Adult Health Exam 3 Questions

A nurse is examining the ECG of a client who is having an acute MI. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? (a) Necrosis (b) Hypokalemia (c) Hypomagnesemia (d) Insufficiency

(a) Necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (SATA) (a) Explain that the client will receive sedation and will not remember the procedure. (b) Verify that the client understands the purpose and nature of the procedure. (c) Offer the client sips of clear liquids until 1hr before the test. (d) Obtain a pre-procedural sputum specimen. (e) Instruct the client to keep his neck in a neutral position.

(a), (b) For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it. The client should remain NPO for 4-8hrs prior to the procedure to minimize aspiration risk. The provider can obtain any necessary sputum specimens during the procedure. The client's neck will be hyperextended to bring the pharynx into alignment with the trachea and allow insertion of the scope without trauma.

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (SATA) (a) Oxygen (b) Sterile water (c) Enclosed hemostat clamps (d) Indwelling urinary catheter (e) Occlusive dressing

(a), (b), (c), (e)

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? (a) Increased cardiac output (b) Increased pulmonary congestion (c) Decreased left atrial pressure (d) Decreased pulmonary artery pressure

(b) Increased pulmonary congestion Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, pulmonary artery pressure increases, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.

A nurse is caring for a client who has COPD and is experiencing shortness of breath. Which of the following actions should the nurse perform first? (a) Monitor the client's arterial blood gas results (b) Instruct the client to perform controlled coughing (c) Teach the client how to use pursed-lip breathing (d) Place the client in an upright position

(d) Place the client in an upright position

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? (a) Trauma (b) Severe infection (c) Iron-deficiency anemia (d) Chronic hypoxemia

(d) Chronic hypoxemia

A nurse is caring for a client 2hrs after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? (a) Antibiotic (b) Beta-blocker (c) Antiviral (d) Beta2 agonist

d) Beta2 agonist

A nurse is caring for an older adult client who is having a stroke. After assessing the client's airway, breathing, and circulation, which of the following assessments is the nurse's priority? (a) Level of consciousness (b) Muscle tone (c) Sensory changes (d) Gag reflex

(a) Level of consciousness

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastronomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (SATA) (a) Room temperature (b) New prescriptions (c) Number of visitors (d) ABG result (e) Tracheal secretion characteristics

(b), (d), (e)

A nurse is caring for a client who had a stroke and is at risk for falling. Which of the following actions should the nurse take? (a) Assign the client to a private room (b) Keep 4 side rails up while the client is in bed (c) Monitor the client at least once every hour (d) Request a PRN prescription for restraints

(c) Monitor the client at least once every hour

A nurse is providing instructions about pursed-lip breathing for a client who has COPD with emphysema. This breathing technique accomplishes which of the following? (a) Increases oxygen intake (b) Promotes carbon dioxide elimination (c) Uses the intercostal muscles (d) Strengthens the diaphragm

(c) Uses the intercostal muscles

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (SATA) (a) Speak to the client at a slower rate. (b) Assist the client to use cards with pictures. (c) Speak to the client in a loud voice. (d) Complete sentences that the client cannot finish. (e) Give instructions one step at a time.

(a), (b), (e)

A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include? (a) "Take quick breaths upon inhalation." (b) "Place your hand over your stomach." (c) "Take a deep breath in through your nose." (d) "Puff your cheeks upon exhalation."

(c) "Take a deep breath in through your nose." This controls the client's breathing.

A nurse is caring for a client who has unstable angina. The nurse should anticipate a prescription from the provider for which of the following medications? (a) Epinephrine (b) Nitroglycerin (c) Lidocaine (d) Atropine

(b) Nitroglycerin

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? (a) Hip arthroplasty 2 weeks ago (b) Elevated sedimentation rate (c) Incident of exercise-induced asthma 1 week ago (d) Elevated platelet count

(a) Hip arthroplasty 2 weeks ago The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (SATA) (a) Impulse control (b) Moving the left side (c) Depth perception (d) Speaking (e) Situational awareness

(a), (b), (c), (e) A patient experiencing a right-hemispheric stroke may have altered perception of deficits (overestimation of abilities); unilateral neglect syndrome (ignore left side of the body: cannot see, feel, or move affected side, so client unaware of its existence; can occur with left hemispheric strokes, but is more common with right-hemispheric strokes); loss of depth perception; poor impulse control and judgment; left hemiplegia or hemiparesis; visual changes (hemianopsia).

A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include? (SATA) (a) Use a 10mL syringe to flush the PICC line. (b) Apply gentle force if resistance is met during injection. (c) Cleanse ports with alcohol for 15 seconds prior to use. (d) Maintain a transparent dressing over the insertion site. (e) Flush with 10mL heparin before and after the administration of medications.

(a), (c), (d)

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (SATA) (a) Oxygen equipment (b) Incentive spirometer (c) Pulse oximeter (d) Sterile dressing (e) Suture removal kit

(a), (c), (d) An incentive spirometer is indicated for a client following thoracic surgery to promote improved oxygenation and pulmonary function. A suture removal kit is needed to remove sutures following surgery.

A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) and has been losing weight about ways to improve his nutritional intake. Which of the following statements by the client indicates an understanding of the teaching? (a) "I will choose hot foods to decrease the sense of fullness when eating." (b) "I should add grated cheese to sauces and vegetables." (c) "I will eat my largest meal of the day in the evening." (d) "I should consume a diet that is high in carbohydrates."

(b) "I should add grated cheese to sauces and vegetables." The nurse should reinforce that adding cheese to side dishes will increase the client's protein and calcium intake as well as increase calories, which will help the client regain weight and stamina. Consuming cold foods (not hot foods) will decrease the client's sense of satiety, allowing him to consume more calories. The client should consume his largest meal early in the day, when his energy is highest. This will allow him to consume more calories without causing fatigue. The client should consume a high-protein diet and limit carbohydrates because these break down into carbon dioxide and increase food-related dyspnea.

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates understanding? (a) "This medication can decrease my immune response." (b) "I take this medication to prevent asthma attacks." (c) "I need to take this medication with food." (d) "This medication has a slow onset to treat my symptoms."

(b) "I take this medication to prevent asthma attacks."

A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teaching? (a) "I will increase my fluid intake when I eat a meal." (b) "I will eat more cold foods at meals rather than hot foods." (c) "I will avoid high-fat foods like butter and gravies." (d) "I will cook my meals instead of eating convenience foods."

(b) "I will eat more cold foods at meals rather than hot foods." The client should prepare more cold foods to eat because they provide a decreased feeling of fullness compared to hot foods. Drinking fluids with meals will contribute to early satiety. The client should consume as much food as possible prior to feeling full or tired. The nurse should encourage the client to add items such as butter, sauces, and gravy to foods to increase caloric intake. The nurse should recommend the client eat convenience foods, easy-to-prepare meals, and ready-prepared meals because they take less energy to cook.

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? (a) Hyperventilate the client with 100% oxygen prior to obtaining the specimen (b) Apply ice to the site after obtaining the specimen (c) Perform an Allen's test prior to obtaining the specimen (d) Release the pressure applied to the puncture site 1 minute after the needle is withdrawn

(c) Perform an Allen's test prior to obtaining the specimen

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, headaches, and increased blood pressure are indications of impending respiratory failure. Wheezing indicates asthma, not respiratory failure. Bradypnea is an indication of respiratory depression. Tachypnea is an indication of respiratory failure. Diaphoresis develops as hypoxemia worsens; therefore, it is a manifestation of worsening, not impending, respiratory failure.

A nurse is teaching a client who has chronic stable angina pectoris and a prescription for sublingual nitroglycerin tablets. What sequence of instructions should the nurse tell the client to use if he experiences chest pain? - Stop activity - Call 911 if the pain is not relieved - Wait 5 min - Place a tablet under the tongue

(1) Stop activity (2) Place a tablet under the tongue (3) Wait 5 min (4) Call 911 if the pain is not relieved

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? (a) Cover the insertion site with a hydrocolloid dressing after removal (b) Provide pain medication immediately after removal (c) Instruct the client to perform the Valsalva maneuver during removal (d) Delegate removal of the chest tube to a licensed practical nurse (LPN)

(c) Instruct the client to perform the Valsalva maneuver during removal. The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space. The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space. The nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube.

A nurse is planning care for a client following placement of a chest tube 1hr ago. Which of the following actions should the nurse include in the plan of care? (a) Clamp the chest tube if there is continuous bubbling in the water seal chamber (b) Keep the chest tube drainage system at the level of the right atrium (c) Tape all connections between the chest tube and drainage system (d) Empty the collection chamber and record the amount of drainage every 8hrs

(c) Tape all connections between the tube and drainage system Taping all connections will ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting. The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. The nurse should not empty the collection chamber or change the system unless it is almost full.

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding? (a) "Air should be instilled into the monitoring system prior to the procedure." (b) "The client should be positioned on the left side during the procedure." (c) "The transducer should be level with the second intercostal space after the line is placed." (d) "A chest x-ray is needed to verify placement after the procedure."

(d) "A chest x-ray is needed to verify placement after the procedure."

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? (a) "I will place the adapter on my finger to read my blood oxygen saturation level." (b) "I will lie on my back with my knees bent." (c) "I will rest my hand over my abdomen to create resistance." (d) "I will take in a deep breath and hold it before exhaling."

(d) "I will take in a deep breath and hold it before exhaling."

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? (a) A client who has a chest tube following a pneumothorax (b) A client who has an acute exacerbation of Crohn's disease (c) A client who is postoperative following a laparoscopic appendectomy (d) A client who is recovering from thyroid storm

(a) A client who has a chest tube following a pneumothorax Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider, as this is possibly due to air leakage in subcutaneous tissue).

A charge nurse is teaching a newly licensed nurse about a client who has severe allergy-related asthma and a new prescription for omalizumab. Which of the following pieces of information should the charge nurse include to describe the medication's mechanism of action? (a) It reduces the number of immunoglobulin E (IgE) molecules on mast cells. (b) It stabilizes the cellular membrane of mast cells. (c) It decreases the synthesis and release of inflammatory mediators. (d) It relaxes the smooth muscles by blocking adenosine receptors.

(a) It reduces the number of immunoglobulin E (IgE) molecules on mast cells. This limits the ability of allergens to trigger immune mediators that cause bronchospasm. Stabilizing the cellular membrane of mast cells is the mechanism of action of mast cell stabilizers. Decreasing the synthesis and release of inflammatory mediators is the mechanism of action of glucocorticoids. Relaxing smooth muscle by blocking adenosine receptors is the mechanism of action of methylxanthines.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? (a) Position the client in an upright position, leaning over the bedside table. (b) Explain the procedure. (c) Obtain ABGs. (d) Administer benzocaine spray.

(a) Positioning the client in an upright position, leaning over the bedside table. This widens the intercostal space for the provider to access the pleural fluid. It is the responsibility of the provider, not the nurse, to explain the procedure. It is not indicated that the client needs ABGs drawn. Benzocaine spray is administered for a bronchoscopy, not a thoracentesis.

A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? (a) Present a single idea in a sentence (b) Avoid using nonverbal communication techniques (c) Speak loudly (d) Use simplified language

(a) Present a single idea in a sentence. This will avoid creating frustration for the client and allow the client time to process and respond to the nurse. The nurse should use language that is appropriate for an adult and avoid using childish tones. The inability to speak does not reflect the client's intelligence. Speaking loudly will not assist the client in understanding what is being said. The nurse should use nonverbal techniques such as body language to help convey meaning to the client through gestures, body movements, and touch. This can reinforce verbal communication.

A nurse is caring for a client who has asthma and requires long-term treatment. The nurses should identify that which of the following medications used for long-term treatment places the client at an increased risk for asthma-related death? (a) Salmeterol (b) Fluticasone (c) Budesonide (d) Theophylline

(a) Salmeterol The nurse should identify that salmeterol is a long-acting beta2-agonist. When this medication is used alone for the long-term treatment of asthma, this class of medication increases the client's risk of asthma-related death. To decrease this risk, the client should be prescribed both a long-acting beta2-agonist along with an inhaled corticosteroid.

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 pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? (a) Total lung capacity (b) Vital lung capacity (c) Functional residual capacity (d) Residual volume

(a) Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. Functional residual capacity measures the amount of air in the lungs after normal expiration. Residual volume measures the amount of air in the lungs after forced expiration.

A nurse is caring for an older adult client who is unresponsive following a stroke. Which of the following actions should the nurse take while providing oral care? (a) Turn the client on his side before starting oral care. (b) Use the thumb and index finger to keep the client's mouth open. (c) Cleanse the client's oral mucosa with a toothbrush. (d) Perform oral care using sterile gloves.

(a) Turn the client on his side before starting oral care. This reduces the risk of aspiration of fluids and secretions. The nurse should use a padded tongue blade or an oral airway, not a thumb and index finger to keep the client's mouth open. The nurse should use a moistened foam swab to clean the oral mucosa.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (SATA) (a) Have suction equipment available or use. (b) Feed the client thickened liquids. (c) Place food on the unaffected side of the client's mouth. (d) Assign an assistive personnel to feed the client slowly. (e) Teach the client to swallow with the neck flexed.

(a), (b), (c), (e) Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (SATA) (a) Nausea and vomiting (b) Diaphoresis and dizziness (c) Chest and left arm pain that subsides with rest (d) Anxiety and feelings of doom (e) Bounding pulse and bradypnea

(a), (b), (d) Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI. Tachypnea is an indication of MI due to anxiety and pain.

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (SATA) (a) Encourage the client to cough and deep breathe. (b) Check for continuous bubbling in the suction chamber. (c) Strip the drainage tubing every 4hrs. (d) Clamp the tube once a day. (e) Obtain a chest x-ray.

(a), (b), (e)

A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (SATA) (a) Cholesterol (total) 245mg/dL (b) HDL 90mg/dL (c) LDL 140mg/dL (d) Triglycerides 125mg/dL (e) Troponin I 0.02ng/mg

(a), (c)

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (SATA) (a) Tracheal deviation to the left (b) Temperature of 38.8C (102F) (c) Absent breath sounds on the right side (d) Neck vein distention (e) Bradypnea

(a), (c), (d)

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (SATA) (a) Dyspnea (b) Localized bloody drainage on the dressing (c) Fever (d) Hypotension (e) Report of pain at the puncture site

(a), (c), (d)

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (SATA) (a) A client who has a BMI of 30 (b) A female client who is postmenopausal (c) A client who has a fractured femur (d) A client who is a marathon runner (e) A client who has chronic atrial fibrillation

(a), (c), (e)

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? (a) "I am allergic to morphine." (b) "I take antacids several times a day for my ulcer." (c) "I had a blood clot in my leg several years ago." (d) "It hurts to take a deep breath."

(b) "I take antacids several times a day for my ulcer."

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? (a) Obtain a chest x-ray. (b) Apply sterile gauze to the insertion site. (c) Place tape around the insertion site. (d) Assess respiratory status.

(b) Apply sterile gauze to the insertion site.

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? (a) Sex (b) Environmental allergies (c) Alcohol use (d) History of diabetes

(b) Environmental allergies

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? (a) Tympanic temperature 38C (100.4F) (b) PaO2 50mmHg (c) Rhonchi (d) Hypopnea

(b) PaO2 50mmHg This client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? (a) Teach the client to scan to the right to see objects on the right side of the body. (b) Place the bedside table on the right side of the bed. (c) Orient the client to the food on the plate using the clock method. (d) Place the wheelchair on the client's left side.

(b) Place the bedside table on the right side of the bed. The client is unable to visualize to the let midline o their body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn the head to the left to visualize the entire field of vision.

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 complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? (a) Nonrebreather mask (b) Venturi mask (c) Nasal cannula (d) Simple face mask

(b) Venturi mask A Venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (SATA) (a) Continuous bubbling in the water seal chamber (b) Gentle constant bubbling in the suction control chamber (c) Rise and fall in the level of water in the water seal chamber with inspiration and expiration (d) Exposed sutures without dressing (e) Drainage system upright at chest level

(b), (c) Continuous bubbling in the water seal chamber indicates an air leak. Gentle bubbling in the suction control chamber is an expected finding as air is being removed. A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly. The nurse should cover the sutures at the insertion site with an airtight dressing. The drainage system should be maintained in an upright position below the level of the client's chest.

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7mmHg and a PAWP of 17mmHg. Which of the following findings should the nurse expect? (SATA) (a) Poor skin turgor (b) Bilateral crackles in the lungs (c) Jugular vein distention (d) Dry mucous membranes (e) Hepatomegaly

(b), (c), (e) Expected reference ranges: CVP 2-6mmHg PAS 15-28mmHg PAD 5-16mmHg PAWP 6-15mmHg CO 3-6L/min SVO2 60-80%

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? (SATA) (a) Bradypnea (b) Pleural friction rub (c) Hypertension (d) Petechiae (e) Tachycardia

(b), (d), (e)

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (SATA) (a) Confusion (b) Pale skin (c) Bradycardia (d) Hypotension (e) Elevated blood pressure

(b), (e) Confusion, bradycardia, and hypotension are late manifestations of hypoxemia.

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? (a) "I can keep my dentures in during the procedure." (b) "I am allowed only clear liquids prior to the procedure." (c) "A tissue sample might be obtained during the procedure." (d) "A signed consent form is not required for this procedure."

(c) "A tissue sample might be obtained during the procedure."

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching/ (a) "This medication can increase my blood sugar levels." (b) "This medication can decrease my immune response." (c) "I can have an increase in my heart rate while taking this medication." (d) "I can have mouth sores while taking this medication."

(c) "I can have an increase in my heart rate while taking this medication."

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates understanding? (a) "I will decrease my fluid intake while taking this medication." (b) "I will expect to have black, tarry stools." (c) "I will take my medication with meals." (d) "I will monitor for weight loss while on this medication."

(c) "I will take my medication with meals."

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? (a) "I'll expect a little leg swelling since I won't be that active for a while." (b) "I'll see the doctor every week to change my vena cava filter." (c) "I'll call the doctor if I see any blood in my urine or stool." (d) I'll have to take the blood thinner for a few more days."

(c) "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report signs of bleeding immediately.

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which fo the following responses should the nurse make? (a) "Two tubes were necessary due to excessive bleeding from the area of the surgery." (b) "The tubes drain blood from 2 different lung areas." (c) "The lower tube will drain blood, and the higher tube will remove air." (d) "The second tube will take over if blood clots block the first tube."

(c) "The lower tube will drain blood, and the higher tube will remove air."

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4C (101.2F), and blood pressure 100/54mmHg. Which of the following nursing actions is the priority? (a) Notify the provider. (b) Administer heparin via IV infusion. (c) Administer oxygen therapy. (d) Obtain a CT scan.

(c) Administer oxygen therapy

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? (a) Occipital (b) Temporal (c) Frontal (d) Limbic

(c) Frontal The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts. The occipital lobe is responsible for vision; temporal lobe is responsible for understanding speech; and the limbic lobe is responsible for memory and learning.

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stoke? (a) Impulse control difficulty (b) Poor judgment (c) Inability to recognize familiar objects (d) Loss of depth perception

(c) Inability to recognize familiar objects A patient with left-hemispheric stroke may have expressive and receptive aphasia (inability to speak and understand language); agnosia (unable to recognize familiar objects; alexia (reading difficulty); agraphia (writing difficulty); right extremity hemiplegia (paralysis) or hemiparesis (weakness); slow, cautious behavior; depression, anger, and quick to become frustrated; visual changes (hemianopsia [loss of visual field in one or both eyes]).

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? (a) Place a nonrebreather mask on the client and increase the oxygen flow to 3L/min (b) Prepare the client for possible endotracheal intubation and mechanical ventilation (c) Increase the oxygen flow and request an arterial blood gas determination (d) Position the client supine and administer an antianxiety medication

(c) Increase the oxygen flow and request an arterial blood gas determination The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88-92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (SATA) (a) Use a 5mL syringe to flush the line (b) Cleanse the insertion site with half-strength hydrogen peroxide (c) Flush the line with sterile 0.9% sodium chloride before and after medication administration (d) Access the PICC for blood sampling (e) Perform a heparin flush of the line at least daily when not in use.

(c), (d), (e) The nurse should flush the line with 10mL of sterile 0.9% sodium chloride solution before and after administration of medications (a 5mL syringe generates too much pressure and could rupture the line). The nurse should use chlorhexidine for cleansing the insertion site. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line.

A nurse is teaching a client who is scheduled for coronary angiography. Which of the following statements should the nurse include? (a) "You should have nothing to eat or drink for 4 hours prior to the procedure." (b) "You will be given general anesthesia during the procedure." (c) "You should not have this procedure done if you are allergic to eggs." (d) "You will need to keep your affected leg straight following the procedure."

(d) "You will need to keep your affected leg straight following the procedure." Instruct the client to remain NPO for at least 8hrs prior to the procedure to decrease the risk for aspiration while lying flat during angiography. Instruct the client that they are awake and sedated during the procedure and that a local anesthetic is used at the catheter insertion site. Assess the client for an allergy to iodine/shellfish due to the use of contrast dye. Instruct the client of the need to remain on bed rest in the supine position with the affected leg straight for a prescribed amount of time. This positioning decreases the client's risk for bleeding and hematoma formation at the catheter insertion site.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? (a) A TIA can cause irreversible hemiparesis. (b) A TIA can be the result of cerebral bleeding. (c) A TIA can cause cerebral edema. (d) A TIA can precede an ischemic stroke.

(d) A TIA can precede an ischemic stroke. TIAs are considered manifestations of advanced atherosclerotic disease and often precede an ischemic stroke. TIAs are brief episodes of a neurological deficit that last less than 24hrs after onset without permanent disabilities. Cerebral edema can be the result of a stroke. TIAs do not produce edema of the cerebrum.

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? (a) Blood-tinged sputum (b) Dry, nonproductive cough (c) Sore throat (d) Bronchospasms

(d) Bronchospasms Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? (a) Chest pain is relieved soon after resting. (b) Nitroglycerin relieves chest pain. (c) Physical exertion does not precipitate chest pain. (d) Chest pain lasts for longer than 15min.

(d) Chest pain lasts for longer than 15min. A client who has unstable angina will have chest pain lasting longer than 15min. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? (a) Measuring heart rate (b) Palpating peripheral pulses (c) Observing sputum for blood (d) Confirming the gag reflex

(d) Confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk.

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? (a) Removing air from the pleural space (b) Creating access for irrigating the chest cavity (c) Evacuating secretions from the bronchioles and alveoli (d) Draining blood and fluid from the pleural space

(d) Draining blood and fluid from the pleural space The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space. The upper chest tube removes air from the pleural space.

A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty. Which of the following medications should the nurse anticipate administering to this client to prevent deep vein thrombosis (DVT)? (a) Aspirin (b) Warfarin (c) Ticagrelor (d) Enoxaparin

(d) Enoxaparin The nurse should anticipate the administration of enoxaparin for a client who is 12hrs postoperative following surgery. Enoxaparin is low-molecular-weight (LMW) heparin that is used to prevent a DVT by inhibiting the effects of antithrombin and thrombin.

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

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? (a) Obtain coagulation laboratory studies from the client (b) Apply pneumatic compression boots to the client (c) Request a referral for a speech-language pathologist (d) Keep the client NPO

(d) Keep the client NPO The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed.

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take? (a) Instruct the client to lie prone with arms by the sides. (b) Complete a surgical checklist on the client. (c) Remind the client that there is minimal discomfort during the removal process. (d) Place an occlusive dressing over the site once the tube is removed.

(d) Place an occlusive dressing over the site once the tube is removed.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? (a) Lying flat on the affected side (b) Prone with the arms raised over the head (c) Supine with the head of the bed elevated (d) Sitting while leaning forward over the bedside table

(d) Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air.

A nurse at a provider's office is reviewing information with a client scheduled for pulmonary function tests (PFTs). Which of the following information should the nurse include? (a) "Do not use inhaler medications for 6hrs following the test." (b) "Do not smoke tobacco for 6 to 8hrs prior to the test." (c) "You will be asked to bear down and hold your breath during the test." (d) "The arterial blood glow to your hand will be evaluated as part of the test."

(b) "Do not smoke tobacco for 6 to 8hrs prior to the test."

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 indicator of pulmonary embolism? (a) Sudden onset of dyspnea (b) Tracheal deviation (c) Bradycardia (d) Difficulty swallowing

(a) Sudden onset of dyspnea

A client comes to the ED in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? (a) Tracheostomy placement (b) Thoracentesis (c) CT scan of the chest (d) Chest tube insertion

(d) Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? (a) A client who has heart failure and is receiving 100% oxygen via partial rebreather mask (b) A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula (c) A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar (d) A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

(a) A client who has heart failure and is receiving 100% oxygen via partial rebreather mask The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has HF and is receiving 100% oxygen via partial rebreather mask.

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? (a) Ask the client to empty his bladder before the procedure (b) Place the client leaning forward over the bedside table for the procedure (c) Inform the client he will be sedated during the procedure (d) Instruct the client to fast for 6hrs prior to the procedure

(a) Ask the client to empty his bladder before the procedure The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder. The client should lean forward over the bedside table for the thoracentesis to be performed. This gives the provider complete access to the client's chest and back and expands the spaces between the client's ribs where the pleural fluid as accumulated. The client is fully awake during the procedure; sedation is not required. The client can eat or drink until the procedure; fasting is not required.

A nurse in the ED is caring for a client who is experiencing an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (SATA) (a) SaO2 95% (b) Wheezing (c) Retraction of sternal muscles (d) Pink mucous membranes (e) Tachycardia

(b), (c), (e)

A nurse in the ED is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? (a) Respiratory alkalosis (b) Metabolic alkalosis (c) Respiratory acidosis (d) Metabolic acidosis

(d) Metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCo2 values will deviate in opposite directions. Since PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic. Therefore, the nurse should report to the provider that the client has metabolic acidosis.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? (a) Simple face mask (b) Nonrebreather mask (c) Bag-valve-mask device (d) Nasal cannula

(d) Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.