Exam 4 CM
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Airway patency
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?
need for suctioning
A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
Stop infusion
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment â negative pressure room.
A nurse is caring for a client who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
Administer a beta 2 agonist (Albuteral)
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 nurseâ s highest priority?
Administering a nebulized beta adrenergic
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Continue monitoring respiratory rate
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 seem to bring anything up. Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Encouraging the client 2 to 3 Liters daily
A nurse is assessing a client who has 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
Hoarsness
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching
I will take my medications after my meals
A nurse is caring for a client with a tracheostomy. The clientâ s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the clientâ s discharge?
Performing a procedure indepently
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Prevent aspiration
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases
Tuberculosis ( remember place patient in a negative pressure room)
A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min
d. A 27-year-old client with a heart rate of 120 beats/min
