Med Surg Exam 1

A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? 1.Thyroid cancer 2.Acute laryngitis 3.Laryngeal cancer Bronchogenic cancer

3

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? "Do you have any metal anywhere in your body?" "Do you have diabetes?" "Are you allergic to iodine or shellfish?" "Do you drink alcohol regularly?"

"Are you allergic to iodine or shellfish?"

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." "Because your body isn't getting enough oxygen you wake up and breathe." "Your tongue may be blocking your throat, and you wake up because you are choking." "You really aren't waking up that often. It just feels that way."

"Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? "Do you take supplements containing vitamin K?" "Did you take metformin today?" "Are you allergic to peanuts?" "Have you had shortness of breath recently?"

"Did you take metformin today?"

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? "But you know you need this to breathe, right?" "Do you have a light scarf that you could place over it?" "Your family and friends probably won't even care." "It won't take you long to learn to manage."

"Do you have a light scarf that you could place over it?"

The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? "Have you eaten a lot of green leafy vegetables?" "Have you experienced swelling of your legs?" "Were you massaging your calves?" "Have you taken any aspirin or salicylates?"

"Have you taken any aspirin or salicylates?"

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."

"I am here to receive the yearly pneumonia shot again."

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." "I can still go about my normal activities of daily living." "I have less chance of getting an infection because the line is not in my hand." "The PICC line can stay in for months."

"I can continue my 20-mile (32-km) running schedule as I have for the past 10 years."

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? Select all that apply. "I can only take baths, but no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will have to learn to suction myself." "I will be unable to wear a necklace."

"I can only take baths, but no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will be unable to wear a necklace."

Which statement by a client with a laryngectomy indicates a need for further discharge teaching? "I must avoid swimming." "I can clean the stoma with soap and water." "I can project mucus when I laugh or cough." "I can't put anything over my stoma to cover it."

"I can't put anything over my stoma to cover it."

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? "All asthma drugs help everybody breathe better." "I must carry my emergency inhaler when activity is anticipated." "I must have my emergency inhaler with me at all times." "Preventive drugs can stop an attack."

"I must have my emergency inhaler with me at all times."

Which statement by a client with chronic obstructive pulmonary disease (COPD) and a 10 pound (4.5 kg) weight loss indicates the need for additional follow-up instruction? "I should consume plenty of fluids with my meal." "I will try eating smaller more frequent meals." "I will try to eat more protein." "I will perform mouth care prior to eating."

"I should consume plenty of fluids with my meal."

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? "I hope I can learn esophageal speech." "I will have to take special care not to aspirate while eating." "I won't be able to breathe through my nose anymore." "It is hard to believe that I will never hear my own voice again."

"I will have to take special care not to aspirate while eating."

The nurse is evaluating understanding of the treatment regimen for a client newly diagnosed with asthma. Which of these statements by the client indicates understanding of the regimen? "I will take albuterol when I go to sleep." "I will keep the rescue medication readily accessible on the first floor of my home." "I will take the long acting beta agonist even when my breathing seems OK." "I will immediately take the anti-inflammatory medication for an acute asthma attack."

"I will take the long acting beta agonist even when my breathing seems OK."

A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question? "Ibuprofen 800 mg every 8 hours as needed for pain." "Elevate the head of the bed 45 to 60 degrees." "Provide humidified air." "Have suction available at the bedside."

"Ibuprofen 800 mg every 8 hours as needed for pain."

A client recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the client has correct understanding of the use of an inhaler with a spacer when the client states which of these? Select all that apply. "I don't have to wait a minute between the two puffs if I use a spacer." "If the spacer makes a whistling sound, I am breathing in too rapidly." "I should rinse my mouth and then swallow the water to get all of the medicine." "I should shake the canister when I want to see whether it is empty." "I should hold my breath for at least ten seconds after inhaling the medication."

"If the spacer makes a whistling sound, I am breathing in too rapidly." "I should hold my breath for at least ten seconds after inhaling the medication."

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? "You can quit when you are ready." "It's never too late to quit." "For safety, turn off your oxygen when you smoke." "Let's discuss why smoking around oxygen is dangerous."

"Let's discuss why smoking around oxygen is dangerous."

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority? "Make sure he gets enough calories each day." "He can only consume milk and ice cream until the wires come off." "He must brush his teeth every 2 hours." "Make sure he always carries the wire cutters with him."

"Make sure he always carries the wire cutters with him."

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? "I hate having IVs started." "It hurts when you are inserting the line." "My hand tingles when you poke me." "My IV lines never last very long."

"My hand tingles when you poke me."

The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate? "Sedation is needed so your loved one does not rip the breathing tube out." "Suctioning is important to remove organisms from the lower airway." "Paralytics and sedatives help decrease the demand for oxygen." "We are encouraging oral and IV fluids to keep your loved one hydrated."

"Paralytics and sedatives help decrease the demand for oxygen."

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? "Handwashing is the best way to prevent transmission." "I should avoid kissing and shaking hands." "It is best to cough and sneeze into my upper sleeve." "The intranasal vaccine can be given to everybody in the family."

"The intranasal vaccine can be given to everybody in the family."

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." "If bleeding develops, we will give platelets to reverse the anticoagulant."

"Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3."

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?

"They minimize health care workers' exposure to contaminated needles."

The client says, "I hate this stupid COPD." What is the best response by the nurse? "Stopping smoking will help your lungs heal." "You sound fed up with managing your illness." "Does anyone in your family have COPD?" "Most clients get used to it after a few months."

"You sound fed up with managing your illness."

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You will not spread the disease unless you stop taking your medication." "You will not pose an increased risk of disease to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."

"You will not pose an increased risk of disease to the people you have been living with."

The nurse is providing preoperative teaching for the client with lung cancer for whom a lobectomy is planned. Which of these does the nurse include in the preoperative education session? Select all that apply. "You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." "You will be able to get out of bed after the chest tube is removed." "Plan to request pain medication before your pain becomes severe." "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing." "You will need to lie on the operative side until the area of tissue removal heals."

"You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." "Plan to request pain medication before your pain becomes severe." "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing."

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply. Client's name and hospital number Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

- Response to insertion - Date and time inserted - Type and size of device - type of dressing - vein used

The client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years? Fill in the blank and record your answer using one decimal place.

0.75 packs X 10 years = 7.5 pack years

A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to implement which intervention? 1.Administering nasal oxygen 2.Placing the client on a cardiac monitor 3.Preparing the client for a perfusion scan 4.Ensuring that the intravenous (IV) line is patent

1

The nurse is monitoring a client for bradypnea. Which description is characteristic of this respiratory pattern? 1.Regular but abnormally slow 2.Labored and increased in depth and rate 3.Regular but interspersed with periods of apnea 4.Abnormally deep, regular, with increased rate

1

The nurse is suctioning a client who has an endotracheal tube in place. Which finding indicates that the client is experiencing an adverse effect of this procedure? 1.Cardiac irregularities 2.Oxygen saturation level of 95% 3.A reddish coloration in the client's face 4.Apical pulse rate of 80 beats per minute

1

¢A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1.Pleural pain and fever 2.Decreased respiratory rate 3.Diaphoresis during the day 4.Hyperresonant breath sounds over the left thorax

1

Which signs/symptoms are indicators of an asthma attack? Select all that apply. 1. Audible wheeze, especially on exhalation 2. Muscle retraction between the ribs 3. Decreased forced expiratory volume in the first second (FEV1) on flowmeter 4. Eosinophils in the sputum 5. Increased, then decreased arterial carbon dioxide (PaCO2) level

1, 2, 3, 4

A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client? Select all that apply. 1.Supplemental oxygen 2.High-Fowler's position 3.Semi-Fowler's position 4.Morphine sulfate intravenously 5.Two tablets of acetaminophen with codeine 6.Meperidine hydrochloride intravenously

1, 2, 4

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1, 3, 4, 5

•The nurse knows that an inflated cuff for a tracheostomy is indicated for which client? Select all that apply. 1.A client at risk for aspiration 2.A client who is physically dependent 3.A client who needs to be able to speak 4.A client who requires mechanical ventilation 5.A client who requires assistance with activities of daily living

1, 4

The health care provider prescribes 1 L 5%D/0.45%NS to be infused over 8 hours. The nurse sets the rate at ___mL/hr of IV solution.

125 1000 mL ______ = 125 mL/hr 8 hr

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? 24 22 18 14

18 Remember the LARGER the number the SMALLER the diameter

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is inserted. Based on this assessment, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe.

2

Which statements are correct regarding the drug management of asthma? Select all that apply. 1. Long-acting beta agonists are indicated to relieve acute attack symptoms. 2. Control therapy medications are used to prevent asthma attacks from occurring. 3. Control therapy medications are used to reduce airway responsiveness. 4. Reliever medications are used to stop an asthma attack once it has started. 5. Anti-inflammatory medications are used to cause bronchodilation.

2, 3, 4

The nurse is caring for a client who has had a lobectomy and placement of a chest tube 8 hours ago. When performing an initial assessment, which of these requires immediate follow up? 200 mL red drainage from chest tube over 2 hours Client sleepy but able to be aroused 3 cm area of red drainage on the incisional dressing Report of pain at the chest tube insertion site

200 mL red drainage from chest tube over 2 hours

The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? 1.Equal bilateral chest expansion 2.Respiratory rate of 22 breaths per minute 3.Diminished breath sounds on the affected side 4.Few scattered wheezes, unchanged from baseline

3

The nurse is caring for a client with a newly placed tracheostomy. Which emergency equipment should be available at the bedside? Select all that apply. 1.Tongue blade 2.Endotracheal tube 3.Tracheostomy tube 4.Tracheostomy insertion tray 5.Manual resuscitation bag with face mask

3, 4, 5

A client is experiencing difficulty coping with decreased ability to tolerate activity because of respiratory disease. The home care nurse determines that the client is showing an adaptive response when which behaviors are observed? 1.Has learned to scale back expectations related to activity 2.Increases the use of medication in order to sleep 8 hours nightly 3.Spends most of the day in one room of the home to decrease fatigue 4.Tries to increase ambulation and complete some small tasks each day

4

A nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest drainage system accidentally disconnects. Which is the initial nursing action? 1. Call a respiratory therapist. 2. Contact the health care provider (HCP). 3. Encourage the client to perform the Valsalva maneuver. 4. Place the end of the chest tube in a container of sterile water.

4

The student nurse is listening to a respiratory lecture on wheezing. Which statement by the student nurse indicates that the teaching has been effective? 1."Wheezing is caused by a grating noise heard on expiration." 2."Wheezing consists of a gurgling noise heard on expiration." 3."A creaking noise heard on inspiration indicates wheezing." 4."Wheezing sounds like a musical or hissing noise heard on inspiration."

4

¢A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1.Respiratory rate of 12 breaths/min 2.Respiratory rate of 16 breaths/min 3.Respiratory rate of 18 breaths/min 4.Respiratory rate of 22 breaths/min

4

¢The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? ¢1. Exhale slowly. ¢ 2. Stay very still. ¢ 3. Inhale and exhale quickly. ¢ 4. Perform the Valsalva maneuver.

4

A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs). 2, 1, 3, 4 4, 3, 1, 2 3, 4, 2, 1 4, 2, 1, 3

4, 2, 1, 3

With which client does the nurse anticipate complications from obstructive sleep apnea (OSA) following abdominal surgery? a. 28-year-old who is 80 lb (36.4 kg) overweight and has a short neck b. 48-year-old who has type 1 diabetes and chronic sinusitis c. 58-year-old who has had gastroesphageal reflux disease for 10 years d. 78-year-old who wears upper and lower dentures and has asthma

A

When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing A client receiving mechanical ventilation who has tracheal deviation A client who was recently extubated and is reporting a sore throat A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

A client receiving mechanical ventilation who has tracheal deviation

The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first? A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask A client who has had a tracheostomy for 1 week, who has SpO2 of 95%-97% and foul-smelling drainage on the tracheostomy ties A client who is being discharged with a new prescription for home oxygen therapy by nasal cannula A client who was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula

A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask

The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? A client with diabetes and cellulitis of the leg A client receiving IV fluids through a peripheral line A client returning from an open reduction and internal fixation of the tibia A client with fluid volume deficit and hypokalemia receiving potassium supplements

A client returning from an open reduction and internal fixation of the tibia

When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed? A nonsteroidal anti-inflammatory drug Lorazepam An increase in the morphine dose Acetaminophen

A nonsteroidal anti-inflammatory drug

The nurse on a medical surgical unit is planning bed assignments for a new admission who has cystic fibrosis (CF) and is infected with Burkholderia cepacia. Which of these room assignments is most appropriate for this client? A room with laminar air flow A room with a client who has Down syndrome and pneumonia A room with another client who has cystic fibrosis A private room with a bathroom

A private room with a bathroom

The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? A woman who frequently flies to Europe A man who works on a farm A man admitted for a myocardial infarction A woman with a bleeding disorder

A woman who frequently flies to Europe

Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? (Select all that apply.) a. Onset of or when the client first noticed dyspnea b. Results of most recent pulmonary function test c. Conditions that relieve the dyspnea sensation d. Whether or not dyspnea interferes with ADLs e. Inspection of the external nose and its symmetry f. Whether stridor is present with dyspnea

A, C, D, F

Which conditions are most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) a. Reduced blood and tissue levels of diphosphoglycerate (DPG) b. Reduced blood and tissue pH c. Increased metabolic demands d. Alkalosis e. Increased body temperature f. Reduced blood and tissue levels of oxygen

A, D

Which interventions are most appropriate for the nurse to teach a client with a nasal fracture to reduce bleeding from the injury? (Select all that apply.) a. "Avoid blowing or picking the nose." b. "Drink at least 2000 mL of fluid daily." c. "Take the antibiotics for as long as they are prescribed." d. "Take in only liquids and eat no solid food for at least a week." e. "Change the drip (moustache) dressing as soon as it becomes wet." f. "Use acetaminophen for pain rather than aspirin or other NSAIDS."

A, F

1. What must the nurse include for discharge education for a client who is newly prescribed to use oxygen therapy at home? (Select all that apply.) a. The consequences of smoking while using oxygen b. The need to limit potted plants in the home c. The types of oxygen delivery devices available for home use d. The use of oxygen when performing ADLs e. The need to travel only in specially designated cars f. Performing proper skin care under the device and its straps

A, c, d, f

The nurse is assessing a client admitted with status asthmaticus. The nurse finds a sudden absence of wheezing in the lung fields and sets which of these as the priority action? Education to prevent future exacerbations Administration of a bronchodilator Measures to reduce anxiety Activation of the rapid response team to secure an airway

Activation of the rapid response team to secure an airway

A client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to an unlicensed assistive personnel (UAP) under the supervision of an RN? Adjust the position of the oxygen tubing. Assess for signs and symptoms of hypoventilation. Change the O2 flow rate to keep SpO2 as prescribed. Select the O2 delivery device used for the client.

Adjust the position of the oxygen tubing.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? Administering preoperative antibiotics and anxiolytics Assessing the client's nutritional status and need for nutrition supplements Having the client sign the operative consent form Teaching the client about the need for tracheal suctioning after surgery

Administering preoperative antibiotics and anxiolytics

A client with acute exacerbation of asthma has been admitted to the medical surgical unit for treatment. The client is reporting increased shortness of breath with inspiratory and expiratory wheezes. When planning care for this client, which medication will the nurse administer first? Albuterol-2 inhalations Fluticasone-2 inhalations Ipratropium-2 inhalations Salmeterol-2 inhalations

Albuterol-2 inhalations

The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session? Alcohol and smokeless tobacco use Chronic laryngitis and voice abuse Marijuana use and exposure to industrial chemicals Poor oral hygiene and smoking cigarettes

Alcohol and smokeless tobacco use

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? Select all that apply. Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine. Shave the hair around the area of insertion. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? Anticipate an order to discontinue the intraosseous IV and start an epidural IV. Call the previous hospital to verify the date. Immediately discontinue the intraosseous IV. Nothing; this is a long-term treatment.

Anticipate an order to discontinue the intraosseous IV and start an epidural IV. IO should only be used as long as necessary

The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg Have the client breathe rapidly and deeply Apply oxygen Administer sodium bicarbonate Collaborate with the provider to increase the pH

Apply oxygen

The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority? Assess for bleeding on the drip moustache dressing. Provide ventilation with a manual resuscitation bag. Perform the abdominal thrust maneuver. Apply oxygen.

Apply oxygen.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? Arrange for a health care worker to observe the client take the medication. Give the client written instructions about how to take prescribed medications. Have the client repeat medication names and side effects. Instruct the client about the possible consequences of nonadherence.

Arrange for a health care worker to observe the client take the medication.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? Ask the client whether the mask fits tightly over the mouth and nose. Discuss the use of autotitrating positive airway pressure (APAP). Plan to teach the client about treatment with modafinil (Provigil). Suggest that a nasal mask be used instead of a full facemask.

Ask the client whether the mask fits tightly over the mouth and nose.

The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action? Apply moist heat over the flap site. Massage the flap site vigorously. Place a tight dressing over the flap. Assess flow to the area using a Doppler device.

Assess flow to the area using a Doppler device.

A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? Increase the sedation. Assess for adequate oxygenation. Explain that the tube in the client's throat helps with breathing. Request that the family leave to decrease the client's agitation.

Assess for adequate oxygenation.

The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make? Measure the cuff pressure. Assess the color and consistency of secretions. Ensure a second tracheostomy tube is available. Assess for tachypnea.

Assess for tachypnea.

When caring for the client returning from thoracotomy and placement of a chest tube, the client reports severe pain. What does the nurse do first? Assess location and quality of pain. Call for the Rapid Response Team (RRT). Check the patency of the chest tubes. Call the health care provider.

Assess location and quality of pain.

The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? Select all that apply. Ask visitors to leave the room. Assess the client's color and respirations. Confirm alarms and ventilator settings. Ensure that the tube is in proper position. Auscultate for bilateral breath sounds. Provide routine tracheostomy and mouth care.

Assess the client's color and respirations. Confirm alarms and ventilator settings. Ensure that the tube is in proper position. Auscultate for bilateral breath sounds.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? Assess the insertion site. Check connections. Check the infusion rate. Discontinue the IV and start another.

Assess the insertion site.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? Place the client in supine position. Apply an ice collar around the client's neck. Assist the client to a sitting position with the head tilted forward. Instruct the client to swallow the blood until the bleeding can be controlled.

Assist the client to a sitting position with the head tilted forward.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? Suction as needed. Clean the tracheostomy inner cannula and stoma. Auscultate lung sounds. Change the tracheostomy dressing as needed.

Auscultate lung sounds.

A client with pulmonary artery hypertension on a continuous IV epoprostenol infusion is in the emergency department with symptoms of possible sepsis. The health care provider prescribes a broad-spectrum antibiotic to be administered IV immediately. What is the nurse's best action? a. Request a prescription for an oral antibiotic. b. Start a peripheral IV line and administer the antibiotic. c. Administer the IV antibiotic through the continuous infusion's side port. d. Stop the epoprostenol infusion for 15 minutes to administer the IV antibiotic.

B

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? a. Pneumothorax b. Pneumonia c. Pleural effusion d. Emphysema

B

The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)? A.29-year old male who is overweight B.32-year-old female with a family history of PH C.43-year-old male with history of right-sided heart failure D.50-year-old female with history of blood clots in the pulmonary artery

B

A client about to undergo radiation therapy for head and neck cancer (pharyngeal) asks what side effects are expected from this therapy. Which side effects does the nurse teach the client to expect? (Select all that apply.) a. Scalp and eyebrow alopecia b. Taste sensation loss or changes c. Increased risk for sinus infections d. Increased risk for skin breakdown e. Moderate weight gain f. Increased risk for cavities

B, D, F

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Select all that apply. Bakers Coal miners Electricians Furniture refinishers Plumbers Potters

Bakers Coal miners Furniture refinishers Potters

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? Corticosteroid Beta agonist Pneumococcal vaccine Antibiotic

Beta agonist

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation? Oropharyngeal airway Bi-level positive airway pressure (BiPAP) Non-rebreather mask with 100% oxygen Positive end-expiratory pressure (PEEP)

Bi-level positive airway pressure (BiPAP)

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? Barrel-shaped chest Bronchial breath sounds heard at the bases Hyperresonance to percussion of the chest Ribs lying horizontal

Bronchial breath sounds heard at the bases

. The nurse notes that a client with a history of chronic obstructive pulmonary disease (COPD), who is receiving oxygen therapy at 2 L/min and had an oxygen saturation of 88% 1 hour ago, now has dyspnea and an oxygen saturation of 80%. Does the nurse increase the FiO2? a. No, increasing the FiO2 will severely depress the respiratory rate by blunting the hypoxic drive. b. No, an oxygen saturation of 80% is acceptable for a client with COPD. c. Yes, hypoxia must be treated despite the risk for oxygen-induced hypercapnia. d. Yes, the expected outcome for any client with hypoxia is to achieve a saturation of at least 97%.

C

A patient is admitted with cough, fever, sore throat, progressive shortness of breath, diarrhea, and vomiting that developed after returning from a business trip overseas. The nurse suspects which illness is the likely cause of the patient's symptoms? A.Pneumonia B.Viral influenza C.Avian influenza D.Tuberculosis exposure

C

For which possible complication of tracheostomy tube dislodgement does the nurse remain alert in a client during the first 72 hours after placement? a. Oxygen toxicity b. Increased secretions c. Movement of the tube into a "false passage" d. Increased risk for aspiration during swallowing

C

Which description of respiratory physiologic features is correct? a. The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange. b. The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound. c. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung. d. The left lung is responsible for approximately 60% of gas exchange and the right lung is responsible for 60% of pulmonary perfusion

C

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? Blood pressure Capillary refill and pulse Neurologic function Questioning the client about the pain level at the site

Capillary refill and pulse - ensures the arterial line is not occluding the artery

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? Back of the hand for an older adult Cephalic vein of the forearm Lower arm on the side of a radical mastectomy Subclavian vein

Cephalic vein of the forearm

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? Change the set immediately. Change the set in about 4 hours. Change the set in the next 12 to 24 hours. Nothing; the set is for long-term use.

Change the set in about 4 hours - intermittent should be changed every 24

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? Administer 5 mL of a heparinized solution. Check for blood return. Flush the port with 10 mL of normal saline. Palpate the port for stability.

Check for blood return

An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? Check the resident's oxygen saturation. Do a complete neurologic assessment. Administer the prescribed PRN lorazepam. Perform a mini mental status exam.

Check the resident's oxygen saturation.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? The left chest caves in on inspiration and "puffs out" on expiration. Chest asymmetry and jugular vein distention are present. The left lung field is dull to percussion with crackles present on auscultation. The client has bloody sputum and wheezes.

Chest asymmetry and jugular vein distention are present.

The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion? Alcohol consumption Cocaine use Cigarette smoking Heroin use

Cigarette smoking

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? Client has a 32 pack-year history Client has a 96 pack-year history Client smoked 3 packs for years Client was a passive smoker for 32 years

Client has a 96 pack-year history

The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)? Client's last ECG showed atrial fibrillation at a rate of 82 Client's blood pressure is 106/80 Client has been cooperative with all treatments Client has developed restlessness over the last hour

Client has developed restlessness over the last hour

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? Asks the charge nurse about the order Contacts the health care provider who ordered it Contacts the pharmacy for clarification Starts the fluid as ordered, with plans to check it later

Contact provider who ordered it

The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? Client on warfarin (Coumadin) with epistaxis with brisk bleeding Client with facial burns caused by a mattress fire while sleeping Client with possible facial fractures after a motor vehicle collision Client with suspected bilateral vocal cord paralysis and stridor

Client on warfarin (Coumadin) with epistaxis with brisk bleeding

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? Client with possible ulcer who just returned from an endoscopy Client with emphysema who needs teaching about pulmonary function testing Client with pancreatitis who needs a preoperative chest x-ray Client who had 1200 mL of pleural fluid removed by thoracentesis

Client who had 1200 mL of pleural fluid removed by thoracentesis

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? Client who is short of breath after walking up two flights of stairs Client with a 10 mm area of redness on the arm after receiving purified protein derivative (Mantoux) skin test Client with sore throat and fever of 102.2°F (39°C) oral Client who is speaking in three-word sentences and has an SpO2 of 90%

Client who is speaking in three-word sentences and has an SpO2 of 90%

The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? Select all that apply. Client with a brainstem tumor Client with acute pancreatitis Client with a C5 spinal cord injury Client using client-controlled analgesia Client experiencing cocaine intoxication

Client with a brainstem tumor Client with acute pancreatitis Client with a C5 spinal cord injury Client using client-controlled analgesia

The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit? Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour Client with emphysema who requires instruction about correct use of oxygen at home Client with lung cancer who has just been transferred from the intensive care unit after a left lower lobectomy yesterday

Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask

The RN has received report about four clients. Which client needs the most immediate assessment? Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago Client with pleural effusion who has decreased breath sounds at the right base

Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry

The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? Client with diabetic ketoacidosis (DKA) Client with atrial fibrillation Client with aspiration pneumonia Client with acute kidney failure

Client with aspiration pneumonia

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is unable to afford prescribed medications. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. Hospice client with end-stage pulmonary fibrosis and an oxygen saturation level of 89%. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%

The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? Client who requires suctioning of oral secretions Client with hypoventilation and decreased breath sounds Client with O2 saturation of 90% Client with thick, purulent secretions and crackles

Client with hypoventilation and decreased breath sounds

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? Client with bacterial pneumonia and a cough productive of green sputum Client with neutropenia and pneumonia caused by Candida albicans Client with possible H5N1 influenza who currently has epistaxis Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)

Client with possible H5N1 influenza who currently has epistaxis

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? Client with group A beta-hemolytic streptococcal pharyngitis who has stridor Client with pulmonary tuberculosis who is receiving multiple medications Client with sinusitis who has just arrived after having endoscopic sinus surgery Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary tuberculosis who is receiving multiple medications

A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. What action will the nurse take next? Collaborate with the provider to lower the FiO2 level. Discuss the need for extubation due to the need for 100% oxygen. Suggest noninvasive positive airway pressure techniques with oxygen. Prepare to suction the client.

Collaborate with the provider to lower the FiO2 level.

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? Bradycardia Confusion Eupnea Pale skin

Confusion

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? Completing the antibiotic medication regimen Taking pain medications every 4 to 6 hours Contacting the health care provider (HCP) if drooling occurs Using warm saline gargles and irrigations

Contacting the health care provider (HCP) if drooling occurs

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? Continuous pulse oximetry Serial arterial blood gas measurements Continuous capnography Apnea monitoring

Continuous capnography

When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. Administering antibiotic prophylaxis Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client Placing a nasogastric tube Placing the client in a negative-airflow room

Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? Crackles Rhonchi Pleural friction rub Wheeze

Crackles

A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? A.Influenza B.Pneumonia C.Tuberculosis D.Pulmonary empyema

D

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

D

The chest tube of a client who is 12 hours postoperative from a lobectomy separates from the drainage system. What is the nurse's best first action? a. Immediately call the surgeon or rapid response team. b. Notify respiratory therapy to set up a new drainage system. c. Cover the insertion site with a sterile occlusive dressing and tape down on three sides. d. Place the end of the disconnected tube into a container of sterile water positioned below the chest.

D6

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse take first? Auscultate the client's breath sounds while applying a nasal cannula. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. Apply a 100% non-rebreather mask while administering high-flow oxygen. Replace the obturator while reinserting the tracheostomy tube.

Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask.

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? Select all that apply. Dizziness and syncope Shortness of breath (SOB) worsening over the last 2 weeks Inspiratory chest pain Productive cough Pink, frothy sputum Tachycardia

Dizziness and syncope Inspiratory chest pain Tachycardia

The nurse is providing teaching for a client who has been newly diagnosed with lung cancer and will be undergoing radiation therapy. Which of these points would be covered in the teaching session? Select all that apply. Hair loss will occur. Do not expose the site to sun. Loss of appetite may develop. Pain in the area is expected. Fatigue may occur. Changes in taste may occur.

Do not expose area to sun Fatigue may occur Change in taste may occur - Not decreased apppetite

When caring for a client who had a lobectomy the nurse notes small bubbles in the water seal chamber of the disposable chest drainage device during coughing. Which of these reflects the appropriate action by the nurse? Document the finding in the medical record. Check the tube for blood clots. Briefly increase the amount of suction. Add additional sterile water to the water seal chamber.

Document the finding in the medical record. - This is normal

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? Administer levofloxacin (Levaquin) 500 mg IV. Draw aerobic and anaerobic blood cultures. Give lorazepam (Ativan) as needed for agitation. Refer to social worker for alcohol counseling.

Draw aerobic and anaerobic blood cultures.

A client is diagnosed with a tumor of the larynx. The nurse determines that the client is in the late stage of the disease process if the client exhibits which finding? 1.Dyspnea 2.Hoarseness 3.Hemoptysis 4.Voice changes

Dyspnea

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? Avoiding public gatherings at all times Early recognition and quarantine of affected persons Vaccinating community members with pneumonia vaccine Widespread distribution of antiviral drugs

Early recognition and quarantine of affected persons

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? Encourage the client to ask questions and verbalize concerns. Provide privacy for the client to be alone to deal with his or her own feelings. Medicate the client with diazepam for anxiety every 8 hours. Provide journals about cancer treatment.

Encourage the client to ask questions and verbalize concerns.

The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time? Ensure a tracheostomy tray is at the bedside Place pressure on areas of hemorrhage Assess the mastoid area for battle sign Administer isotonic fluid replacement

Ensure a tracheostomy tray is at the bedside

A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? Ensure that the tubing is patent and that oxygen flow is high. Notify the chaplain and the family member of record. Call the Rapid Response Team (RRT) and prepare to intubate. Comfort the client.

Ensure that the tubing is patent and that oxygen flow is high.

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? Administer bronchodilator medication on call. Encourage clear fluid intake 12 hours before the procedure. Ensure the client does not smoke for 6 hours before the test. Provide supplemental oxygen.

Ensure the client does not smoke for 6 hours before the test.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? Obtain informed consent. Ensure the client has had nothing by mouth. Review dietary and medication allergies. Perform aggressive chest physiotherapy.

Ensure the client has had nothing by mouth.

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? Asks the client to both say and spell his or her full name before starting the blood transfusion Ensures that another qualified health care professional checks the unit before administering Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

Ensures that another qualified health care professional checks the unit before administering

The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively? Educate the client about ways to avoid aspiration when swallowing after the surgery. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. Teach the client and significant others about how to suction and perform wound care of the stoma.

Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? Hemoglobin A1C Culture and Sensitivity report Evaluating pneumonia vaccine status Ensuring education to cough into the upper sleeve

Evaluating pneumonia vaccine status

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? Ecchymosis Edema Excessive swallowing Sore throat

Excessive swallowing

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? Expiratory wheezing not cleared by coughing Bronchial breath sounds over the trachea Crackles throughout the lung fields Bronchovesicular breath sounds in the lung bases

Expiratory wheezing not cleared by coughing

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select? Face tent Venturi mask Nasal cannula Non-rebreather mask

Face tent

Is the following statement true or false? Bradypnea is the most common sign for a possible pulmonary embolism

False Rationale: Tachypnea is the most common sign for a possible pulmonary embolism

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? "OSHA, a government agency, requires us to use this new type of IV." "These systems are designed to save time, not money." "They minimize health care workers' exposure to contaminated needles." "They minimize clients' exposure to contaminated needles."

Grade 3 Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present? Select all that apply. Sore throat Rhinorrhea Harsh cough Stridor Low grade fever

Harsh cough, stridor

The nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover? Hyperkalemia Hyperglycemia Hypercalcemia Hypernatremia

Hypercalcemia

The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? Hyperoxygenate before and after suctioning. Repeat suctioning until the tube is clear. Apply suction during insertion of the tube. Suction through the tracheostomy tube for 30 seconds.

Hyperoxygenate before and after suctioning.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? Inadequate nutrition related to food-drug interactions with anticoagulant therapy Risk for infection related to leukocytosis Hypoxemia related to ventilation-perfusion mismatch Insufficient knowledge related to the cause of PE

Hypoxemia related to ventilation-perfusion mismatch

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply. During insertion, draping the area around the site with a sterile barrier Immediately removing the client's venous access device (VAD) when it is no longer needed Making certain that observers of the insertion are instructed to look away during the procedure Thorough hand hygiene (i.e., no quick scrub) before insertion Using chlorhexidine for skin disinfection

Immediately removing the client's venous access device (VAD) when it is no longer needed Thorough hand hygiene (i.e., no quick scrub) before insertion Using chlorhexidine for skin disinfection

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? Inability to state name and date of birth Slight kyphoscoliosis Soft speaking voice Need to rest after activity

Inability to state name and date of birth

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? Controller Glass container Infusion pump Syringe pump

Infusion pump

The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan? Individuals with a titanium plate should not have an MRI and should carry a wallet card stating this. It is important to have good oral hygiene using an irrigating device such as Waterpik. Let the health care team know if you are experiencing any pain. We will be checking behind your ear for any bruising to assess for additional trauma.

It is important to have good oral hygiene using an irrigating device such as Waterpik.

The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? Keep the head of the bed elevated. Teach about incentive spirometer use. Monitor vital signs every 5 minutes. Adjust the nasal oxygen flow rate.

Keep the head of the bed elevated.

A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? 1.Thyroid cancer 2.Acute laryngitis 3.Laryngeal cancer 4.Bronchogenic cancer

Laryngeal cancer

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? Check the ventilator alarm settings. Assess the set tidal volume. Listen to the client's breath sounds. Call the respiratory therapist.

Listen to the client's breath sounds.

The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care? Select all that apply. Encourage frequent sipping from a cup. Encourage water with meals. Inflate the tracheostomy cuff during meals. Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow.

Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow.

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? Midline catheter Peripherally inserted central catheter (PICC) Short peripheral catheter Tunneled central catheter

Midline catheter

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? Midline catheter Tunneled percutaneous central catheter Peripherally inserted central catheter Short peripheral catheter

Midline catheter - fragile veins present

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? Assess breath sounds. Offer clear liquids when gag reflex returns. Determine level of consciousness. Monitor blood pressure and pulse.

Monitor blood pressure and pulse.

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? Teach the client to avoid using dental floss. Monitor the platelet count daily. Ensure adequate staffing for the unit. Notify radiology of an impending scan.

Monitor the platelet count daily.

The nurse is providing education to a client with chronic bronchitis who has a new prescription for a mucolytic. Which of these will the nurse teach the client about the purpose of the medication? Mucolytics decrease secretion production. Mucolytics increase gas exchange in the lower airways. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. Mucolytics thin secretions, allowing for easier expectoration.

Mucolytics thin secretions, allowing for easier expectoration.

The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority? Observing the dressing for bright-red blood Monitoring for decreased level of consciousness Evaluating the outcome of pain management strategies Analyzing trends of urine output since surgery

Observing the dressing for bright-red blood

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours Postoperative client receiving blood products after excessive blood loss during surgery

Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours

The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action? Attempt to remove the obstruction. Call the Rapid Response Team (RRT). Apply oxygen by non-rebreathing mask. Perform the abdominal thrust maneuver.

Perform the abdominal thrust maneuver.

The adult client with degenerative arthritis is admitted for surgery to create a tracheostomy. What is the best communication method for this client during the postoperative period? Computer keyboard Magic Slate Picture board Pen and paper

Picture board

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.

Place a respiratory mask on the client.

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? Administer purified protein derivative (PPD) for tuberculosis testing. Assess vital signs and the puncture site one day post thoracentesis. Monitor oxygen saturation using pulse oximetry every 4 hours. Plan client and family teaching regarding upcoming pulmonary function testing.

Plan client and family teaching regarding upcoming pulmonary function testing.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? Ensures that the client is wearing a mask Informs the visitor that the client cannot receive visitors at this time Provides a particulate air respirator to the visitor Provides the visitor with a surgical mask

Provides the visitor with a surgical mask

The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? Providing frequent explanations and reassurance Keeping the lights on to promote orientation Administering sedation Providing television or radio for stimulation

Providing frequent explanations and reassurance

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? RN who is certified in the administration of oral and infused chemotherapy medications RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? Remain with the client and provide oxygen in a calm manner. Have the client breathe into a brown paper bag using pursed lips. Offer the client a mild sedative. Allow a family member to remain in the room.

Remain with the client and provide oxygen in a calm manner.

The nurse is educating the client with COPD who requires home oxygen therapy for discharge. Which of these teaching points takes the highest priority? Correct performance when setting up the oxygen delivery system Removing combustion hazards present in the home Understanding the signs and symptoms of hypoxemia Demonstrating how to use a pulse oximetry device

Removing combustion hazards present in the home

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? Encourage coughing and deep breathing. Schedule an immediate chest x-ray. Document the volume of removed fluid in the medical record. Set up a water seal drainage unit.

Schedule an immediate chest x-ray.

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Select all that apply. Slowing heart rate Sensation of air hunger Tracheal deviation Pain on the unaffected side Blue discoloration of the lips

Sensation of air hunger Tracheal deviation Blue discoloration of the lips

The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Severe coughing spasms

Severe coughing spasms

Which statement is true about the special needs of older adults receiving IV therapy?

Skin integrity can be compromised easily by the application of tape or dressings.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? Assess the midline IV insertion site. Have the client cough and deep-breathe. Notify the health care provider about the crackles. Slow the rate of the IV infusion.

Slow the rate of the IV infusion.

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? Ensure that ED staff members receive oseltamivir (Tamiflu). Administer IM influenza vaccination. Place the client in a negative air pressure room. Start an IV line and begin intravenous hydration.

Start an IV line and begin intravenous hydration.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? Decrease the pressure being used to flush the line. Obtain a 10-mL syringe and reattempt flushing the line. Stop flushing and try to aspirate blood from the line. Use "push-pull" pressure applied to the syringe while flushing the line.

Stop flushing and try to aspirate blood from the line.

The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider? Aphonia Hoarseness Loud snoring Stridor

Stridor

The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care? Select all that apply. Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. Suction the client if needed. Cleanse the inner cannula with a mixture of peroxide and saline. Replace the dressing with a sterile, folded 4 × 4 gauze. Provide clean tracheostomy ties that fit snugly against the neck.

Suction the client if needed. Cleanse the inner cannula with a mixture of peroxide and saline Replace the dressing with a sterile, folded 4 × 4 gauze..

The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by the nurse? Humidify the oxygen source Increase provided oxygenation Remove the inner cannula of the tracheostomy Suction the tracheostomy tube

Suction the tracheostomy tube

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? Complete the referral form for a home health agency. Suction the tracheostomy using sterile technique. Teach the client and spouse about tracheostomy care. Consult with the health care provider (HCP) about using a fenestrated tube.

Suction the tracheostomy using sterile technique.

The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care? Swallow twice to clear the airway Thicken all foods to a honey consistency Elevate the head of the bed to 45 degrees Review the results of the radiographic swallowing study

Swallow twice to clear the airway

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. Take a supplement containing B vitamins. Avoid alcohol containing beverages. Have kidney function tests monthly. Report changes in vision to the health care provider. Notify the health care provider for red-orange urine.

Take a supplement containing B vitamins. Avoid alcohol containing beverages. Report changes in vision to the health care provider.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. The client states she will complete the entire dose of antibiotic prescribed. The client reports fatigue and malaise. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). The client has been afebrile for 48 hours.

The client has been afebrile for 48 hours.

The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision? The client requires frequent respiratory assessment. NPPV uses positive pressure to keep the alveoli open. The client is unable to cough and protect the airway. A full face mask may not fit this client's small face well.

The client is unable to cough and protect the airway.

A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best? The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula The client with chronic lung disease who is being evaluated for possible home oxygen use The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? The client with blood in the sputum The client with mucoid sputum The client with pink, frothy sputum The client with yellow sputum

The client with pink, frothy sputum

A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse? The client's skin has pink color. The oxygen reservoir deflates during inspiration. The client has crackles at the lung bases. The client is expectorating rust colored sputum.

The oxygen reservoir deflates during inspiration. - suffocation can occur

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia. The nurse recognizes that a positive outcome to therapy has been achieved by which of these findings? The pCO2 is within normal range. The client's face is very pink. The client reports decreased distress. The oxygen saturation is between 88% and 90%.

The oxygen saturation is between 88% and 90%.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Combination medication therapy is effective in eliminating cough and fever. Combination medication therapy improves adherence. Combination medication therapy has fewer side effects, particularly liver damage. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? Client states, "It really hurt when the nurse put the IV in." The vein feels hard and cordlike above the insertion site. Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 72 hours ago.

The vein feels hard and cordlike above the insertion site.

The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth? They will keep the mouth moist during treatments. They prevent yellow teeth after treatment. They prevent radiation scatter from metal in the mouth. They will protect the taste buds on the tongue.

They prevent radiation scatter from metal in the mouth.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. Breast cancer survivors Those in the local prison Homeless adults Recent immigrants to the United States Those who have received bacille Calmette-Guérin (BCG) vaccine

Those in the local prison Homeless adults Recent immigrants to the United States

A client has just been admitted to the intensive care unit after having a left lower lobectomy via video-assisted thorascopic surgery. Which of these prescriptions will the nurse implement first? Titrate oxygen flow rate to keep O2 saturation at or greater than 93%. Administer 2 g of cephazolin IV now. Give morphine sulfate 4 to 6 mg IV for pain. Transfuse 1 unit of packed red blood cells (PRBCs) over 2 hours.

Titrate oxygen flow rate to keep O2 saturation at or greater than 93%.

The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use? Alphabet board Picture board Translation phone service Word board

Translation phone service

A client with COPD calls the pulmonary clinic reporting the last 24 hours the peak flow meter readings have been in the yellow range. Which of these interventions by the nurse is appropriate at this time? Use your prescription for rescue medication and retest yourself. This is a satisfactory reading, continue your present regimen. Go to the nearest emergency department. Increase your controller medication dose.

Use your prescription for rescue medication and retest yourself.

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? Stay in bed to prevent fatigue. Walk as tolerated each day. Consume adequate calcium. Perform oral hygiene twice daily.

Walk as tolerated each day.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant? Administering throat-numbing lozenges Assessing the mouth for inflammation and infection Teaching about skin care while receiving radiation Washing the skin with plain soap and water

Washing the skin with plain soap and water

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? Keeping the door to the client room closed Performing oral care after suctioning the oropharynx Washing hands and donning gloves prior to the procedure Wearing a disposable particulate mask respirator

Wearing a disposable particulate mask respirator

A client with CF who is 2 months post-operative from a bilateral lung transplant wants to begin riding his bicycle again, as his pulmonary specialist has said he can do, but his wife is concerned that this will "wear out" his new lungs faster. How will the nurse advise this couple? a. Remind the wife that activity does not damage or "wear out" the lungs and that exercise will reduce the risk for other health complications. b. Tell the wife that because the client has a reduced life expectancy, she should allow him to do whatever he wants. c. Remind the client that this is the "honeymoon phase" of recovery and that he will not feel well for very long. d. Advise the client to protect his lungs at all cost.

a

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A.Administer the rescue drugs. B.Take the patient's vital signs. C.Notify the patient's prescriber. D.Repeat the PEF reading to verify the results.

a

Which interventions are important for the nurse to teach a client with severe chronic obstructive pulmonary disease (COPD) to help ensure adequate nutrition? (Select all that apply.) a. Avoid eating gas-producing foods b. Cough to clear mucus right before eating c. Drink plenty of fluid with every meal d. Eat smaller meals more frequently e. Rest immediately following a meal f. Eat more raw fruits and vegetables g. Use your bronchodilator about 30 minutes before each meal

a, b, d, g,

The nurse understands which is the primary risk factor for lung cancer? A.Air pollution B.Cigarette smoking C.Chronic exposure to asbestos D.Occupational radiation exposure

b

Based on the patient's diagnosis of COPD, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.) A.Bradycardia B.Shortness of breath C.Use of accessory muscles D.Sitting in a forward posture E.Barrel chest appearance

b, c, d, e

. A client newly diagnosed with moderate asthma asks whether he can just take salmeterol instead of salmeterol and albuterol, because he has read that they are both beta agonists. What is the nurse's best advice? a. Yes, both of these drugs have the same action, and you only need one. b. Yes, because they both need to be used daily whether you are having symptoms or not, just take a little more of the salmeterol and don't take any of the albuterol. c. No, albuterol is used to relieve the symptoms during an actual asthma attack and salmeterol is used to prevent an attack. Both are needed. d. No, albuterol is taken through the use of an aerosol inhaler and salmeterol is an oral drug (tablet) that is activated in the stomach. Both are needed.

c

The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? A.Fever B.Cough C.Confusion D.Weakness

c

When caring for the client with chronic bronchitis, which of these interventions will assist the client in mobilizing secretions? Elevate the head of the bed 45 degrees consume at least 2 liters of fluid daily avoid triggers which cause coughing assume the tripod position

consume at least 2 liters of fluid daily

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What action will the nurse take first? a. Report the client's problem to the health care provider. b. Document findings and actions in the electronic health record. c. Change the IV insertion site to a new location. d. Stop the infusion of the drug immediately.

d. Stop the infusion of the drug immediately.