Adult Health I Exam 1 Practice Questions

A nurse is preparing to administer potassium chloride elixir 40mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEg/5ml. How many mL should the nurse administer per dose? (If needed round to the answer to the nearest whole number.) ______mL

15 mL 40/2 = 20 20/6.7 = 2.98 = 3 3 x 5 = 15

A nurse is caring for a client with a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneous every 12 hr. The client weighs 245 lbs. How many mg should the nurse administer per dose? (if needed, round to the nearest whole number) ______mg

167 Convert lbs to kg: 245 lb = 111.4 kg Calculate Dose: STEP 1: What is the unit of measurement to calculate? mg STEP 2: Set up the equation and solve for X. mg x kg/dose = X 1.5 mg x 111.4 kg = 167.1 mg STEP 3: Round, if necessary. 167.1 mg = 167 mg STEP 4: Reassess to determine whether the amount to administer makes sense. If the provider prescribed 1.5 mg/kg/dose and the client weighs 111.4 kg, it makes sense to administer 167.1 mg per dose. The nurse should administer enoxaparin subcutaneous 167 mg every 12 hr.

A nurse is caring for a client and identifies an infiltration at the IV caterer site. Identify the order the nurse should perform the following actions. 1. Apply a sterile dressing 2. Stop the infusion 3. Elevate the extremity 4. Remove the IV Catheter 5. Apply warm or cold compresses

2, 4, 1, 3, 5 2. Stop the infusion 4. Remove the IV Catheter 1. Apply a sterile dressing 3. Elevate the extremity 5. Apply warm or cold compresses

A nurse is preparing to administer albuterol syrup 1.6 mg P.O tid. Available is albuterol 2mg/5ml. How many mL should the nurse administer per dose? _____mL

4 mL

A nurse is teaching a client who has asthma how to use a metered dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Move the steps into the box on the right placing them in the selected order of performance. Use all steps). 1. Place her lips firmly around the mouthpiece 2. Breathe in deeply over 2 to 3 seconds while pushing down on the canister 3. Hold her breath for 10 seconds 4. Wait 60 seconds between each puff 5. Exhale slowly through pursed lips 6. Inhale deeply and then exhale completely

6, 1, 2, 3, 5, 4 CORRECT ORDER: 1. Inhale deeply and then exhale completely 2. Place her lips firmly around the mouthpiece 3. Breathe in deeply over 2 to 3 seconds while pushing down on the canister 4. Hold her breath for 10 seconds 5. Exhale slowly through pursed lips 6. Wait 60 seconds between each puff

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100mL ice chips, an IV bolus of 150 ml, and 8 oz of broth. The nurse should record how many mL of intake on the client's record? ______mL

740

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

A, B, C, E, F a. Age b. Blood pressure c. Respiratory rate e. Presence of confusion f. Blood urea nitrogen (BUN) level Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess but are not used for CURB-65 scoring.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following finding indicates fluid volume excess? Select all that apply. A. bounding pulse B. pitting edema C. swelling at the IV site D. Urine specific gravity greater than 1.030 E. crackles upon auscultation

A, B, E A. bounding pulse B. pitting edema E.crackles upon auscultation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply. A. Increased blood pressure B. Increased temperature C. Increased heart rate D. Increased respiratory rate E. Increased hematocrit

A, C, D A. Increased blood pressure C. Increased heart rate D. Increased respiratory rate

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitoring to prevent fluid volume overload? (Select all that apply) A. Jugular vein distention B. Gastrointestinal bloating C. Dyspnea D. Confusion E. Hypotension

A, C, D A. Jugular vein distention C. Dyspnea D. Confusion

A college health nurse interprets the peak expiratory flow rate for a student with asthma and finds that the student is in the yellow zone of the asthma action plan. The nurse should base her actions on which of the following information? ( Select all that apply) A. The student's asthma is not well controlled B. The nurse should obtain a second expiratory flow rate C. They should use his quick relief inhaler D. The student's peak flow is 50% to 80% of his best peak flow E. The student needs to go to the hospital

A, C, D A. The student's asthma is not well controlled C. They should use his quick relief inhaler D. The student's peak flow is 50% to 80% of his best peak flow

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply) A. Rifampin B. Acyclovir C. Pyrazinamide D. Isoniazid E. Montelukast

A, C, D A. Rifampin C. Pyrazinamide D. Isoniazid A client who has tuberculosis should take rifampin to kill slower growing micro-organisms. The nurse should instruct the client to avoid drinking alcohol, to expect body secretions to have a reddish-orange tinge, and to report a yellow tinge to the skin or whites of the eyes.A client who has tuberculosis should take isoniazid to kill actively growing mycobacteria. The nurse should instruct the client to take the medication on an empty stomach and to take a daily multiple vitamin.A client who has tuberculosis usually takes pyrazinamide for the first 12 months of therapy and can shorten the entire course of therapy to 6 months. The nurse should instruct the client to drink at least 240 mL (8 oz) of fluid when taking the medication and to protect himself from the sun with cotton clothing and sunscreen.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Agitation B. Dysphagia C. Nausea D. Hypotension

A. Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse is assessing a client 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Arterial thrombus D. Pulmonary embolism

A. Atelectasis Rationale: Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse in the emergency department is assessing an older adult client with community acquired pneumonia. Which of the following findings should the nurse expect? A. Confusion B. Hypertension C. Unequal pupils D. Tympany upon chest percussion

A. Confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Ibuprofen 400 mg every 6 hours c. Lantus insulin 24 U every evening d. Metoprolol (Lopressor) 12.5 mg/day

A. Digoxin (Lanoxin) 0.25 mg/day Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias.The nurse will need to do more assessment about the other medications, but they are not of as much concern with the potassium level.

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for the condition? A. Hypoxemia B. Apnea C. Pleural effusion D. Dysphagia

A. Hypoxemia

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? A. Lethargy B. Hyperactive bowel sounds C. Hyperactive deep tendon reflexes D. Prolonged ST segment

A. Lethargy A serium calcium of 12.3 mg/dL is above the expected range. The nurse should monitor the client for lethargy, generalized weakeness and confusion.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? A. Place the client on his left side in Trendelenburg position B. Prepare for chest tube insertion C. Remove the catheter D. Replace the infusion system

A. Place the client on his left side in Trendelenburg position

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A. auscultate lung fields B. assess pulse and respirations C. assess characteristics of her sputum D. instruct to slowly exhale with pursed lips

A. auscultate lung fields

A nurse in a health care provider's office is assessing a client. The nurse should identify that which of the following findings are manifestation of pulmonary tuberculosis? (Select all that apply) A. Flushed cheeks B. Night sweats C. Blood in the sputum D. Weight gain E. Low-grade fever

B, C, E B. Night sweats C. Blood in the sputum E. Low-grade fever

A Nurse is assessing a client that reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply) A. Flat neck veins B. Hypotension C. Pale yellow urine D. Poor skin turgor E. Bradycardia

B, D B. Hypotension D. Poor skin turgor

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. " I will avoid getting a flu shot" B. " I will follow a daily diet high in calories and protein . C. " I will inhale slowly through pursed lips to help me breathe better" D. " I will lie on my stomach to practice abdominal breathing every day"

B. " I will follow a daily diet high in calories and protein .

A nurse is providing education to a patient who has a new diagnosis of asthma. Which of the following statement should the nurse include in the teaching? A. " Take cough medication at the first sigh of breathing difficulty" B. "Avoid triggers that cause an attack" C. " Use the peak expiratory flow meter once per week " D. " You should stop playing basketball , but you asn swim?

B. "Avoid triggers that cause an attack"

A nurse is caring for an older adult client admitted to the medical surgical unit. Which nursing action is most effective in preventing hospital acquired pneumonia? A. Encourage client to drink through a straw to prevent aspiration B. Assist client to cough, turn, and deep breathe every 2 hours C. Monitor oxygen saturation, and frequently assess lung bases. D. Discontinue humidification delivery device to keep excess fluid from lungs.

B. Assist client to cough, turn, and deep breathe every 2 hours

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D. Clubbing of the fingers Rationale: The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.

A nurse is asking to interpret an arterial blood gas (ABG) and report the interpretation to the healthcare provider of a client recently admitted to the intensive care unit ( ICU ) . Using the results below, which ABG interpretation should the nurse report to the healthcare provider? pH 7.52 PaCo2 47 mm Hg Bicarbonate 36 mEq/L A. Normal ABG results B. Metabolic alkalosis with respiratory compensation C. Respiratory Acidosis D. Respiratory alkalosis with respiratory compensation

B. Metabolic alkalosis with respiratory compensation The pH is alkalotic. Although both PaCO2 and bicarbonate have changed, the bicarbonate matches the pH. The elevated PaCO2 represents the efforts of the respiratory system to compensate for the alkalosis by retaining carbon dioxide.

A nurse is assessing a client with a sodium level of 116mEq/L. Which of the following findings should the nurse expect? A. Flushed skin B. Nausea and vomiting C. Fever D. Extreme thirst

B. Nausea and vomiting

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-base imbalances should the nurse identify the client as being at risk for developing initially? A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

B. Respiratory acidosis

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? A. Place the client in a room with negative airflow. B. Wear a mask when providing care to the client. C. Ensure the client's room has HEPA filtration. D. Wear a gown when providing care to the client.

B. Wear a mask when providing care to the client. Rationale: The nurse should wear a mask when within 3 feet of a client who requires droplet precautions.

A nursing is reviewing the arterial blood gas (ABG) results of a client with suspected metabolic acidosis. Which of the following results should the nurse expect to see? A. HCO3 above 26 mEq/L B. pH below 7.35 C. PaCO2 above 45 mm Hg D. PaO2 below 70 mm Hg

B. pH below 7.35 With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply ) A. Bradycardia B. Deep respirations C. Dyspnea D. Barrel chest E. Clubbing of the fingers

C, D, E C. Dyspnea D. Barrel chest E. Clubbing of the fingers Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow.

The nurse is caring for a postoperative client who has a chest tube connected to a suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? A. Absence of fluid in the drainage tubing B. Equal amounts of fluid drainage in each collection chamber C. Continuous bubbling within the water seal chamber D. Fluctuation of the fluid level within the water seal chamber

C. Continuous bubbling within the water seal chamber Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily near the site of the chest tube insertion

A nurse is caring for a patient with a magnesium level of 3.0 mEq/L. Which of the following are expected findings related to this electrolyte imbalance? A. Sticky mucous membranes B. Bone pain C. Decreased deep tendon reflexes D. Peaked T waves

C. Decreased deep tendon reflexes

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently. B. Encourage coughing and deep breathing. C. Encourage the client to increase fluid intake. D. Encourage regular use of the incentive spirometer.

C. Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Discomfort at the puncture site B. Serosanguineous drainage from the puncture site C. Increase heart rate D. Decreased temperature

C. Increase heart rate clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the X-ray Department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times D. Empty the collection chamber prior to transport

C. Keep the drainage system below the level of the client's chest at all times

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. Notify the provider who inserted the PICC line B. Remove the PICC line C. Measure the circumference of both upper arms D. Apply a cold pack to the client's upper arm

C. Measure the circumference of both upper arms The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Hyperventilate the client 100% oxygen prior to suctioning B. Lubricate the suction catheter to with sterile saline C. Suction two to three times with a 60-second pause between passes D. Perform chest physiotherapy prior to suctioning

C. Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60seconds should be allowed between passes to prevent hypoxia.

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? A. The client exhales as the medication are released from the inhaler B. The client waits 10 mins between inhalations C. The client holds his breath for 10 seconds after inhaling the medication D. The client takes a quick inhalation while releasing the medication from the inhaler

C. The client holds his breath for 10 seconds after inhaling the medication. Rationale: The medication should be retained in the lungs for a minimum of 10 seconds so the maximumamount of the dosage can be delivered properly to the airways. To use the inhaler, the clientexhales normally just prior to releasing the medication, inhales deeply as the medication isreleased, then holds the medication in the lungs for approximately 10 seconds prior to exhaling

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A. Hematocrit 44% B. Sodium 120 mEq/L C. Urine specific gravity 1.035 D. Bun 19 mg/dL

C. Urine specific gravity 1.035

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sound? A. Rhonchi B. Crackles C. Wheezes D. Stridor

C. Wheezes Rationale: Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

A nursing is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? A. Irrigate the client's throat every 4 hr B. Have the client refrain from talking for 24 hr C. Withhold food and liquids until the client's gag reflex returns D. Suction the client's oropharynx frequently

C. Withhold food and liquids until the client's gag reflex returns Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Sodium level B. Intake and output C. Tissue turgor D. Daily weight

D. Daily weight

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot , but I can't see to bring anything up." Which of the following actions should the nurse tale to help this client with tenacious bronchial secretions? A. Helping the client select a low-salt diet B. Maintaining a semi-Fowler's position as often as possible C. Administering oxygen via nasal cannula at 2 L/min D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration

A nurse in instructing a group of clients regarding nutrition. Which of the following is a good source of omega- 3 fatty acids that the nurse should include in the teaching? A. Corn oil B. Leafy green vegetables C. Dietary supplements D. Fish

D. Fish

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? A. Increased urine ketones B. Decreased Hgb C. Decreased urine specific gravity D. Increase BUN

D. Increase BUN

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nursing expect? A. Bradypnea B. Lethargy C. Bradycardia D. Intercostal retractions

D. Intercostal retractions

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. Darbepoetin alfa B. Sevelamer C. Lactulose D. Kayexalate

D. Kayexalate (AKA Sodium Polystyrene) (Normal potassium levels are 3.6-5.2)

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D. Tachycardia Rationale: The nurse should expect the client who has hypoxia to manifest tachycardia.

A nurse is assessing a client with end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? A. Return of skin to previous position when the client's shin is palpated B. Flattened neck veins C. Oxygen saturation 93% D. The client has a 5 lbs weight gain since yesterday

D. The client has a 5 lb weight gain since yesterday. The nurse should identify that a gain of 2 lb per day is stable. A gain of more than 2 lb per day or 5 lb per week is an indication of fluid overload.

A nurse is caring for a client with a single lumen central venous catheter. Which of the following actions should the nurse take when assessing the catheter? A. Apply firm pressure to the syringe plunger when flushing the lumen B. Use clean technique when assessing the catheter C. Flush the lumen with sterile water after each use D. Use a 10mL syringe to flush the catheter

D. Use a 10mL syringe to flush the catheter

A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use? A. Postural drainage B. Nebulization C. Percussion D. Vibration

D. Vibration Rationale: Vibration after percussion, or alternately with percussion, increases the velocity and turbulence of the air the client exhales, while loosening secretions and triggering coughing.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. initiating oxygen therapy B. providing immediate rest for the client C. positioning the client in high-Fowler's D. administering a nebulized beta-adrenergic

D. administering a nebulized beta-adrenergic

A nurse is assessing a client with a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was. A. Weight loss B. Dysphagia C. Dyspnea D. hoarseness

D. hoarseness

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

a. Auscultate for breath sounds. The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin with minerals d. Over-the-counter (OTC) laxative

a. Daily alcohol intake Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultatio

a. Increased tactile fremitus Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suctionfor 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribedtherapy should the nurse question? a. Infuse 5% dextrose in water intravenously at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. d. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.

a. Infuse 5% dextrose in water intravenously at 125 mL/hr. Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate.

a. Listen to the patient's breath sounds. Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

a. Lung sounds Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

a. Monitor ionized calcium level. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

he emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. O2 saturation is >90%. b. No wheezes are audible. c. Respiratory rate is 16 breaths/min. d. Accessory muscle use has decreased.

a. O2 saturation is >90%. The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack

Aspiration of oral secretions increases a patient's risk for which complication? a. Pneumonia b. Bronchiectasis c. Pneumothorax d. Emphysema

a. Pneumonia Aspiration could lead to pneumonia; bronchiectasis is related to dilation and is not associated with aspiration. Neither pneumothorax nor emphysema is associated with aspiration

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing stridor. b. The patient reports generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips

a. The patient is experiencing stridor. Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

he nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

b. "I will continue to do deep breathing and coughing exercises at home." Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia

A patient seen in the asthma clinic has recorded daily peak flowrates that are 75% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointment.

b. Administer a bronchodilator and recheck the spirometry. The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient first needs to be taught how to control symptoms now and use the bronchodilator

A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments? a. Assign the patient to a semiprivate room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves.

b. Assign the patient to a room near the nurse's station. The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted.Therefore, a confused patient should not be placed near a water fountain. Peaked T waves area sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia.Which assessment data should be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for 8 hours. d. Skin tenting over the sternum is prolonged.

b. Blood pressure is 90/40 mm Hg. The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypo perfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence

b. Daily weight Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

A 10-year-old develops pneumonia. Physical exam reveals subcostal and intercostal retractions. The child reports that breathing is difficult with feelings that, "I cannot get enough air." What term should the nurse use to document this condition? a. Cyanosis b. Dyspnea c. Hyperpnea d. Orthopnea

b. Dyspnea Dyspnea is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." Cyanosis is a bluish discoloration to the skin. Hyperpnea is an increased ventilatory rate and orthopnea is dyspnea that occurs when an individual lies flat.

An older adult patient who is malnourished presents to the emergency department with aserum protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect? a. Pallor b. Edema c. Confusion d. Restlessness

b. Edema The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause adecrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causingedema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

Which of the following lab values would the nurse expect in a patient who has sustained trauma to the lungs and chest wall and is experiencing respiratory failure? a. Electrolyte imbalances b. Elevated PaCO2 c. Low hematocrit d. Elevated pH

b. Elevated PaCO2 In respiratory failure, inadequate gas exchange occurs such that PaO2 £ 60 mm Hg or PaCO2 ³ 50 mm Hg with pH £ 7.25. Electrolyte imbalances do not occur, but changes in blood gas values do. Hematocrit may be unaffected. pH will be decreased.

IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia.Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a maximum rate of 10 mEq/hr. c. Discontinue cardiac monitoring during the infusion. d. Refuse to give the KCl through a peripheral venous line.

b. Infuse the KCl at a maximum rate of 10 mEq/hr. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered bythis route. Cardiac monitoring should be continued while patient is receiving potassiumbecause of the risk for dysrhythmias.

A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO 2 34 mm Hg; PaO 85 mm Hg; HCO3 -18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

b. Kussmaul respirations Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Acidosis does not cause intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure.

After the nurse has received change-of-shift report, which patient should the nurse asses first? a. A patient with pneumonia who has crackles in the right lung base. b. A patient with chronic bronchitis who has a low forced vital capacity. c. A patient with possible lung cancer who has just returned after bronchoscopy. d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing.

c. A patient with possible lung cancer who has just returned after bronchoscopy. Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse

Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

b. Place a patient with altered consciousness in a side-lying position. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding

A patient is admitted to the emergency department with severe fatigue and confusion.Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

b. Serum calcium is 18 mg/dL. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should start cardiac monitoring and notify the health care provider.The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium of 120 mg/dL c. Urinary output of 280 mL in 8 hours d. Reported weight gain of 2.2 pounds (1 kg)

b. Serum sodium of 120 mg/dL Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected

Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which assessment should the nurse complete first? a. Verify the serum potassium level. b. Test for presence of Chvostek's sign. c. Observe for blood on the neck dressing. d. Confirm a prescription for thyroid replacement.

b. Test for presence of Chvostek's sign. The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of an urgent need to check the potassium level, the thyroid replacement, or for bleeding.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Whichassessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/min. b. There are crackles throughout both lung fields. c. There is sediment and blood in the patient's urine. d. The patient's blood pressure increases to 142/94 mm Hg.

b. There are crackles throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective? a. "I should use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I will inhale deeply and blow out hard during the test." d. "My blood pressure and pulse will be checked every 15 minutes."

c. "I will inhale deeply and blow out hard during the test." For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

c. Decreased peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Encourage fluid intake up to 4000 mL daily. d. Monitor for Trousseau's and Chvostek's sign

c. Encourage fluid intake up to 4000 mL daily. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged inpatients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

c. Help the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

c. Mental status Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum sodium level of 145 mEq/L who is asking for water b. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates

c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.

A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next? a. Complete a head-to-toe assessment. b. Administer an inhaled bronchodilator. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

c. Place the patient on high-flow oxygen. Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of O2 delivered to tissues, so high oxygen concentrations should be given. A head-to-toe assessment and repeat ABGs may be implemented later. Bronchodilators are not needed for metabolic alkalosis and there is no indication that the patient is having difficulty with airflow

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flowmeter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone.

c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting B2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flowmeter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but is used for maintenance therapy

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/μL. d. Increased tactile fremitus is palpable over the right chest.

c. The patient's white blood cell (WBC) count is 6000/μL. The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

d. "I will drink apple juice instead of orange juice for breakfast." Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium(e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking acetaminophen every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler frequently over the last 4 days."

d. "I've been using my albuterol inhaler frequently over the last 4 days." The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching

A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed fluid bolus and insulin.

d. Administer the prescribed fluid bolus and insulin. The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need forcorrection of the acidosis with a saline bolus to prevent hypovolemia followed by insulinadministration to allow glucose to reenter the cells. Oxygen therapy is not indicated becausethere is no indication that the increased respiratory rate is related to hypoxemia. Therespiratory pattern is compensatory, and the patient will not be able to slow the respiratoryrate. Lorazepam administration will slow the respiratory rate and increase the level ofacidosis.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d. Respiratory alkalosis The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratorycause. The other responses are incorrect based on the pH and the normal HCO3.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

d. Suggest that the health care provider order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

d. Tremors are an expected side effect of rapidly acting bronchodilators. Tremors are a common side effect of short-acting B2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.

d. UAP lowers the head of the patient's bed to 15 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia

The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% ABGs with a decreased pH and increased PaCO2 indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal, close to normal, or compensated

Pneumonia is caused by: a. use of anesthetic agents in surgery. b. atelectasis. c. chronic lung changes seen with aging. d. viral or bacterial infections.

d. viral or bacterial infections. Pneumonia is caused by a viral or bacterial infection; infections are not caused by anesthetic agents. Neither atelectasis nor lung changes associated with normal aging cause pneumonia.