quiz 2

A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr

35

A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? Penicillin G Vancomycin Meropenem Ceftriaxone

Ceftriaxone

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? Class III Class II Class IV Class I

Class III

Which client would the nurse consider to have the highest risk of pneumonia? Client 1 Client 2 Client 3 Client 4

Client 4

When caring for a client with pneumonia, which nursing intervention is the highest priority? Employ breathing exercises and controlled coughing increase fluid intake maintain a NPO status Ambulate as much as possible

Employ breathing exercises and controlled coughing

The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Maintaining fluid balance in the client Encouraging the client to perform breathing exercises Providing adequate oxygenation for the client Assisting the client in eating and drinking

Providing adequate oxygenation for the client

Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. ___ gtt/minute

25

A client will be discharged with a peripherally inserted central venous catheter (PICC) for administration of peripheral parenteral nutrition (PPN). What would be appropriate for the nurse to include in the client's discharge teaching? Notify the healthcare provider Inspect the catheter Clamp the remaining device Assess the respiratory status

Inspect the catheter

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? Clamp the chest tubes when suctioning the patient Palpate the area around the tubes for crepitus Change the clients dressing daily using aseptic techniqueEmpty the drainage chamber at the end of the shift

Palpate the area around the tubes for crepitus

the Nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop giving the medication Elevate the head of the client's bed Measure the other vital signs Report to the primary healthcare provider

Stop giving the medication

A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. Administering 100% oxygen manually to the client Administering IV fluids to the client Reporting to the primary healthcare provider Stopping the suctioning procedure immediately

Stopping the suctioning procedure immediately

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. Goggles Surgical Mask Gown Shoes covers N95 mask Gloves

Surgical Mask Gown Gloves

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine The nurse has a sample of the new product. How should the nurse proceed? There is less chance of this infusion infiltrating It is more convenient so clients can use their hands It prevents the development of infection The large amount of blood helps dilute the unconcentrated solution

The large amount of blood helps dilute the unconcentrated solution

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Cleanse the site with the new product first and then follow the agency's protocol Use the new product sample when changing the dressing Follow the agency's policy unless it is contraindicated by a primary healthcare provider's prescription Cleanse the site with alcohol first and the with povidone-iodine

Follow the agency's policy unless it is contraindicated by a primary healthcare provider's prescription

A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? Temperature Respirations Heart rate Pulse oximetry

Heart rate

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do first? Determine which days to self-administer the PPN solution Arranging for professional help to monitor the alternative solution Learning how to change the percutaneous catheter Scheduling administration of the PPN solution around mealtimes

Arranging for professional help to monitor the alternative solution

The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activitiy of the client might have led to this condition? Using drugs such as aspirin Applying excess petroleum jelly to the nares Using nasal saline sprays Blowing the nose vigorously

Applying excess petroleum jelly to the nares

A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? Discuss with spouse the risk for morphine addiction Add a placebo to the morphine to appease the spouse Assess the client's pain before increasing the dose of morphine Check the client's heart rate before increasing the morphine to the next level

Assess the client's pain before increasing the dose of morphine

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do first? Apply warm compress to the affected extremity Check the IV access for blood return Slow the IV infusion until the burning sensation is gone Request an oral supplement from the primary healthcare provider

Check the IV access for blood return

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Increase fluid intake to at least 2L per day Place the client in a high-Fowler position Administer continuous O2 Instruct the client to gargle deep in the throat using warmed normal saline

Increase fluid intake to at least 2L per day

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Turn the client to the unaffected side Check the tube to ensure that it is not kinked Take the client's vital signs Inform the healthcare provider

Check the tube to ensure that it is not kinked

A Patient who is scheduled for open-heart surgery ask why he will be getting chest tubes after surgery. What should the nurse consider before responding in language that the patient will understand? Chest tubes increase tidal volume Chest tubes facilitate drainage of air and fluid Chest tubes regulate pressure on the pericardium and chest wall Chest tubes maintain positive intrapleural pressure

Chest tubes facilitate drainage of air and fluid

The nurse is using the CURB-65 scale in the assessment of four clients with manifestations of pneumonia. Which client requires immediate admission to the intensive care unit? Client 1 Client 2 Client 3 Client 4

Client 3

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? Sustain a continuance of the water seal Ensure adequate suction Collect drainage Maintain negative pressure

Collect drainage

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. Thenurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? Adventitious sounds Wheezing Decreased sounds Crackling

Decreased sounds

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? Inhaling air fully before inserting the mouthpiece Performing 10 breaths per session every hour Taking a long slow, deep breath keeping the mouthpiece in place Recording the volume of the air inspired

Inhaling air fully before inserting the mouthpiece

A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? Healthcare provider UAP LPN RN

RN

A client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted. What is the primary reason total parenteral nutrition is infused through a central line rather than a peripheral line? Apply oxygen Raise the head of the bed Call the primary healthcare provider Assess breath sounds

Raise the head of the bed

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Permit the development of positive pressure between the layers of the pleura Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Provide access for the installation of medication into the pleural space

Remove the air that is present in the intrapleural space

A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. Deep tendon reflexes Urinary output ABG results Last bowel movement Patency of the IV access Last serum potassium level

Urinary output Patency of the IV access Last serum potassium level

A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? Active range-of-motion exercises at least every four hours Isometric exercises every two hours while awake Gait training in the physical therapy department daily Passive range-of motion exercises at least every eight hours

Passive range-of motion exercises at least every eight hours

Which chest examination findings can be observed in a client with pneumonia? Absent sounds on auscultation Prolonged expiration on inspection Hyperresonance on percussion Increased fremitus over affected area on palpation

Increased fremitus over affected area on palpation

A nurse is providing tracheostomy care. Which action is priority? Monitor body temperature after the procedure is completed Maintain sterile technique during the procedure Clean the inner cannula with sterile water when it is removed Place the client in the semi-Fowler position

Maintain sterile technique during the procedure