antibodies against pancreatic beta cells"

a. "my cells are resistant to the effects of insulin"

A nurse in the ED is assessing a client for closed pneumothorax & significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

a. absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. crackles in the lungs b. edema of the lower extremities c. a rapid, irregular heart rate d. a systolic murmur

a. crackles in the lungs Left-sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs.

A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following pieces of information should the nurse include? a. cut the wiring if emesis occurs b. consume three meals daily as part of a low-protein diet c. swab the mouth with hydrogen peroxide if wiring produces oral irritation d. resume a soft diet in 3-5 days

a. cut the wiring if emesis occurs

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? a. discuss the ways the client can reduce the number of cigarettes smoked per day b. suggest the client switch from smoking cigarettes to smoking a pipe c. inform the client that treatment will be ineffective if smoking continues d. discourage the use of nicotine gum

a. discuss the ways the client can reduce the number of cigarettes smoked per day

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. eat high-calorie foods first b. increase intake of water at mealtimes c. perform active ROM exercises before meals d. keep saltine crackers nearby for snacking

a. eat high-calorie foods first

A nurse is planning care for a client who has type 2 DM. Which of the following interventions should the nurse include in the plan? a. encourage the client to control weight b. inspect the client's feet once each week c. restrict the client's activity d. apply moisturizer between the client's toes

a. encourage the client to control weight

A nurse is checking lab values to determine if a client with DM is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination? a. glycosylated hemoglobin levels b. urine sugar and acetone levels c. glucose tolerance test d. fasting serum glucose

a. glycosylated hemoglobin levels Checking glycosylated hemoglobin levels (HbA1c) is an accurate method of determining if the client is routinely compliant.

A nurse is caring for a client who has a chest tube. Which of the following action should the nurse take? a. monitor the client for subcutaneous emphysema. b. expect continuous bubbling in the water seal chamber. c. keep the drainage system above the level of the client's chest. d. clamp the chest tube tubing when the client ambulates.

a. monitor the client for subcutaneous emphysema. This could indicate a leak or blockage of the system.

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? a. nasal cannula b. nonrebreather mask c. partial rebreather mask d. simple face mask

a. nasal cannula Oxygen via nasal cannula can be delivered at low concentrations of 1 to 4 L/min.

A nurse is providing teaching to a client who has type 1 DM about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? a. shakiness b. urinary frequency c. dry mucous membranes d. excess thirst

a. shakiness A client who has hypoglycemia can experience early manifestations of shakiness, as well as fatigue, a headache, difficulty thinking, sweating, and nausea.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? a. stabbing chest pain b. calf tenderness c. elevated temperature d. bradycardia

a. stabbing chest pain A manifestation of a PE is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? a. sudden onset of dyspnea b. tracheal deviation c. bradycardia d. difficulty swallowing

a. sudden onset of dyspnea

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? a. use pursed-lip breathing during periods of dyspnea b. limit fluid intake to 1,500 mL per day c. practice chest breathing each day d. wear home oxygen to maintain an SaO2 of at least 94%

a. use pursed-lip breathing during periods of dyspnea

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take? a. perform chest percussion therapy six times per day b. listen for a hollow sound when performing chest percussion therapy c. use flat hands to perform chest percussion therapy d. apply chest percussion therapy over the client's ribs

b. listen for a hollow sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions.

A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? a. tachycardia b. murmur c. gallop d. stroke volume

b. murmur

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis d. metabolic acidosis

b. respiratory acidosis This is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale CO2 due to a loss of elastic recoil in the lungs.

A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? a. hypertension b. ringing in the ears c. fever d. dilated pupils

b. ringing in the ears The nurse should identify that ringing in the ears, as well as headache, disorientation, and muscle twitching, can indicate oxygen toxicity.

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia? a. diabetic ketoacidosis b. smoke inhalation c. administration of a stimulant medication d. right-sided heart failure

b. smoke inhalation

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect? a. regurgitation b. stenosis c. muscle atrophy d. hypotension

b. stenosis Stenosis is a narrowing or stiffening of the heart valve that causes backflow of the blood.

A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? a. the volume of air inspired & expired with a regular breath b. the maximum volume of air that is expired after a maximum inspiration c. the amount of additional air that can be inspired after a regular inspiration d. the amount of air in the lung after maximal inspiration

b. the maximum volume of air that is expired after a maximum inspiration.==

A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation? a. "atrial fibrillation is caused by electrical signals that come from the ventricles" b. "atrial fibrillation causes a lower-than-expected heart rate" c. "atrial fibrillation is caused by electrical signals outside of the SA node" d. "atrial fibrillation causes diaphoresis in most clients"

c. "atrial fibrillation is caused by electrical signals outside of the SA node" Atrial fibrillation is caused when electrical impulses start outside of the SA node, causing an irregular heart rate

A nurse is providing teaching to a client who has type 2 DM. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse provide? a. "let's discuss this with your doctor; giving up daily pasta may not be necessary" b. "is there another favorite dish you can substitute?" c. "you don't have to give up pasta; just adjust the amount you eat" d. "you can use no-added-salt tomato products on your pasta"

c. "you don't have to give up pasta; just adjust the amount you eat" The American Diabetes Association recommends individualizing carbohydrate restriction for each client. A careful assessment of the client's usual dietary practices & modifications is an important part of teaching clients to manage this disorder.

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output? a. respiratory rate b. blood pressure c. stroke volume d. vital capacity

c. stroke volume Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the client's heart rate by the client's stroke volume.

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? a. wheezing b. bradypnea c. tachycardia d. diaphoresis

c. tachycardia Tachycardia, dyspnea, restlessness, and increased blood pressure are indications of impending respiratory failure.

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following IV fluids is contraindicated for this client? a. whole blood b. lactated ringer's c. dextran 40 in 0.9% NaCl d. 0.45% NaCl

d. 0.45% NaCl This is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma & body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.

A nurse is caring for a client who has DKA. Which of the following findings should the nurse expect? a. urine negative for ketones b. distended neck veins c. Kussmaul respirations d. elevated BP

c. Kussmaul respirations The nurse should expect this client to experience Kussmaul respirations. These deep & rapid respirations are the body's attempt to exhale carbon dioxide to reverse the metabolic acidosis that occurs with DKA.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? a. provide chest physiotherapy b. perform oropharyngeal suction c. encourage deep breathing and coughing d. assist the client with ambulation

c. encourage deep breathing & coughing The first action the nurse should take when using the ABC approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.

A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? a. decreased WBC count b. increased albumin level c. increased serum lipase level d. decreased blood glucose level

c. increased serum lipase level Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level.

A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active tuberculosis? a. rhinitis b. air hunger c. night sweats d. weight gain

c. night sweats

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following action should the nurse take first? a. auscultate the lung sounds b. document the respiratory rate c. obtain the oxygen saturation d. check the capillary refill

c. obtain the oxygen saturation The greatest risk to this client is injury from hypoxia; therefore, the first action the nurse should take is to obtain the O2 sat, which will assist the nurse in determining the next intervention.

A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? a. proteinuria b. oliguria c. polyuria d. glycosuria

c. polyuria Diabetes insipidus is characterized by increased thirst and increased urination. A client who has diabetes insipidus will excrete large quantities of urine with a very low specific gravity.

The nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication? a. use of probiotics b. prescribed antibiotics c. prescribed anticholinergics d. use of antiseptic skin cleanser

c. prescribed anticholinergics Given to decreased secretions in the upper airway, but they can cause delirium, which poses a risk for a client who has dementia.

A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing? a. general b. local c. regional d. epidural

c. regional Temporary loss of feeling to an area of the body

A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with DKA? a. blood glucose 30 mg/dL b. negative urine ketones c. blood pH 7.38 d. bicarbonate level 12 mEq/L

d. bicarbonate level 12 mEq/L A client who has DKA should have a bicarbonate level that is <15 mEq/L due to the increased production of counter-regulatory hormones that lead to metabolic acidosis.

A nurse is reviewing the laboratory results of a client who has DM. Which of the following results indicates that the client's diabetes is controlled? a. HbA1c 8.5% b. postprandial blood glucose 190 mg/dL c. casual blood glucose 205 mg/dL d. fasting blood glucose 95 mg/dL

d. fasting blood glucose 95 mg/dL This is within the expected reference range of 70 to 110 mg/dL. a. above expected reference is <7% b. above expected range of <160mg/dL c. above reference of <200 mg/dL

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? a. hypernatremia b. hypomagnesemia c. hypercalcemia d. hyperkalemia

d. hyperkalemia

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? a. place the drainage system at the head of the client's bed b. increase the suction to the chest drainage system c. place the client on low-flow oxygen via nasal cannula d. immerse the end of the chest tube in a bottle of sterile water

d. immerse the end of the chest tube in a bottle of sterile water If the chest tube and drainage system have become disconnected, air can enter the pleural space, producing a pneumothorax that can result in severe respiratory distress. To prevent a pneumothorax from developing, a temporary water seal can be established by immersing the end of the chest tube in an open bottle of sterile water. This allows air to escape and not enter the pleural space.

A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? a. nasal cannula b. nonrebreather mask c. partial rebreather mask d. simple face mask

d. simple face mask A simple face mask can deliver oxygen at medium concentrations of 5-8 L/min. a. nasal cannula = 1-4 L/min b. nonrebreather = 10-15 L/min c. partial rebreather = 10-15 L/min

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelctasis? a. lymphatic fluid b. oxygenated blood c. synovial fluid d. surfactant

d. surfactant Surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of surfactant can result in atelectasis.