med surg @ mid term

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care

A develop an alternate method of communication

A client comes into the ER with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis

Apply direct continuous pressure

Suspicious of lumbar punctuation

Cerebral fluid is cloudy

Rhomber test

For balance- standing with your feet together and your arms at your side or crossed in front of you. Part of the test is with your eyes open, and the second part is with your eyes closed.

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client

Is not responding to stimuli

Covering of axons called?

Myelin shealth

A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first

Place a dilator in the stoma to maintain the opening

The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis

Salt water gargle

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order the client states not being able to produce sputum. Which suggestion offered by the nurse is helpful in producing the sputum sample.

Take a deep breath and cough forcefully

The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be able to include regarding cold tablets containing first generation antihistamines

They can cause urinary hesitancy.

The nurse is caring for a 2-year-old child who experienced near-drowning. The nurse will monitor for what possible complication?

acute resp distress syndrome

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

acute respiratory distress syndrome

Which action should the nurse take first when providing care for a client during an acute asthma attack?

administer rx short acting bronchodilator

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea. tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?

apply air tight dressing

A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?

apply oxygen as prescribed

#6 glasgow coma scale

comatose

When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?

fluid rises and falls with resp

Perpetrating diaphragm

impaired gas exchange

the cient with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking) cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse

ineffective airway clearance

Findings of closed head injury

lethargy

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

localized calf tenderness

Newly diagnosis of Parkinson

maintaining safe environment

A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?

measure the level of consciousness

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction?

moving the client head to clean behind the ears

The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?

observing the pt response to painful stimul

The nurse is receiving the post tonsilectomy and post adenoidctomy pt in the PACU. The nurse aide is assisting the client from the stretcher to the bed. The pt remains drowsy from anesthesia. In which position would the nurse instruct the aide to place the client

on one side

Priority nurse action for nurse with pt seizure

protect the head

What should the nurse assess for post invasive procedure

resp distress

Surgery for brain tumor d/c teaching

select all that apply

The nurse is caring for a client with a disease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which breath sounds are anticipated

sibilant wheezes

I am really worried about the thoracentesis, which statement is more helpful

tell me what you're worried about

The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Temp 101.2

temperature rise

A cient with pulmonary hypertension asks the nurse to explain the heart changes that can occur with this disorder. Which is the best response by the nurse?

the left side of the heart is not pumping well and blood backs into the lungs

What resp structure is most helpful in protecting against infection

tonsils

First steps for a pt having a seizure

turn to sideline position

Whats the difference between resp and ventilation

ventilation is the movement of airway into and out of the resp tract

icp cerebellumvasculitis

vision and hearing