ADN 240 Exam 3

a 4-year-old with bronchiolitis has been admitted to the hospital with respiratory compromise. The father asks the nurse why the physician won't prescribe an antibiotic, "My child just keeps getting worse." what is the best response by the nurse.

"bronchiolitis is almost always caused by the respiratory syncytial virus (RSV). Unfortunately antibiotics don't work on viruses."

digoxin toxicity

-visual disturbances -CNS abnormalities -cardiovascular abnormalities

a client has been admitted to the hospital with a diagnosis of preeclampsia with severe features. which nursing intervention is the priority

confine the client to bed rest in a darkened room

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

a group of students is reviewing information about bone healing in children. the students demonstrate understanding of this information when they state...

a child's bones heal more quickly than those of an adult

the nurse is teaching the parents about medications for their 9-year-old boy who has a respiratory disorder. The nurse would be alert for an increased need for medications if the child was exposed to second-hand smoke and has which condition?

asthma

to help prevent osteoporosis, what should a nurse advise a young woman to do?

consume at least 1,000 mg of calcium daily

a woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. which finding would alert the nurse to the development of magnesium toxicity in this client?

diminished reflexed

which of the following is an important assessment parameter for the patient diagnosed with congestive heart failure

distended veins

a nurse is caring for a client with left-sided heart failure. to reduce fluid volume excess, the nurse should anticipate using

diuretics

a nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. where should the nurse expect to note edema in this child?

lower extremities

a client is hospitalized for treatment of hypertension is being prepared for discharge. which teaching topic should the nurse be sure to cover?

maintaining a low-sodium diet

which of the following terms refers to the failure of fragments of a fractured bone to heal togther?

nonunion

what is the number 1 treatment for hypoxemia

oxygen

this nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. in light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment

"Lately, I have this cough that just never seems to go away"

The nurse is working with a group of caregivers of children diagnosed with asthma. Which statement made by a caregiver is most accurate regarding the triggers that may cause an asthma attack?

"my sister and her family loves animals, and when we go to their house my daughter always has an asthma attack

a male patient newly diagnosed with COPD tells the nurse, "I can't believe I have COPD, I only had a cough; are there other symptoms I should know about?" which of the following is the nurse's best response

"other symptoms you may develop are shortness of breath on exertion, and sputum production"

the experienced licensed practical/vocational nurse under the supervision of the registered nurse team leader is providing nursing care for an infant with respiratory syncytial virus. which tasks are appropriate for the RN to delegate to the LPN/VN?

-administer prescribed aerosolized medications -auscultate breath sounds -check oxygen saturation using the pulse oximetry

the nursing student recalls that the underlying pathophysiology of chronic obstructive pulmonary disease (COPD) includes the following components

-inflamed airways obstruct airflow -mucus secretions block airways -overinflated alveoli impair gas exchange

the nurse is assessing the heart rate of a health 6-month-old. in which range should the nurse expect the infant's heart rate?

90-160 bpm

Key diagnostic indicator of heart failure

BNP

the nurse is caring for a patient at risk for atelectasis. the nurse implements a first-line measures to prevent atelectasis development in the patient. what is an example of a first-line measure minimize atelectasis?

Incentive spirometry

a nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the patient's oxygen saturation

a nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD?

Respiratory failure

the nurse is caring for a child with a fractured femur in traction. which action will the nurse complete while caring for this client?

ensure traction weights are hanging freely, not touching the bed or floor

what instruction should the nurse's discharge teaching plan for the client with heart failure

obtaining daily weights at the same time each day

the caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. their friends child has often been hospitalized for asthma; they are concerned that hteir child has a similar illness. the nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with...

a bronchodilator and mast cell stabilizers

which of the following would be LEAST likely to contribute to a case of hospital-acquired pneumonia?

a nurse washes her hands before beginning patient care

a nurse is managing the care of a client with osteoarthritis. appropriate treatment strategies for osteoarthritis include

administration of NSAIDS and initiation of an exercise program

which ethnic group is more likely to develop severe hypertension

african

a physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. The nurse knows this would probably be

albuterol

a nurse is apply a cast to a 12-year-old boy with a simple fracture of the radius in the arm. what is most important for the nurse to do when she has finished applying the cast

assess the fingers for warmth, pain and function

which of the following is the most common chronic disease of childhood?

asthma

a woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical?

blood pressure evaluation

a nurse is caring for an elderly female client with osteoporosis. when teaching the client, the nurse should include information about which major complication

bone fracture

in a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. which of the following complications do the assessments help the nurse to monitor in the patient?

compartment syndrome

which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg?

complaints of numbness and tingling in toes of affected leg

symptoms of asthma

dry hacking cough wheezing difficulty breathing

the client with a fractured left humerus reports dyspnea and chest pain. pulse oximetry is 88%. temp is 100.2 degrees. heart rate is 110. rr is 32 breaths per minute. the nurse suspects the client is experiencing

fat embolism syndrome

Strategies to prevent atelectasis (first-line)

frequent turning early ambulation lung-volume expansion maneuvers coughing

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets

which of the following measures may increase complications for a patient with COPD?

increased oxygen supply

in caring or the child with asthma, the nurse recognizes that which nursing diagnosis would be the highest priority in this child's plan of care?

ineffective airway clearance related to the diagnosis

the plan of care for a client with hypertension taking propranolol hydrochloride should include:

instructing the client to notify the health care provider of irregular or slowed pulse rate

the nurse identifies which of the following symptoms as a characteristic of right-sided heart failure?

jugular vein distention

Second-line to prevent atelectasis

positive end-expiratory pressure (PEEP) continuous or intermittent positive-pressure breathing (IPPB) Bronchoscopy

during a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 with mild facial edema. the nurse recognizes that the client has which condition?

preeclampsia without severe feature

the nurse is caring for a child with a broken wrist that has just been placed in a cast. the nurse would elevate the arm to:

prevent edema

the nurse enters the room of a client who has pneumonia. the client has a low oxygen level and is working hard to breathe. the nurse raises the head of the bed and has the client tilt her head back. What is the next appropriate action by the nurse?

provide oxygen therapy to the client

a client is receiving NSAIDS to manage the pain of rheumatoid arthritis. what information should the nurse give to the client about taking these medications?

take NSAIDS with food

a student nurse is developing a teaching plan for an adult patient with asthma. which teaching point should have the highest priority in the plan of care that the student is developing?

take prescribed medications as scheduled

health promotion activities to reduce the incidence of osteoporosis include:

teaching women to maintain adequate calcium intake

a school nurse finds a 10-year-old's blood pressure is over the 95th percentile. the nurse advises the parent to seek medical attention for the child. what outcome would the nurse expect?

the child will need the blood pressure checked two more times

which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized

the client's skin is intact with non-blanchable redness of a localized area over a bony prominence

the nurse is caring for a child admitted with asthma. which clinical manifestations would likely have been noted in the child with this diagnosis

wheezing

the nurse is preparing to administer digoxin to a client with heart failure. the nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. what is the first action by the nurse

withhold the medication and notify the provider

the nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. the nurse tells the client to...

purse the lips when exhaling air from the lungs

During a community health fair, 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

receive vaccinations

which of the following is the strongest predisposing factor for asthma?

allergy

the nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70, heart rate 115, temperature 101, and oxygen saturation 86%. which diagnostic test is priority for the nurse ot complete?

arterial blood gas (ABG)

what statement is the most accurate regarding the structure and function of the newborn's respiratory system?

most infants are nasal breathers rather than mouth breathers

when the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating

orthopnea

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

when developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated?

smoking cessation

a client is being sent home with oxygen therapy. the nurse instructs that...

smoking or a flame is dangerous near oxygen

the nurse is caring for a client with heart failure. what procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump

echocardiogram

the nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle ton, or fixation of joints. which nursing interdisciplinary interventions recommended to help precent these adverse conditions

encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion

which of the following are general nursing measures for a patient with a fracture reduction

encourage participation in ADL's

the nurse is evaluation the client's risk for having a pressure sore. which s the best indicator of risk for the client's developing a pressure sore?

mobility status

the nurse is caring for a child who has been admitted with a diagnosis of asthma. what laboratory/diagnostic tool would likely have been used for this child?

pulmonary function test

a client has been diagnosed with heart failure. one of the main overall objectives of management of heart failure is which of the following

reduce the workload of the heart

the client has had hypertension for 20 years. the nurse should assess the client for...

renal insufficiency and failure

a nurse is giving instructions to a client who's going home with a cast on his leg. which teaching point is most critical

reporting signs of impaired circulation

which action would be most helpful in preventing pressure ulcer formation in an at-risk client

repositioning every hour

which nursing diagnosis is most appropriate for an elderly client with osteoarthritis

risk for injury related to altered mobility

a child with heart disease is receiving digoxin and a diuretic. which laboratory test result would be most important for the nurse to monitor?

serum potassium level