Module 9: Monitoring for Health Problems

A nurse has a rx to apply a Holter monitor to a client for continuous cardiac monitoring for a 24 hour period. What steps should the nurse take to initiate this rx SATA a) giving the client a device holder to wear around the waist b) giving the client in a diary in which to record activity and symptoms c) telling the client to rest as much as possible during the next 24 hours d) instructing the client to enclose the monitor in plastic wrap before taking a bath

a) giving the client a device holder to wear around the waist b) giving the client in a diary in which to record activity and symptoms

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the HCP SATA a) unequal chest expansion b) resp rate of 22/min c) complaints of discomfort at the needle insertion site d) diminished breath sounds in the right lung e) HR of 82bpm

a) unequal chest expansion d) diminished breath sounds in the right lung

A client with CVD is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the HCP before administering the dose? a. 3.0 mEq/L b. 3.8 mEq/L c. 4.2 mEq/L d. 5.2 mEq/L

a. 3.0 mEq/L

A nurse is assessing the status of a client with DM. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated HbA1c is less than which value? a. 7% b. 9% c. 10% d. 15%

a. 7%

A client reports for a scheduled EEG. Which statement by the client indicates a need for additional prep for the test? a. I didn't shampoo my hair b. I ate my breakfast this morning c. I didn't take my anticonvulsant today d. It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't

a. I didn't shampoo my hair

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? a. Left Sims position b. lithotomy position c. knee chest position d. right Sims position

a. Left Sim's position

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a CXR. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? a. no fluctuation in the water seal chamber b. continuous bubbling in the water seal chamber c. increased drainage in the collection chamber d. continuous gentle suction in suction control chamber

a. no fluctuation in the water seal chamber

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the HR is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. the nurse should take which immediate action? a. notify the surgeon b. continue the assessment c. check the client's BP d. obtain a flashlight, gauze, and a curved hemostat

a. notify the surgeon

A nurse checks the residual volume from a client's NG tube feeding before administering an intermittent tube feeding and finds 35mL of gastric contents. What should the nurse do before administering the prescribed 100mL of formula to the client? a. pour residual volume into the NGT through a syringe with no plunger b. discard the residual volume properly and record it as output on the client's fluid balance record c. dilute the residual volume with water and inject it into the NGT, using plunge

a. pour the residual volume into the NG tube through a syringe with no plunger

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? a. pulse rate b. blood pressure c. pulmonary artery systolic pressure d. pulmonary artery end-diastolic pressure

a. pulse rate

A nurse is reviewing lab results for a newly admitted client. Which serum lab result does the nurse document as abnormal? a. serum creatinine 0.2 b. PT 11-12.5 seconds c. sodium cholesterol d. serum sodium 136-145

a. serum creatinine 0.2

A nurse is watching as a nursing student suctions a client through a trach tube. Which action son the part of the student would prompt the nurse to intervene and demonstrate correct procedure? SATA a. setting the suction pressure to 60 b. applying suction throughout the procedure c. assessing breath sounds before suctioning d. placing the client in a supine position e. hyperoxygenating the client with 100% O2 before suctioning

a. setting the suction pressure to 60 b. applying suction throughout the procedure d. placing the client in a supine position

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? SATA a. sodium 149 b. hct 30% c. LDL 140 d. Mg 2.2 e. bicarb 21

a. sodium 149 b. hct 30% c. LDL 140 e. bicarb 21

A client who has undergone an EGD returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? a. taking the client's vital signs b. giving the client a drink of water c. monitoring the client for a sore throat d. being alert to complaints of heartburn

a. take the client's vital signs

A client has just been scheduled for an ERCP. What should the nurse tell the client about the procedure? SATA a. that informed consent is required b. that the test takes about 4 hours to complete c. that no premedication for sedation will be necessary d. that food and fluids will be withheld before the procedure e. that multiple position changes may be necessary to pass the tube

a. that informed consent is required d. that food and fluids will be withheld before the procedure e. that multiple position changes may be necessary to pass the tube

A nurse is performing nastotracheal suctioning on a client. Which observations should be cause for concern to the nurse? SATA a. the client becomes cyanotic b. secretions are becoming bloody c. the client gags during the procedure d. clear to opaque secretions are removed e. HR varies from 80-82 bpm

a. the client becomes cyanotic b. secretions are becoming bloody

a client has a chest drainage system in place. the fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? a. the tube is patent b. there is probably a kink in the tubing c. suction should be added to the system d. the client is retaining airway secretions

a. the tube is patent

A client with DM is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? a. water b. tea without any sugar c. coffee without any milk d. clear liquids such as apple juice

a. water

A nurse receives a call from a nurse on the PACU, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? a. assess the patency of the airway b. check tubes and drains for patency c. check the dressing for bleeding d. assess the vital signs to compare them with postop measurements

a. assess the patency of the airway

a client who has undergone renal bx complains of pain, radiating to the front of the abdomen, at the bx site. For which finding should the nurse assess the client? a. bleeding b. renal colic c. infection at the site d. increased temperature

a. bleeding

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate his procedure a. darken the exam room b. administer local anesthetic c. obtain signed consent form d. shave the skin and scrub with betadine

a. darken the exam room

The nurse is admitting a client with a dx of renal calculi. What does the nurse know can contribute to the client's dx? a. dehydration b. foods low in protein c. decreased intake of dairy products d. low level PTH

a. dehydration

A client with a hx of lung disease is at risk for resp acidosis. For which s/s does the nurse assess this client? a. disorientation and dyspnea b. drowsiness, headache, tachypnea c. tachypnea, dizziness, paresthesias d. dysrhythmias and decreased respiratory rate and depth

a. disorientation and dyspnea

A nurse is preparing a client for transfer to the OR. Which action should the nurse take in the care of this client at this time? a. ensuring that the client has voided b. administering all daily medication c. practicing postoperative breathing exercises d. verifying that the client has not eaten for the last 24 hours

a. ensuring that the client has voided

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? a. flat b. semi-fowler c. side-lying, HOB elevated d. sitting up in a recliner with feet elevated

a. flat

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum lab studies. Which abnormal lab results should the nurse report to the surgeon's office SATA a. hct 30% b. sodium 141 c. hgb 8.9 d. plts 210 e. creatinine 0.8

a. hct 30% c. hgb 8.9

a client has been given a dx of multiple myeloma. Which result does the nurse reviewing the client's lab findings recognize as being specifically related to this dx? a. increased calcium level b. decreased BUN c. increased WBC count d. decreased number of plasma cells in the bone marrow

a. increased calcium level

A client is brought to the ED by a neighbor. The client is lethargic and has a fruity odor on the breath. The ABG results are pH 7.25, PaCO2 34mmHg, PaO2 86mmHg, HCO3 14 mEq/L. Which acid-base disturbance does the nurse recognize in these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis

A client with type 1 DM has a BGL of 620. After the nurse calls the HCP to report the finding and monitors the client closely for which condition? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis

A client w/o a hx of resp disease has a pulse-ox in place after surgery. The nurse monitors the pulse-ox readings to ensure that oxygen saturation remains above which value? a. 85% b. 89% c. 95% d. 100%

c. 95%

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? a. 140 mg/dL b. 200 mg/dL c. 250 mg/dL d. 300 mg/dL

b. 200mg/dL

oxygen by way of NC has been prescribed for a client with emphysema. The nurse checks the HCP's rx to ensure that the prescribed flow is not greater than which liter per min? a. 1 liter b. 3 liters c. 4 liters d. 6 liters

b. 3L/min

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. which action should the nurse take first? a. contact the primary health care provider b. check for kinks in the drainage system c. check the client's BP and HR d. connect a new drainage system to the client's chest tube

b. check for kinks in the drainage system

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? a. continue suctioning to remove the blood b. check the degree of suction being applied c. encourage the client to cough out the bloody secretions d. remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth

b. check the degree of suction being applied

Blood for arterial blood gas determinations is drawn on a client with PNA and testing reveals a pH of 7.45, PaCO2 of 30mmHg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of which disorder? a. compensated metabolic acidosis b. compensated resp alkalosis c. uncompensated metabolic alkalosis d. uncompensated resp acidosis

b. compensated resp alkalosis

A client with COPD who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2L/min. The nurse responds that this would be harmful b/c it could cause which effect? a. be drying to nasal passages b. decreased the client's O2 based respiratory drive c. increase the risk of pneumonia as a result of drier air passages d. decrease the client's CO2 based respiratory drive

b. decrease the client's oxygen based resp drive

The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the hx of the client. What areas should the nurse focus on? a. hx of anemia b. dietary supplements c. previous problems with fluid overload 8.9 d. family hx of urinary calculi e. prescribed and OTC meds f. previous episodes of stone formation

b. dietary supplements d. family hx of urinary calculi e. prescribed and OTC meds f. previous episodes of stone formation

A client has just returned to the nursing unit after CT with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? a. administering a laxative b. encouraging fluid intake c. maintaining the client on strict bedrest d. holding all meds for at least 24 hours

b. encourage fluid intake

a nurse reviews a client's UA report. Which finding does the nurse recognize as abnormal? a. pH of 6 b. glucose noted c. casts apparent d. absence of protein e. presence of ketones f. specific gravity 1.018

b. glucose noted c. casts apparent e. presence of ketones

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids". For which acid-base disturbance does the nurse recognize a risk? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

b. metabolic alkalosis

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

b. metabolic alkalosis

A client has been scheduled for an MRI. Which condition, is a contraindication to MRI, does the nurse check the client's medical hx? a. pancreatitis b. pacemaker insertion c. type 1 dm d. chronic airway limitation

b. pacemaker insertion

A client has just undergone a renal bx. Which intervention should the nurse include in the post-procedure plan of care? a. restricting fluid intake for the first 24 hours b. periodically testing the urine for occult blood c. avoiding the administration of opioid analgesics d. having the client ambulate in the room and hall for short distances

b. periodically testing the urine for occult blood

A client is scheduled for a barium swallow in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure? a. eat a regular supper and breakfast b. remove all metal and jewelry before the test c. expect diarrhea for a few days after the procedure d. take all oral medications as scheduled with milk on the day of the test

b. remove all metal and jewelry before the test

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contract medium by monitoring for the presence of which? a. bradycardia b. respiratory distress c. hematoma in the right groin d. discomfort in the right groin

b. respiratory distress

A nurse is reviewing the results of serum lab studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? a. hemoglobin b. serum bilirubin c. BUN d. ESR

b. serum bilirubin

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? a. assessing the client's chest for crepitus once every 24 hours b. taping the connections between the chest tube and drainage system c. adding 20 ml of sterile water to the suction control chamber every shift d. recording the volume of secretions in the drainage collection chamber every 24 hours

b. taping the connections b/w the chest tube and the drainage system

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic mm of blood. the nurse interprets this test result as indicating which? a. improvement in the client b. the need of retroviral therapy c. the need to discontinue antiretroviral therapy d. an effective response to the treatment for HIV

b. the need for antiretroviral therapy

A HCP is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? a. supine b. upright c. left side-lying d. right side-lying

b. upright

A nurse is assessing a client who has a closed chest tube drainage system. the nurse notes constant bubbling in the water seal chamber. What actions should the nurse take SATA a) assess the system for an external air leak b) reduce the degree of suction being applied c) clamp the chest tube d) document assessment findings, actions taken and client response e) change the drainage system

c) clamp the chest tube e) change the drainage system

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose is therapeutic? a. 3 mcg/mL b. 8 mcg/mL c. 16 mcg/mL d. 28 mcg/mL

c. 16mcg/mL

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? a. O2 sat 97% b. equal breath sounds in both lungs c. absence of cough and gag reflex d. respiratory rate of 20

c. absence of cough and gag reflexes

a client who has just undergone surgery suddenly experiences CP, dyspnea and tachypnea. the nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? a. preparing the client for a perfusion scan b. attaching the client to a cardiac monitor c. administering O2 by NC d. ensuring the IV line is patent

c. administering O2 by NC

A client who has just undergone a skin bx is listening to d/c instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates that he plans to do what as part of aftercare? a. use the antibiotic ointment as prescribed b. return in 7 days to have the sutures removed c. apply cool compresses to the site BID for 20 mins d. call the primary health care provider if excessive drainage from the wound occurs

c. apply cool compresses to the site BID for 20 min

a nurse is assessing a postop client on an hourly basis. The nurse notes that the client's UOP for the past hour was 25mL. On the basis of this finding, the nurse should take which action first? a. contact the primary health care provider b. increase the IV infusion rate c. check the client's overall I&O record d. administer a 250ml bolus of NS

c. check the client's overall I&O record

A nurse is monitoring a client who has undergone pleural bx. Which finding causes the nurse to suspect that the client is experiencing a complication? a. warm, dry skin b. mild pain at the biopsy site c. complaints of shortness of breath d. capillary refill time <3 seconds

c. complaints of SOB

A nurse administers scopolamine as prescribed to a client. For which s/e of this med does the nurse monitor the client? a. pupil constriction b. increased urine output c. complaints of dry mouth d. complaints of feeling sweaty

c. complaints of dry mouth

A client is recieving a continuous IV infusion of heparin for the tx of DVT. The client's aPTT level is 88sec. The client's baseline before the initiation of therapy was 30sec. Which action does the nurse anticipate is needed? a. shutting off the heparin infusion b. increasing the rate of the heparin infusion c. decreasing the rate of the heparin infusion d. leaving the rate of the heparin infusion as is

c. decreasing the rate of heparin infusion

A client has undergone pericardiocentesis to treat cardiac tamponade. for which signs should the nurse assess the client to determine whether the tamponade is recurring? a. decreasing pulse b. rising BP c. distant muffled heart sounds d. falling central venous pressure

c. distant muffled heart sounds

Polyethylene glucol-electrolyte solution is rx'd for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? a. administering a cleansing enema b. calling the primary healthcare provider c. documenting the diarrhea in the medical record d. giving IV replacement fluids in large amounts

c. document the diarrhea in the medical record

A pelvic u/s is prescribed o evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it is important to do before the procedure? a. eat only a light breakfast b. wear comfortable clothing c. drink 6-8 glasses of water without voiding d. stop eating or drinking midnight before the test

c. drink 6-8 glasses of water without voiding

A nurse has a rx to d/c a client's NG tube. The nurse auscultates the client's bowel sounds, positions the client properly and flushes the tube with 15mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what? a. exhale during tube removal b. bear down during tube removal c. hold breath during tube removal d. breathe normally during tube removal

c. hold the breath during tube removal

A client who is mouth breathing is receiving oxygen by facemask. The UAP asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? a. prevent the client from getting a nose bleed b. give the client added fluid by way of the respiratory tree c. humidify the O2 that is bypassing the client's nose d. prevent fluid loss from the lungs during mouth breathing

c. humidify the oxygen that is bypassing the client's nose

A nurse is monitoring the resp status of a client who has just undergone surgery and is wearing a pulseox. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? a. infection b. hypertension c. low BP d. loss of cough reflex

c. low BP

A client with histoplasmosis has the following ABG results: pH 7.30, PaCO2 58mmHg, PaO2 75mmHg, HCO3 26 mEq/L. Which acid-base disturbance does the nurse recognize in these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

c. respiratory acidosis

A nurse reviews the blood gas results of a client in resp distress. The pH is 7.32 and the PaCO2 is 50mmHg. Which acid-base imbalance does the nurse recognize in these findings? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

c. respiratory acidosis

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The HCP has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? a. straw b. napkin c. suction equipment d. O2 sat monitor

c. suction equipment

A client who is anxious about an impending surgery is at risk for resp alkalosis. For which s/s of resp alkalosis does the nurse assess this client? a. disorientation and dyspnea b. drowsiness, headache, tachypnea c. tachypnea, dizziness, paresthesias d. dysrhythmias and decreased respiratory rate and depth

c. tachypnea, dizziness, and paresthesias

A nurse is reading the CXR report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm about the carina. The nurse interprets that the tube is positioned above which anatomical area? a. the first tracheal cartilagenous ring b. the point where the larynx connects to the trachea c. the bifurcation of the right and left main stem bronchi d. the area connecting the oropharynx to the laryngopharynx

c. the bifurcation of the right and left main stem bronchi

A client is tested for HIV with the use of ELISA and the test result is positive. The nurse should provide which information to the client about the test? a. HIV infection has been confirmed b. the client probably has an opportunistic infection c. the test will need to be confirmed with the use of a western blot d. a positive test is a normal result and does not mean that the client is infected with HIV

c. the test will need to be confirmed with the use of a Western blot

A nurse is watching as an UAP measure the BP of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? SATA a. measuring BP after client sat quietly for 5mins b. having client sit with arm bared and supported at heart level c. using cuff with rubber bladder encircling 60% of limb d. measuring BP after client reports drinking cup of coffee e. allowing client to talk as BP is being measured

c. using cuff with rubber bladder encircling 60% of limb d. measuring BP after client reports drinking cup of coffee e. allowing client to talk as BP is being measured

A nurse in a HCP's office has just made an appt for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? a. wear sweatpants b. eat a small meal just before the procedure c. wear comfortable rubber-soled shoes such as sneakers d. avoid consuming caffeine for 30 mins before the procedure

c. wear comfortable rubber-soled shoes such as sneakers

A client's baseline VS are temp 98 F, HR 74bpm, resp rate 18/min, and BP 124/76 mmHg. The client suddenly spikes a fever of 103 F. Which resp rate would the nurse anticipate as part of the body's response to the change in client status? a. 12 breaths/min b. 16 breaths/min c. 18 breaths/min d. 22 breaths/min

d. 22 breaths/min

A client is receiving intermittent bolus feedings bu way of a NG tube. In which position should the nurse place the client once the feeding is complete? a. supine b. HOB flat c. left lateral position d. HOB elevated to 30-45 degrees

d. HOB elevated 30-45 degrees

A nurse has a rx to insert a NG tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? a. placing the tube in warm water b. hyperextending the head while inserting the tube c. removing the tube if any resistance to insertion is met d. asking the client to swallow as the tube is being advanced

d. asking the client to swallow as the tube is being advanced

A nurse has a rx to collect a 24 hour urine specimen from a client. Which measure should the nurse take during this procedure? a. keeping the specimen at room temp b. saving the first urine specimen collected at the start time c. discarding the last voided specimen at the end of the collection time d. asking the client to void, discarding the specimen and noting the start time

d. asking the client to void, discarding the specimen and noting the start time

A client who experienced the sudden onset of resp distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? a. tape the tube in place b. send the client for a chest x ray c. note how far the tube has been inserted d. auscultate both lungs for the presence of breath sounds

d. auscultate both lungs for the presence of breath sounds

a client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? a. ambulating the client b. administering pain medication c. encouraging copious fluid intake d. checking for the return of the gag reflex

d. checking for the return of the gag reflex

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? a. document the findings b. contact the primary healthcare provider c. place the client in a supine position d. cover the abdominal wound with a sterile dressing moistened with sterile saline solution

d. cover the abdominal wound with a sterile dressing moistened with sterile saline solution

a nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? a. reinsert the chest tube b. contact the primary health care provider c. transfer the client back to bed

d. cover the insertion site with a sterile occlusive dressing

A nurse is admitting a client with a dx of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit? a. increased HR and BP b. increased HR and decreased BP c. decreased HR and increased BP d. decreased HR and BP

d. decreased HR and decreased BP

a nurse is suctioning a client through a trach tube. During the procedure, the client begins to cough and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first? a. call a code b. contact the primary health care provider c. administer a bronchodilator d. disconnect the suction source from the catheter

d. disconnect the suction source from the catheter

A client is scheduled to undergo a CT with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? a. the test may be painful b. the test takes 2-3 hours c. food and fluids are not allowed for 4 hours after the test d. dye is injected and may cause a warm flushing sensation

d. dye is injected and may cause a warm flushing sensation

A client who has received sodium bicarb in large amounts is at risk for metabolic alkalosis. For which s/s does the nurse assess this client? a. disorientation and dyspnea b. drowsiness, headache, tachypnea c. tachypnea, dizziness, paresthesias d. dysrhythmias and decreased respiratory rate and depth

d. dysrhythmias, and decreased resp rate and depth

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the HOB and the client complains of dizziness. which action should the nurse take first? a. check the client's BP b. check the O2 level c. have the client take some deep breaths d. lower the HOB slowly until the dizziness is relieved

d. lower the HOB slowly until the dizziness is relieved

A client in the PACU has an as-needed rx for ondansetron. Which occurrence would prompt the nurse to administer this med to the client? a. paralytic ileus b. incisional pain c. urine retention d. nausea and vomiting

d. nausea and vomiting

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? a. steak b. veal c. cheese d. oranges

d. oranges

a client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? a. urine output of 40/hr b. BP 118/76 c. respiratory rate 18/min d. pallor and coolness of the right leg

d. pallor and coolness of the right leg

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? a. it is unnecessary to use both hands b. feeling both carotid pulsations may lead to an incorrect measurement c. palpating both carotid pulses simultaneously could occlude the trachea d. palpating both carotid pulses simultaneously could cause the HR and BP to drop

d. palpating both carotid pulses simultaneously could cause the HR and BP to drop

A nurse is preparing for intershift report when a UAP pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who reutrned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's BP is 88/60 mmHg. Which action should the nurse take first? a. call the primary healthcare provider b. check the hourly urine output c. check the IV site for infiltration d. place the client in a modified trendelenburg position

d. place the client in a modified Trendelenburg position

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? a. administering a sedative b. encouraging fluid intake c. administering an oral preparation of radiopaque dye d. questioning the client about allergies to iodine or shellfish

d. questioning the client about allergies to iodine or shellfish

A client has the following ABG results: pH 7.51, PaCO2 31 mmHg, PaO2 94mmHg, HCO3 24 mEq/L. Which acid-base disturbance does the nurse recognize in these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

d. resp alkalosis

A client admitted to the hospital with a dx of acute pancreatitis has blood drawn for several serum lab tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time? a. hgb 15 g/L b. potassium 4 c. total calcium 9 d. serum amylase 395 units/L

d. serum amylase 395 units/L (normal range is 30-122)

A client who has sustained a MI is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? a. imposing NPO status for 4 hours b. asking the client to sign an informed consent form c. asking the client about the hx of allergy to iodine or shellfish d. telling the client that the procedure is painless and takes 30-60 mins to complete

d. telling the client that the procedure is painless and takes 30-60 min to complete

A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? a. that mammography takes about 1 hour b. not to eat or drink on the morning of the test c. that there is no discomfort associated with the procedure d. that deodorants, powders, or creams in the axillary/breast area must be washed off before the test

d. that deodorants, powders, or creams in the axillary or breast area must be washed off before the test

A nurse is assessing the chest tube drainage system of a postop client who has undergone the right upper lobectomy. The closed drainage system contains 300mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? a. the client's vital signs b. the a

d. the chest tube connections

A nurse provides info to a client who is scheduled for cardiac catheterization to r/o coronary occlusion. The nurse should provide which information to the client? a. the procedure is performed in the operating room b. it is necessary to lie quietly on a hard x-ray table for about 4 hours c. the room is bright and well lit, and it is best to keep the eyes closed d. the client may have feelings of warmth or flushing during the procedure

d. the client may have feelings of warmth or flushing during the procedure

A client has made an appt for her annual Pap smear. The nurse who schedules the appt should provide which information to the client? a. vaginal douching is required an hour before the test b. spicy foods should not be eaten on the day of the test c. the test has absolutely no discomfort associated with it d. the test cannot be performed while the client is menstruating

d. the test cannot be performed while the client is menstruating

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? a. to resume full activity the next day b. not to eat/drink anything until next morning c. to keep the shoulder completely immobilized for the rest of the day d. to report to the primary healthcare provider the development of fever or redness and heat at the site

d. to report to the HCP the development of fever or redness and heat at the site