Principles Practice Exam #2

Providing discharge teaching to a client who requires home oxygen therapy. Which statements indicates need for further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen"

A nurse is preparing to administer 0.9% sodium chloride 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many ml/hr? Round to nearest whole number

125 mL/hr

A nurse is preparing to administer clindamycin 900mg by intermittent IV bolus over 30 min. Available is clindamycin 900 mg in 100 mL dextrose 5% (D5W). The nurse should set the IV pump to deliver how many mL/hr? Round to nearest whole number

200 mL/hr

A nurse is caring for a client who is receiving oxygen at 2L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28%

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne

When checking a client's capillary refill, the nurse finds the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

Arterial Insufficiency

A nurse is assessing a client who is 2 days postoperative and auscultated bilaterally breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Atelectasis

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via nasal cannula. Which of the following actions should the nurse take?

Attach a humidifier bottle to the base of the flow meter

An assistive personnel report a clients vitals signs as tympanic temperature of 37.1 (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP

Which of the following pulse sites should you avoid assessing bilaterally at the same time

Carotid

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?

Check for carotid pulse

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter to which of the following locations?

Earlobe

A nurse is assessing an IV infusion site on an infants left hand. Which of the following findings should the nurse identify as an indication of an infiltration?

Edema in the palm of the hand

A nurse is caring for a client with pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Mask

A nurse is caring for a client 1 day postoperative who had developed atelectasis. Which of the following manifestations is an expected finding for this condition?

Hypoxemia

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?

Keep the client's affected leg elevated while in bed

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.

Left pedal pulse (left-sided angiography)

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Place the client's arm above the level of the client's heart

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

Remove all metal necklaces

A nurse is planning discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client.

Respiratory Therapist

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two or three times with 60-second pause between passes

Assessing a client with hypoxia the nurse should expect the following findings.

Tachycardia

A nurse in the emergency department is caring for a client who reports chest pressure and SOB. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I (The troponins I and T are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage)

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

Wheezes

A nurse is caring for a client who had just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? Select all that apply a) Check peripheral pulses in the affected extremity. b) Place the client in high-Fowler's position. c) Measure the client's vital signs every 4 hr. d) Keep the client's hip and leg extended. e) Have the client remain in bed up to 6 hr.

a) Check peripheral pulses in the affected extremity. d) Keep the client's hip and leg extended. e) Have the client remain in bed up to 6 hr.

Discharge teaching for home oxygen therapy via nasal cannula. Select all that apply. a) Verify the oxygen flow rate every other day. b) Check the cannula position on a regular basis. c) Check the tops of the ears for skin breakdown. d) Post "no smoking" signs in a prominent location in the home. e) Apply petroleum ointment to nares if they become dry and irritated.

b) Check the cannula position on a regular basis. c) Check the tops of the ears for skin breakdown. d) Post "no smoking" signs in a prominent location in the home.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

conjunctivae