Respiratory Assignment

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect?

-Dry skin -Abdominal Pain -Kussmaul Respirations

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia?

-Decreased heart rate -Decreased bowel sounds

A female client receiving cortisone therapy for adrenal insufficiency expresses concern about why she is developing facial hair. How should the nurse respond?

"The drug contains a hormone that causes male characteristics."

A client in thyroid storm tells the nurse, "I know I'm going to die. I'm very sick." What is the nurse's best response?

"You must feel very sick and frightened."

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse?

"You must have been upset to try to take your life."

A nurse determines that confrontation is an appropriate tool for use with a client. What is an example of therapeutic confrontation?

"You say you're not a good parent, but you were effective when you were talking with your son today."

A postpartum client tells the nurse that she wishes to breastfeed. When the nurse brings her newborn to be breastfed, the client asks whether she may drink a small glass of wine to help her relax. How should the nurse respond?

"You seem a little tense. Tell me how you feel about breastfeeding."

The parent of a 7-year-old child states, "My 7-year-old is the same size as my friend's 10-year-old. I get embarrassed when we are all out together, as my child is not nearly so well behaved." What is the best response from the nurse?

"Your child's behavior is age-appropriate."

What nursing actions best promote communication when obtaining a nursing history?

-Establishing eye contact -Paraphrasing the client's message -Using broad,open-ended statements

A client with recently diagnosed diabetes states, "I feel bad. My spouse and I do not get along. It seems as though my spouse doesn't care about my diabetes." The nurse's most appropriate response is:

"You are unhappy. I wonder—have you tried to talk to your spouse?"

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis?

-Excessive thirst -Fruity-scented breath -Confusion

A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior?

An increased blood urea nitrogen level

After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What observation should the nurse document that will aid confirmation of the diagnosis?

Characteristics of stools

A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the child health unit for corrective surgery. What is the primary objective of preoperative care for this infant?

Correcting fluid and electrolyte imbalances

The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it:

Fits within standards accepted by one's society

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?

Kussmaul respirations

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. The type of respiration that the nurse expects the client to exhibit is:

Kussmaul's breathing

A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding?

LGA and preterm

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?

Potassium

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent?

Shock

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention?

Sitting quietly with the client.

A 3-year-old child with sickle cell anemia is admitted to the child health unit during a painful episode. Splenomegaly is identified. The nurse explains to the parents that splenomegaly is:

Triggered by a vaso-occlusive crisis

A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs?

Urinary output of 30 mL in an hour

How can a nurse best accomplish therapeutic communication with an adolescent?

By establishing a relationship over time

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary edema

Elbow restraints are prescribed for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to keep the child from:

Putting fingers into the mouth

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss?

Imbalance between nutrient intake and fluid loss

A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience?

Explore ways to promote communication with family and friends

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient?

Fats

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the health care provider. What should the nurse do to help prevent the client from developing a urinary tract infection?

Maintain the prescribed hydration

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restore fluid volume

A nurse teaches a client with chronic renal failure that salt substitutes cannot be used in the diet because:

Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats.

An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

Say the child's name and touch the child's arm before starting care

During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn't kill him! You know the truth — tell that police officer! Please help me!" What is the most appropriate response by the nurse?

Saying, "I want to help you. I realize that you must be very frightened."

At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using:

Simple declarative statements

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. The nurse explains that the abilities that will be affected include:

Stating wishes verbally

An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse invites the client to come to dinner, the client refuses and says, "I don't want anyone to see me. Leave me alone." What is the best response by the nurse?

"You sound upset; let's talk about it."

A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?

"You would rather not live."

A 9-year-old child with a tentative diagnosis of leukemia is to undergo bone marrow aspiration. What information should the nurse give the child before the procedure?

"You'll be given medication to relax you before the test, and you'll remember nothing afterward."

During a group discussion regarding the unexpected suicide of a young female client who was on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you're all thinking. You think that I should've known that she was going to kill herself. You think I helped her plan this." What is the most therapeutic response by the group leader?

"You're upset because you think we're blaming you for her death?"

A depressed client cries when the family does not visit. What is the most therapeutic response by the nurse?

"Your family didn't visit, and now you're feeling rejected."

A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider?

Calcium supplements

What should the nurse discuss with new parents to help them prepare for infant care?

Learning specific behaviors involving states of wakefulness to promote positive interactions

A male client with dementia due to Parkinson's disease has been placed in a nursing home. His wife appears tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone, "Let's see what you can do with him." What is the most therapeutic response by the nurse?

"It sounds like it's been difficult for you."

Allopurinol (Zyloprim) is prescribed for a 6-year-old child undergoing chemotherapy regimen for cancer of the bone. When given the medication, the child asks, "Why do I have to take this pill?" What is the best response by the nurse?

"Because with the other medicines it helps you get rid of the things that are making you sick."

A client who appears dejected, barely responds to questions, and walks very slowly about the mental health unit tells the nurse in a barely audible voice that life is no longer worth living. What is the most therapeutic response to this statement by the nurse?

"Have you been thinking about suicide?"

A client has been on the psychiatric unit for several days. The client arouses anxiety and frustration in the staff and manipulates them so well that staff members are afraid to approach the client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best response by the nurse?

"I don't like hearing your threats, but tell me more about your feelings."

On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond?

"It seems that you've changed your mind about rooming in."

A 4-year-old child is found to have acute lymphoblastic leukemia. One of the parents tells the nurse, "We just had a discussion with our pediatrician about starting chemotherapy, consolidation therapy, and radiation therapy. We're so confused, and we don't know what to do. We want to do what is best for our child, but we don't want any unnecessary suffering." What is the best response by the nurse?

"Maybe you could talk with your health care provider about getting a second opinion from a specialist in leukemia."

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client?

"Medication may interfere with the baby's first breaths; keep breathing."

A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent?

"Tell me again how your child fell down the stairs."

A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1-year-old daughter with sickle cell anemia. She asks the nurse, "Will this baby also have sickle cell anemia?" How should the nurse respond?

"The chance that another child will have sickle cell anemia is 25%."

The family of a pregnant client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the best response by the nurse?

"The progression is slow, so people with myasthenia will spend their younger life with few problems."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

"The swelling and discharge are expected. They're a response to your hormones."

A genetic counselor is working with a couple, each of whom is a carrier of an autosomal recessive disorder. Which statement indicates that the couple has understood the teaching about this disorder?

"There is a 1-in-4 chance of having a child with the disorder."

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin (Dilantin) for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse?

"You are worried about having more seizures?"

A delusional client has refused to eat for the past 24 hours because, he says, "the food is poisoned." How should the nurse respond?

"You feel worried that someone wants to poison you?"

A pregnant woman at 6 week's gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client?

-Stop taking the supplement immediately. -Discuss the use of the supplement with the practitioner. -Discuss the use of any over-the-counter products with the practitioner.

An antidepressant is prescribed for a depressed older client. After 1 week the client's son expresses concern that there does not seem to be much improvement. How should the nurse respond?

Antidepressant therapy requires several weeks before it becomes effective."

A client who is to undergo dilation and curettage, and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally?

Asking whether something is troubling the client and whether she'd like to talk about it

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL. What should the nurse do first in response to this laboratory result?

Assess for decreased urine output.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer?

At the time of admission

A client is scheduled for head and neck surgery. Although the health care provider has explained the surgery, the client still has moderate to severe anxiety. What action should the nurse take initially?

Attempt to discover what the client is concerned about.

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe?

Calcium

A 2-year-old boy born with cryptorchidism is to undergo orchiopexy. What should the nurse tell the parents about the anticipated outcome of this surgery?

Damage to the undescended testicle will be prevented.

After a successful kidney transplant for a client with end-stage kidney disease, the nurse anticipates that laboratory studies will demonstrate:

Decreasing serum creatinine

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?

Delusion of grandeur

A nurse is planning to communicate with a preschool child. What is most important for the nurse to know about the child first?

Developmental level

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Documenting the heart rate

A 4-week-old infant is found to have hypertrophic pyloric stenosis (HPS) and is scheduled for surgery. Oral feedings are usually initiated a few hours after surgery. What does the nurse expect the practitioner to prescribe initially?

Electrolyte solution

A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care?

Ensuring a large fluid intake

An 11-year-old child has gained weight. The mother tells the nurse that she is concerned that her child, who loves sports, may become obese. What is the most appropriate response by the nurse?

Explaining that this is expected during preadolescence

A nurse in the clinic is taking the health history of a 16-year-old girl. When the nurse asks questions concerning sexual activity, the adolescent begins to perspire and hyperventilate. As her anxiety increases, she indicates that she feels dizzy and short of breath and that her heart is racing. What condition does the nurse identify?

Hyperventilation syndrome

An adolescent with a history of type 1 diabetes is admitted in ketoacidosis. What does the nurse suspect as a precipitating cause of this episode of ketoacidosis?

Infection

A client with the diagnosis of multiple sclerosis (MS) develops increased visual problems, progressive muscular weakness, and frequent episodes of emotional lability. The difficulties experienced are very distressing to the client. The client bursts into tears for no apparent reason while having a discussion with the nurse. What is the nurse's best response?

Let the client cry and then resume the discussion

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?

Monitor for signs of electrolyte imbalance.

A 3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, the respiratory rate is 56 breaths/min, the pulse is 102 beats/min, and there is a nonproductive cough. What does the nurse expect regarding the child's blood gas values?

pH of 7.32

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for:

Tachycardia

When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," the nurse should respond by:

Telling the client that these words cannot be understood

A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure?

The Pap smear can detect cancer of the cervix.

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client?

-Anorexia -Leg cramps

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy?

-Fatigue -Altered taste sensations

A female client with Hodgkin disease is to start total nodal irradiation. She and her partner, who are planning a family, become concerned when they learn that the radiation therapy includes the pelvic area. Before responding what must the nurse consider?

The eggs in the ovaries can be removed and frozen for future use.

A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan?

This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."

An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer's solution intravenously. The nurse concludes that the treatment has been effective after noting:

Three wet diapers in 24 hours

After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is:

"There is no cure for AIDS but there are drugs that can slow down the virus."

A client has just been informed by the health care provider that she has cervical polyps. The client asks the nurse whether she should worry about them. How should the nurse respond?

"They're usually benign, and a biopsy rules out a malignancy."

A client is diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. While being admitted to ambulatory surgery by the nurse, the client has tears in her eyes and her chin is quivering. In a shaky voice the client says, "I can't believe this is happening." The nurse's best response is:

"This must be a very scary time for you."

A client who was admitted with severe abdominal pain and vomiting states, "I know I am very sick. Do you think I have cancer?" What is the best response by the nurse?

"What are your feelings about the diagnosis of cancer?"

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse?

"Why don't you share your feelings with him while you can?"

A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse?

"You must be frightened by this."

A client with agitation and mood swings approaches the nurse and shouts, "I've been watching you for a few days. You think you're so damned perfect and good. I think you stink!" What is the most appropriate response by the nurse?

"You seem to be angry with me."

A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse?

"You seem to be having very frightening thoughts right now."

The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response?

"You seem to be nervous about going home."

A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse?

-"Every time I turn around the kid is falling over something." -"I can't understand it. He didn't have a problem using the stairs without my help before this."

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record?

-Acetone Breath -Decreased arterial carbon dioxide level

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client?

-Muscle Cramps -Extreme fatigue

The person with which type blood is considered a universal blood recipient?

AB

A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump?

150 mL/hr

A client who is dehydrated is to receive an intravenous (IV) solution of normal saline to be infused at 175 mL/hr. The drop factor of the IV set is 15 gtts/mL. At what drop rate should the nurse adjust the flow to provide the prescribed solution?

44 gtts/min

An infant is undergoing parenteral therapy. The health care provider has instructed that 400 mL of D5W 0.45% sodium chloride be infused over 8 hours. At how many milliliters per hour should the nurse maintain the hourly rate?

50 mL

A client has a permanent colostomy. During the first 24 hours, there is no drainage from the colostomy. The nurse concludes that this is a result of the:

Absence of intestinal peristalsis

What does the nurse determine is the most likely cause of renal calculi in clients with paraplegia?

Accelerated bone demineralization

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client?

Ankle edema

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

Calcium gluconate

Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test?

Serum potassium level

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate:

Flight of ideas

A client arrives in the emergency department with complaints of epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Based on the client's database, the primary nursing concern is:

Metabolic alkalosis

A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery?

Nasogastric

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:

Neologism

While caring for a client, a nurse notes that the client has begun to create new words. What term does the nurse use to document this finding?

Neologism

A nurse is caring for a 6-year-old child with a diagnosis of glomerulonephritis. The child's urine output decreases to less than100 mL/24 hr, the creatinine clearance is 60 mL/min, and there is an irregular apical pulse. A diagnosis of acute renal failure is made. Blood is drawn for testing. Which serum level requires immediate intervention?

Potassium 6.1 mEq/L

A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the:

Preload of the heart, thereby reducing the cardiac workload

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. The nurse concludes that the ascites is most likely the result of increased:

Pressure in the portal vein

A client is admitted to the hospital with the diagnosis of intestinal obstruction and has an intestinal tube inserted. The plan of care includes a prescription to instill 30 mL of normal saline into the tube as needed to maintain patency. When considering the normal saline that is instilled, the nurse should:

Record the 30 mL on the intake and output record

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic?

Relaxation of tensed muscles

When caring for an anxious patient, the nurse should monitor for which signs of hyperventilation?

Respiratory alkalosis