S3 Practice Written Comp #2 (4/19/23 ) - 37/73

36. A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assess the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. All options must be used. Appoint a person to call 911. Check for a pulse. Check for normal breathing. Perform chest compressions. Perform a head tilt-chin lift maneuver. Deliver two rescue breaths.

Appoint a person to call 911. Perform chest compressions. Perform a head tilt-chin lift maneuver. Check for normal breathing. Deliver two rescue breaths. Check for a pulse. Explanation: Following the 2015 American Heart Association (AHA) guidelines and the 2016 Heart and Stroke Foundation of Canada guidelines for cardiopulmonary resuscitation (CPR), the rescuer would attempt to awaken the victim, then activate the emergency response system, and get an automatic external defibrillator (AED) or appoint another person to do this. Past guidelines include checking for a pulse; however, current guidelines move the pulse check later in the sequence. One of the changes was removing the old "Look, Listen, and Feel" process. Lay rescuers and even experienced health care providers may have a hard time finding a pulse and spend too long looking for one before starting CPR; thus, changes state to feel for a pulse for no longer than 10 seconds. The next step is to give 30 chest compressions. Next, the rescuer opens the airway with the head tilt-chin lift or jaw thrust maneuver and checks for breathing. If breathing is not detected, the rescuer gives two rescue breaths, checks for a pulse, and immediately resumes chest compressions. The rescuer would use the AED as soon as it arrives.

37. A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? Encourage a family member to be present to speak for the client. Make time to read the client's lips to foster communication. Encourage the client's communication, allowing time to select or write words. Answer questions for the client to reduce frustration when communicating.

Encourage the client's communication, allowing time to select or write words. Explanation: The nurse should allow ample time for the client to respond and shouldn't speak for the client. The nurse should use as many aids as possible to assist the client with communicating and encourage the client's attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate. While it is appropriate for the family member to be present, encouraging them to speak for the client does not foster the client's goal of improving verbal communication.

16. The nurse is caring for a client with a new tracheostomy. In what order should the nurse perform suctioning procedures after handwashing is complete? All options must be used. Explain the procedure to the client. Adjust the suction control to 120 mmHg. Hyperoxygenate the client. Apply sterile gloves. Insert the suction catheter for no more than 10 seconds. Allow 20-30 seconds between catheter passes.

Explain the procedure to the client. Adjust the suction control to 120 mmHg. Hyperoxygenate the client. Apply sterile gloves. Insert the suction catheter for no more than 10 seconds. Allow 20-30 seconds between catheter passes. Explanation: Explain the procedure and rationale to the client regardless of the level of consciousness. Place the client in Semi-Fowler's/Fowler's position, turn on suction (100-120 mmHg vacuum). Administer 100% oxygen for 1 minute to hyperoxygenate the client. Hyperoxygenate the client before and after each time the airway is entered for suctioning, and wait 1 minute before suctioning again to prevent severe hypoxemia. Don sterile gloves, hold catheter with the dominant hand and attach to suction with the non-dominant hand, and lubricate the sterile catheter by dipping it into a cup with sterile normal saline/water. Using the dominant hand, insert the catheter into tracheostomy without applying suction-suctioning during insertion, as this deprives the client of oxygen and inhibits catheter advancement. Advance the catheter quickly, 1-2 cm beyond the end of the tracheostomy tube, until resistance is felt, as deep suctioning traumatizes tracheal mucosa. Suction intermittently by placing and releasing non-dominant thumb over catheter suction port while withdrawing catheter using a rotating motion; intermittent versus continuous application of suction may help to reduce airway injury. Limit suction to no more than 10 seconds, as this will prevent hypoxemic complications induced by suctioning.

18. A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be Ineffective airway clearance. Impaired tissue integrity. Ineffective breathing pattern. Risk for falls.

Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

53. The nurse has reviewed the Nurse's Notes and orders from 0930 and is implementing the plan of care with this client. Which action(s) will the nurse take? Select all that apply. Encourage the client to use one pharmacy to fill and renew prescriptions. Instruct the client to contact the provider before taking any herbals, supplements, or over-the-counter medications. Infuse potassium chloride using an infusion pump. Review the daily schedule with the client to determine the optimal timing of the diuretic. Educate the client about increasing intake of potassium-rich foods. Encourage the client to drink at least 500 ml of fluid each day. Teach the client signs and symptoms of digoxin toxicity to report to the provider.

Infuse potassium chloride using an infusion pump. Teach the client signs and symptoms of digoxin toxicity to report to the provider. Review the daily schedule with the client to determine the optimal timing of the diuretic. Instruct the client to contact the provider before taking any herbals, supplements, or over-the-counter medications. Educate the client about increasing intake of potassium-rich foods. Encourage the client to use one pharmacy to fill and renew prescriptions

2. A nurse is instructing a client on how to use an incentive spirometer. The nurse should instruct the client to use the spirometer using steps. Place the steps in order from first to last. All options must be used. Instruct the client to inhale on the mouthpiece and hold the breath for 3 seconds. Instruct the client to client exhale fully. Instruct the client to take a deep breath and cough. Instruct the client to passively exhale.

Instruct the client to client exhale fully. Instruct the client to inhale on the mouthpiece and hold the breath for 3 seconds. Instruct the client to passively exhale. Instruct the client to take a deep breath and cough. Explanation: The nurse should instruct the client to first exhale fully. The client should then place the mouthpiece of the spirometer in the mouth and inhale and hold the breath for 3 seconds. The client should then exhale passively. Finally, the client should take a deep breath and cough.

11. The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure). The nursing policy manual recommends use of the gauze pad. What should the nurse do? Make sure the gauze pad is dry and the client is in a comfortable position. Reposition the gauze pad around the stoma with the open end downward. Ask the unlicensed assistive personnel to tie the tracheostomy tube ties in the back of the client's neck. Ask a registered nurse to change the ties and position another gauze pad around the stoma.

Make sure the gauze pad is dry and the client is in a comfortable position. Explanation: The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse team leader should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad.

57. The nurse is caring for a client with a metabolic acidosis (pH 7.25). Which value is most useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? PaO2 serum sodium level PaCO2 anion gap

anion gap Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.

63. The healthcare provider prescribes aspirin 325 mg by mouth each day for a client diagnosed with a transient ischemic attack (TIA). During education, how should the nurse identify the purpose of this medication? enhances the immune response controls headache pain reduces the chance of blood clot formation prevents intracranial bleeding

reduces the chance of blood clot formation Explanation: TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, aspirin is prescribed to prevent clot formation by reducing platelet aggregation. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin does not affect the body's immune response. Intracranial bleeding is not associated with TIAs, and aspirin probably would worsen any existing bleeding.

70. The nurse is teaching a client who has had a myocardial infarction about using nitroglycerin spray. Which information should the nurse include in the teaching plan? Select all that apply. "Spray the medication under your tongue as soon as you have chest pain." "If the chest pain continues after 2 spays of the medication, wait 5 minutes and use one more spray." "Store the medication in the refrigerator when not in use." "Call 911 if chest pain continues after 10 minutes of using the third spray." "Swallow the medication as soon as you have sprayed it in your mouth." "Shake the medication container before using."

"Spray the medication under your tongue as soon as you have chest pain." "If the chest pain continues after 2 spays of the medication, wait 5 minutes and use one more spray." "Call 911 if chest pain continues after 10 minutes of using the third spray." Explanation: The nurse should instruct the client to spray the nitroglycerin under the tongue at the first sign of chest pain. If pain continues after using two doses of the medication, wait 5 minutes and administer one more spray. If the chest pain continues after 10 minutes, the client should call 911 and seek emergency assistance. The client should not swallow the medication. The medication should be stored at room temperature away from heat and light, not in the refrigerator. It is not necessary to shake the medication container before use.

68. A nurse is completing discharge instructions for a client who has severe chronic obstructive pulmonary disease. Which information on activity tolerance should the nurse include in the plan of care? Select all that apply. "Eat six small meals each day." "Limit exercise to activities of daily living." "Walk until it is a little hard to breathe." "Sit down if you can when you are cooking, eating, dressing, and bathing." "Walk 15 to 20 minutes daily at least 3 times a week."

"Walk until it is a little hard to breathe." "Eat six small meals each day." "Walk 15 to 20 minutes daily at least 3 times a week." "Sit down if you can when you are cooking, eating, dressing, and bathing." Explanation: Encourage the client to walk 15-20 minutes a day at least three times a week with gradual increases to build up strength. Clients should be instructed to walk until it is a little hard to breathe. Eat smaller meals more often, such as six small meals a day, to make it easier to breathe when the abdomen is not full. Conserve energy by sitting down while cooking, eating, dressing, and bathing.

65. The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the healthcare provider? continuous bubbling in the suction-control chamber subcutaneous emphysema at the insertion site intermittent bubbling in the water seal chamber 600 mL of blood in the collection chamber in 1 hour

600 mL of blood in the collection chamber in 1 hour Explanation: A blood loss of 600 mL may place the client in danger of developing hypovolemic shock. All of the other choices are normally expected with a chest tube.

24 The nurse is evaluating the client after receiving t-PA 12 hours ago. Which findings indicate that the t-PA has been effective? Select all that apply. Headache pain rated as 1 on a scale of 0 to 10 Slightly slurred speech Blood glucose 105 mg/dL (5.83 mmol/L Client exhibiting resistance to gravity Pupils are equal and respond to light and accommodation (PERRLA) Temperature 98.1°F (36.7°C)

Headache pain rated as 1 on a scale of 0 to 10 Slightly slurred speech Client exhibiting resistance to gravity

67. When providing care for clients with possible arterial disease, the nurse recognized which clients should have a baseline ankle-brachial index (ABI) assessed? Select all that apply. 72-year-old client in the nursing home 55-year-old client with family history of arterial disease 50-year-old client with hypertension 65-year-old client with decreased pulses 75-year-old client with diabetes

65-year-old client with decreased pulses 72-year-old client in the nursing home 75-year-old client with diabetes Explanation: ABI is the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the arm. It is used to quantify the degree of stenosis in a client with arterial disease. Nurses should perform a baseline ABI on clients with decreased pulses or any clients older than 70 years, especially clients with a history of diabetes or tobacco use.

35. The nurse has performed the interventions as prescribed by the health care provider. For each assessment finding, click to specify whether the finding indicates that the client's condition has improved, has not changed, or has declined. Assessment FindingImprovedNo ChangeDeclinedUse of accessory musclesPulse oximetry reading 90%Absent lung soundsWheezing Improved. No Change Declined Absent lung sounds Pulse oximetry reading 90% Use of accessory muscles Wheezing

Absent lung sounds - Improved Pulse oximetry reading 90% - Improved Use of accessory - Improved muscles Wheezing - No Change

6. When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which instruction? Avoid exposure to people with known respiratory infections. Participate regularly in aerobic exercises. Abstain from cigarette smoking. Maintain a high-protein diet.

Abstain from cigarette smoking. Explanation: Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneficial, will not decrease the risk of COPD. Insufficient protein intake and exposure to people with respiratory infections do not increase the risk of COPD.

25. The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular fibrillation (see photo). What should the nurse do? Move the paddle in the nurse's left hand to the midline. Move the paddle in the nurse's right hand to above the client's nipple. After pressing the charge button and calling "all clear," push the shock button. Grasp the handles of the paddles to allow visibility of the black markings on the paddle.

After pressing the charge button and calling "all clear," push the shock button. Explanation: The paddles are in the correct position. The nurse can push the shock button to defibrillate the client.

29. The nurse is caring for a client during the postsurgical period after having a right femoral-popliteal bypass graft. The nurse enters the room to conduct a nursing assessment and care. Order the nurse's actions according to priority. All options must be used. Assess incision site. Assess peripheral pulses. Assess lung fields. Assess pain/obtain medication. Instruct on client positioning. Offer clear fluids.

Assess peripheral pulses. Assess incision site. Assess lung fields. Assess pain/obtain medication. Instruct on client positioning. Offer clear fluids. Explanation: Following a femoral-popliteal bypass, it is most important to assess circulation to the lower extremity by assessing the quality of the right pedal (peripheral) pulse. By assessing a strong pulse, the nurse knows that the graft is functioning. Next, the nurse assesses the incision site noting any bleeding. Lung sounds are assessed because the client had anesthesia. Lastly, the nurse assesses the client's pain level and obtains medication as

8. A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first? Place the client on oxygen. Administer amiodarone I.V. as prescribed. Confirm the rhythm with a 12-lead ECG. Assess the client's airway, breathing, and circulation.

Assess the client's airway, breathing, and circulation. Explanation: The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless. Therefore, the nurse must first assess the airway, breathing, circulation, and level of consciousness to establish the client's stability. Different actions are required if the client's VT is unstable or pulseless.

23. The nurse is developing a plan of care to prevent the client from aspirating. Which step(s) can the nurse take to prevent aspiration? Select all that apply. Raise the head of the bed above 90 degrees. Request a consultation with occupational therapy. Introduce foods on the unaffected side when the client first takes food. Complete a dysphagia screening before providing the client with solids or fluids. Teach the client to tuck their chin before swallowing. Liquify solid foods.

Complete a dysphagia screening before providing the client with solids or fluids. Introduce foods on the unaffected side when the client first takes food. Request a consultation with occupational therapy. Teach the client to tuck their chin before swallowing.

21. The nurse has received orders from the health care provider. Which three orders should the nurse perform right away? Enoxaprin sodium 150 nEq t-PA stat Cranial x-ray Blood glucose stat CT scan stat Neurologic assessment every 15 minutes

CT scan stat Neurologic assessment every 15 minutes Blood glucose stat

43. The nurse is caring for a client who states an increase in dyspnea. Which intervention would the nurse perform first? call MD Check O2 sat Put O2 mask

Check O2 sat Explanation: Assessment is the first step in the nursing process. Assessing the pulse oximeter reading provides valuable information on the client's condition. Once the information is known, obtaining a breathing treatment or applying an oxygenated facemask, especially for a pulse oximeter reading under 90%, is appropriate. Health care provider notification would also be necessary as oxygen is a medication requiring an order.

50. For each assessment finding, click to specify if the finding indicates digoxin toxicity or salicylate toxicity. Each finding may support more than one condition. Digoxin Toxicity vs Salicylate Toxicity Dizziness Abdominal discomfort Loss of appetite Yellow-green halos

Dizziness - both Abdominal discomfort - both Loss of appetite - Digoxin Toxicity Yellow-green halos - Digoxin Toxicity

64. A client returns from left aortofemoral bypass surgery. Identify the area on the illustration where the nurse should place the Doppler ultrasound to assess the left dorsalis pedis pulse.

L top foot Explanation: The pulse is located on the anterior aspect of the left foot.

34. The health care provider has called with prescriptions for the client. Highlight the prescriptions the nurse should perform right away. O2 at 2 L via nasal cannula. Titrate to keep O2 saturation above 96%. IV saline lock Methylprednisolone sodium succinate 40 mg IV x1 dose. Notify health care provider of response to medication. ABGs, complete blood count (CBC), comprehensive metabolic panel (CMP) Chest x-ray Albuterol sulfate via nebulizer inhalation 2.5 mg every 4 hr Montelukast sodium 10 mg PO qhs Bed rest

O2 at 2 L via nasal cannula. Titrate to keep O2 saturation above 96%. IV saline lock Methylprednisolone sodium succinate 40 mg IV x1 dose. Notify health care provider of response to medication. ABGs, complete blood count (CBC), comprehensive metabolic panel (CMP) Albuterol sulfate via nebulizer inhalation 2.5 mg every 4 hr

27. The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next? Use goggles that include the hairline. Wear a powered air purifying respirator (PAPR) face shield. Proceed to suction the client's tracheostomy. Change to a surgical mask.

Proceed to suction the client's tracheostomy. Explanation: The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.

62. A client with a history of heart failure has just been admitted with dyspnea and pulmonary edema. What is the appropriate action of the nurse? Select all that apply. Raise the head of the bed. Administer furosemide 60 mg I.V. push. Administer carvedilol 3.125 mg. Administer morphine 2-4mg I.V. push. Administer hi-flow oxygen.

Raise the head of the bed. Administer morphine 2-4mg I.V. push. Administer furosemide 60 mg I.V. push. Administer hi-flow oxygen. Explanation: This client is experiencing acute decompensated heart failure. Treatment for heart failure exacerbation and pulmonary edema includes oxygenation (raise head of the bed and administer oxygen); remove fluids with furosemide and decrease the workload of the heart; improve alveolar gas exchange; and increase cardiac output using morphine also with administration of additional cardiac medications. Carvedilol is not used for worsening heart failure.

33. The nurse is planning care for the client. Which intervention(s) would the nurse include in the client's plan of care? Select all that apply. Position client in high Fowler position. Monitor the client's pulse oximetry. Request a prescription for a central line to be placed. Encourage ambulation. Encourage pursed-lip and diaphragmatic breathing. Request a prescription for oxygen. Request a prescription for arterial blood gases (ABGs). Place a crash cart with intubation drawer at the bedside.

Request a prescription for oxygen. Monitor the client's pulse oximetry. Request a prescription for arterial blood gases (ABGs). Position client in high Fowler position. Encourage pursed-lip and diaphragmatic breathing.

19. (1 of 6) The nurse is caring for a 50-year-old male client in the emergency department (ED). Nurses' Notes Today: 0800 A client presented to the ED with a headache, slurred speech, and right-sided arm weakness. The client was brought to the ED by a family member, who states they were at lunch when the client began to show symptoms about 30 minutes ago. The client is alert and oriented to person, place, time, and situation. Vital signs are temperature 97.7°F (36.5°C); heart rate 89 bpm; respiration rate 22 breaths/min; blood pressure 170/89 mm Hg; and oxygen saturation 96% on room air. PERRLA assessment reveals a 4-mm pupil size. The client reports a headache pain of 8 on a scale of 0 to 10. The client has a medical history of high blood pressure, diabetes, and high cholesterol. Confusion Heart rate of 89 bpm Right-sided arm weakness Headache Respiration rate of 22 breaths/min Slurred speech

Right-sided arm weakness Slurred speech Headache Confusion Explanation: The client has right-sided arm weakness, headache, and notable slurred speech, which are findings that indicate the client may be having a stroke. The heart rate and the respiration rate are within normal limits. Summary Explanation: The nurse is caring for a 50-year-old male client in the emergency department (ED). Recognize the most important cues that need to be addressed immediately: right-sided arm weakness, slurred speech, headache, and confusion. Identify the most likely hypothesis for the client: cranial hemorrhage is a risk if t-PA is administered after a hemorrhagic stroke. Anticipate the client will need a CT scan, neurological assessments every 15 minutes, and a blood glucose check right away. Knowing clinical judgment when administering t-PA, the nurse knows contraindications include: currently taking anticoagulant medications and any gastrointestinal bleeding within the past 3 weeks. Knowing clinical judgment when feeding a client with dysphasia, the nurse should complete a dysphagia screening prior to providing food or fluids, introduce foods on the unaffected side, and request a consultation with occupational therapy. Evaluate whether the t-PA has been effective; headache 1/10, slight slurred speech, and client now exhibits resistance against gravity are signs of improvement.

4. What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? Select all that apply. reduce fat decrease cholesterol refrain from eating processed foods limit calorie intake to 1500 calories per day substitute saturated fats for unsaturated fats

reduce fat decrease cholesterol Explanation: Intermittent claudication is a symptom of atherosclerosis. Association guidelines recommend a diet with decreased fat, decreased cholesterol, and unsaturated fats instead of saturated fats to prevent disease. Guidelines do not recommend limiting the number of calories to 1500, nor do they specifically recommend refraining from processed foods.

52. The nurse is collaborating with the health care provider on a plan of care for this client. Which order(s) should the nurse anticipate in the care for this client? Select all that apply. Restrict fluids. Monitor serum electrolytes. Hold digoxin. Monitor serum digoxin levels. Provide education on medication safety. Provide continuous cardiac monitoring. Administer potassium. Perform medication reconciliation.

.Hold digoxin. Monitor serum digoxin levels. Monitor serum electrolytes. Provide continuous cardiac monitoring. Perform medication reconciliation. Provide education on medication safety.

69. The nurse is revising a care plan for a client with peripheral arterial disease and a risk for impaired skin integrity. Which client outcomes would indicate the client was successful with interventions? Select all that apply. Wears protective shoes. Adheres to meticulous hygiene schedule. Avoids prolonged standing or sitting. Experiences decreased muscle pain with walking. Avoids trauma and irritation to skin.

Adheres to meticulous hygiene schedule. Avoids trauma and irritation to skin. Wears protective shoes. Explanation: The client with peripheral arterial disease has a risk for impaired skin integrity due to poor circulation. Adhering to a meticulous hygiene schedule will keep the skin clean and dry; wearing protective shoes can prevent blisters and foot injury. Avoiding trauma and irritation to the skin will help protect the skin from injury. While avoiding prolonged standing or sitting and having decreased muscle pain with walking can help with improved circulation, it does not prevent skin integrity impairment.

3. A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Administer oxygen by nasal cannula as ordered. Auscultate breath sounds bilaterally every 4 hours. Instruct the client to breathe into a paper bag.** Encourage the client to deep-breathe and cough every 2 hours.

Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

55. (1 of 1) The nurse is reviewing the Nurse's Notes and Diagnostic Test Results of today and 3 months ago with the health care provider. For each assessment finding, click to specific if the finding indicates the client's condition has improved, declined, or has not changed. Improved Declined No change Apnea/hypopnea index Oxygen saturation Vital signs Headache BMI Alcohol intake

Apnea/hypopnea index - Improved Oxygen saturation - Improved Vital signs - No change Headache - Improved BMI - Improved Alcohol intake - Improved Explanation: Obstructive sleep apnea causes the upper airway to become obstructed during sleep, producing periods of apnea and arterial oxygen desaturation that result in hypertension, daytime sleepiness, and increased risk of accidents, diabetes, and cardiovascular disease. The apnea/hypopnea index, measured during the polysomnogram, determines the number of episodes of apnea and hypopnea and divides it by the number of hours of sleep to calculate the severity of apnea. This client's apnea/hypopnea index declined from 20 to 25 respiratory episodes/hour 3 months ago to 14 to 20 respiratory episodes/hour currently, indicating an improvement in their obstructive sleep apnea. The client's oxygen saturation during periods of apnea increased from 85% to 89% from the first sleep study to the second study, respectively. The client was waking up with a headache 4-5 days/week 3 months ago and now wakes up with a headache 2-3 days/week, showing an improvement in the frequency of this symptom. The client's BMI has declined from 30.7 to 29.2. Since obesity is a risk factor for obstructive sleep apnea, a reduction in body weight is an improvement. The client has also reduced their intake of alcohol, another risk factor for obstructive sleep apnea, from 2-3 beers/night to one beer/night. No findings indicate the client's condition has declined.The vital signs from 3 months ago and today are essentially the same. The blood pressure, which was elevated 3 months ago, is still elevated today. Obstructive sleep apnea can result in hypertension. Summary Explanation: A 52-year-old male client presents to the sleep clinic with daytime fatigue and loud snoring at night. Recognize the most seriou

48. When teaching the client with hypertension to avoid orthostatic hypotension, the nurse should provide which instructions? Select all that apply. Arise slowly from bed. Avoid standing still for long periods. Avoid hot baths. Plan regular times for taking medications. Avoid excessive alcohol intake.

Arise slowly from bed. Avoid standing still for long periods. Explanation: Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.

72. A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply. Place gauze between the ears and oxygen tubing to prevent skin irritation. Request a large, pressurized oxygen tank for use during car travel. Increase oxygen flow at night during hours of sleep. Avoid use of a microwave oven when using oxygen. Apply petroleum jelly on lips and nose to prevent dryness and irritation. Avoid areas where people are smoking cigarettes or cigars.

Avoid areas where people are smoking cigarettes or cigars. Place gauze between the ears and oxygen tubing to prevent skin irritation. Explanation: Close proximity to smoking, fire, and small electrical appliances can be a fire hazard and should be avoided. The use of gauze is helpful in preventing skin irritation from the constant pressure and friction of the oxygen tubing. Typically, oxygen needs are lower at rest and during sleep. Increasing oxygen flow should be done at the discretion of the prescribing healthcare provider and not the client. Water soluble lubricants are considered safer than petroleum-based lubricants. Small liquid oxygen tanks are easier to transport during travel than pressurized tanks. Use of microwave ovens for cooking is considered safe for those using supplemental oxygen.

30. (1 of 6) The nurse is caring for a 19-year-old client who has presented to the emergency department (ED). Nurses' Notes 1600: A 19-year-old client presented to the ED with dyspnea and nonproductive cough. The client appears to be using accessory muscles to breathe and is diaphoretic. The client's friend states that the client used a rescue inhaler twice earlier today but symptoms appear to have gotten worse. The friend reports that the client "was fine this morning" but that the symptoms appeared when the client participated in a 5K road race. The client is alert and oriented to person, time, and place. Vital signs (VS) are temperature 98.8°F (37.1 C), heart rate 96 bpm, respiratory rate 24 breaths/min, blood pressure 142/74 mm Hg. and pulse oximetry 92% on room air. Wheezes are heard bilaterally in upper lobes, and diminished lung sounds are heard bilaterally in lower lobes. S1, S2 auscultated; rapid and regul

Dyspnea Use of accessory muscles Lung sounds Explanation: The client's dyspnea, use of accessory muscles to breathe, and wheezes with diminished lung sounds are concerning. The client appears to be in respiratory distress, and these findings require follow-up. The client's cardiovascular assessment, capillary refill, and neurological assessment are not of highest concern to the nurse at this time. The only abnormal finding is tachycardia in the cardiovascular assessment, and a heart rate of 96 bpm is within normal range.

10. Which of the following outcomes is desired when a client with arterial insufficiency has poor tissue perfusion in the extremities? Select all that apply. Lungs clear to auscultation. Decreased muscle pain with activity. Participation in self-care measures. Extremities warm to touch. Improved respiratory status.

Extremities warm to touch. Decreased muscle pain with activity. Explanation: The desired outcome for the client with poor circulation to the extremities is evidence of adequate blood flow to the area. The temperature of the involved extremity is an important indicator for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indicates adequate blood flow. Pain is also an indicator of blood flow. Pain, such as muscle pain, suggests ischemia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Thus, a decrease in muscle pain with activity would suggest improvement in blood flow to the area. Improved respiratory status and clear lungs are unrelated to the poor tissue perfusion. Although participation in self-care measures is always helpful, this outcome is not a result of establishing circulation to the extremities.

60. A nurse is caring for a monitored client on the telemetry unit. When analyzing a cardiac monitor strip, the nurse notes an abnormality in the QRS wave on lead II. Identify the area in the conduction cycle of the heart where this abnormality occurs. picture of heart

Left side at purkinje fibers Explanation: The correct location is the left ventricle. The electrocardiography (ECG) shows the electrical activity of the heart over time as detected by electrodes attached to the body surface. Lead II is noted as a limb lead. The QRS complex reflects the rapid depolarization of the right and left ventricles, thus an abnormality in the ventricular conduction will be reflected in the QRS wave.

39. The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do? Lower the drainage system to maintain gravity flow. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. Notify the health care provider (HCP) of the amount of chest tube drainage. Add water to maintain the water seal.

Lower the drainage system to maintain gravity flow. Explanation: To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the HCP. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.

44. A client is admitted to the emergency department with a broken humerus after a motor vehicle collision. Significant assessment findings include respiratory rate 28 breaths/min and arterial blood gas (ABG) readings of pH 7.51, PaCO2 30 mm Hg (3.99 kPa), HCO3 23 mEq/L (23 mmol/L), and PaO2 90 mm Hg (11.97 kPa). Which nursing action would be a priority? Continuously assess pulse oximetry. Offer reassurance, and treat the client's pain. Administer lorazepam sublingually. Administer albuterol (salbutamol) inhaler.

Offer reassurance, and treat the client's pain. Explanation: The client is hyperventilating and exhibiting respiratory alkalosis. The priority action is to reduce the client's respiratory rate by reducing anxiety and pain. The client's PaO2 on the blood gas analysis is within normal range, so pulse oximetry is not an immediate priority. Administering albuterol is not required in respiratory alkalosis and could increase the client's anxiety. Pharmacologic control of anxiety is used only if nonpharmacologic interventions are not effective.

38. A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values (see report). Which finding is abnormal? pH PaO2. HCO3-. PaCO2

PaCO2 Explanation: The normal range for PaCO2 is 35 to 45 mm Hg (4.7 to 6 kPa). Thus, this client's PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the health care provider (HCP) because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.

31. The nurse is analyzing clinical manifestations to determine which condition the client may be experiencing. For each client finding below, click to specify whether the finding is consistent with pneumonia, tension pneumothorax, or asthma. Each finding may support more than one condition. Pneumonia Tension Pneumothorax Asthma Decreased cardiac output Dyspnea Cough Trachea deviated away from the affected side Fever

Pneumonia Decreased cardiac output - Dyspnea X Cough X Trachea deviated away from the affected side - Fever - Tension Pneumothorax Decreased cardiac output X Dyspnea X Cough X Trachea deviated away from the affected side X Fever - Asthma Decreased cardiac output - Dyspnea X Cough X Trachea deviated away from the affected side - Fever X

45. The nurse is preparing a teaching plan for a client who is being discharged after being admitted for chest pain. The client has had one previous myocardial infarction 2 years ago and has been taking simvastatin 40 mg for the last 2 years. After reviewing the lab results for the client's cholesterol levels (see chart), what should the nurse do? Ask if the client is taking the simvastatin regularly. Instruct the client to lower the saturated fat in the diet. Review the chart for lab reports of hemoglobin and hematocrit. Tell the client that the cholesterol levels are within normal limits.

Tell the client that the cholesterol levels are within normal limits. Explanation: The serum cholesterol is within normal range for this client indicating the medication is effective. Since the cholesterol levels are within normal limits, it is likely that the client is taking the medication and asking may indicate the nurse has doubts or mistrusts that the client is taking the medication. The client does not need to change the diet at this point. Hemoglobin and hematocrit are not affected by simvastatin; since liver damage is a side effect of simvastatin, the nurse could review the liver function studies.

22. The nurse is determining if the client has any contraindications to receiving t-PA medication. Which finding(s) would be a contraindication to the administration of t-PA? Select all that apply. The symptoms began less than 3 hours ago. The client is younger than 85 years of age. The client takes metformin for diabetes. The blood pressure is lower than 185/110 mm Hg The client is experiencing disabling stroke symptoms. The client had a gastrointestinal bleed 2 weeks ago. The client currently uses anticoagulant medications.

The client currently uses anticoagulant medications. The client had a gastrointestinal bleed 2 weeks ago.

7. A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately? oxygen saturation of 70 % on room air increased fremitus absent breath sounds on the affected side pain on the affected side of 6 on a scale of 1 to 10 when the client breathes

absent breath sounds on the affected side Explanation: Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds and is indicative of a pneumothorax. The nurse should notify the health care provider. An oxygen saturation of 70 percent is expected when a client has a crushing chest injury. Fremitus is a sign of increased lung consolidation. Moderate to severe pain is an expected finding following a crushing chest injury.

46. A sedentary, obese, middle-aged client is recovering from surgery to remove an embolus in the right iliac artery. The nurse should develop a discharge plan with the client that will focus on participating in which activities? Select all that apply. wearing supportive athletic shoes weight control stress management aerobic activity strength training

aerobic activity weight control Explanation: Discharge teaching begins when the client enters the hospital. One of the risk factors for clot formation is a sedentary lifestyle, and the client should engage in daily aerobic activity, such as biking or swimming (non-weight-bearing). The client is also overweight and should plan to control the weight through dietary counseling or attending weight management programs in the community. Strength training is beneficial by increasing strength and lean body mass, but not helpful in preventing vascular disease. Stress management is not a focus based on the client's needs at this time. It is not necessary to wear special supportive shoes; comfortable shoes for walking are adequate.

28. The nurse performs an assessment on a newly-admitted client with a diagnosis of left-sided heart failure. What data should the nurse document to support this diagnosis? Select all that apply. lower extremity edema chest pain rapid weight gain flushed face chronic cough rapid pulse

chronic cough lower extremity edema rapid weight gain rapid pulse Explanation: Chronic cough, lower extremity edema, rapid weight gain, and rapid pulse are the classic symptoms of left-sided heart failure. A flushed face is usually associated with hypertension. Chest pain is usually associated with a myocardial infarction.

51. The nurse is reviewing the Nurse's Notes and Laboratory Results of 0930 to develop a plan of care for this client. Complete the following sentence by choosing from the lists of options. The client is at highest risk for developing __________ dysrhythmias anaphylaxis renal failure due to the client's __________ potassium level blood glucose level cardiac exam and__________ serum digoxin level serum creatinine vital signs

dysrhythmias potassium level serum digoxin level

13. What should the nurse recognize as the first sign of peripheral arterial disease (PAD) in inactive older adults? dry, shiny skin of the extremities pain in the extremities diminished pulses gangrene

gangrene Explanation: In older adults who are inactive, limb ischemia or gangrene may be the first sign of PAD because these clients manage their lifestyle by adjusting for limitations imposed by comorbidity; therefore, not walking far enough to develop the pain of claudication. Even though diminished pulses and dry, shiny skin may be present, this is not apparent until trauma occurs and gangrene develops.

14. The nurse is caring for a client who is suspected to have overdosed on opioids. Assessment findings include a heart rate of 60 beats/minute, respiratory rate of 6 breaths/minute, a blood pressure of 95/55 mmHg, and an oxygen saturation of 96% on room air. Based on the assessment findings, what is the nurse's priority concern? total airway occlusion hypoxic respiratory failure hypercapnic respiratory failure decreased organ perfusion

hypercapnic respiratory failure Explanation: When ventilation is impaired, as is indicated by the low respiratory rate of 6 breaths/minute, the body retains CO2 because the carbonic acid level increases in the blood. The client's oxygen saturation is in an acceptable range, so hypoxia and airway occlusion are not evident at present. The blood pressure is low but has an adequate mean arterial pressure (MAP) of 68 mmHg, which is adequate for organ perfusion. Preferred MAP is > 65 mmHg, and an adequate MAP for perfusion is > 60 mmHg.

32. Complete the following sentence by choosing from the list of options. The client is at risk for _________ hypoxia pulmonary embolism pneumothorax stroke as evidenced by ________ respiratory assessment neurological assessment cardiovascular assessment capillary refill

hypoxia respiratory assessment

17. The nurse receives a change-of-shift report on the following four clients. Which client should the nurse assess first? client with cystic fibrosis who has an albuterol nebulizer treatment due in 10 minutes immobile client with a sudden onset of shortness of breath client with influenza who has a temperature of 101.5°F (38.6°C) client with atrial fibrillation who has a dose of diltiazem due in 15 minutes

immobile client with a sudden onset of shortness of breath Explanation: Immobility places a client at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in an immobile client suggests the presence of a possible pulmonary embolism and requires immediate assessment and action, such as oxygen administration. The remaining clients are stable with expected symptoms, medications, and/or tests associated with their disease processes.

59. The nurse is conducting a health history on a client with peripheral vascular problems. Which statements would suggest increasing problems with the peripheral vascular circulation? Select all that apply. Acute lower leg pain and swelling to the left calf over the past 24 hours numbness and tingling in both feet when sitting for long periods of time mild chest pain that is relieved with rest. more swelling in the feet at the end of the day. increased pain in the legs at rest and a chronic ulceration on the right heel

increased pain in the legs at rest and a chronic ulceration on the right heel Acute lower leg pain and swelling to the left calf over the past 24 hours more swelling in the feet at the end of the day. numbness and tingling in both feet when sitting for long periods of time Explanation: Increased pain at rest with ulcers, as well as numbness and tingling to the feet, can be indications of peripheral vascular disease, either arterial or venous. Mild chest pain relieved with rest is angina. Acute lower leg swelling to the calf is most likely a deep vein thrombosis, and swelling in the feet at the end of the day is generally a sign of congestive heart failure; both of these health problems involve an etiology that includes peripheral vascular circulation.

49 (1 of 6) The nurse on the telemetry unit is caring for a 78-year-old female client, with heart failure and a history of atrial fibrillation, who is admitted with dizziness, loss of appetite, and abdominal pain for the past 2 days. Nurse's Notes Medications Diagnostic Tests Medical History 0900 Client reports the onset of dizziness and abdominal pain over the last 2 days. In addition to a lack of appetite, client reports not drinking a lot due frequent urination at night. Client also reports seeing yellow-green halos and the recent onset of dizziness when standing from lying in bed or sitting in a chair. Client thought presenting symptoms may be due to a recent cold, which they self-treated with ginseng, recommended by a family member. Client denies shortness of breath. Basilar crackles auscultated bilaterally. Auscultation of heart reveals S1, S2, and S3; no murmurs or rubs heard. Bilateral 1+ pedal edema noted. S

loss of appetite and abdominal pain dizziness when standing tenting of skin when pinched Explanation: This older adult with atrial fibrillation, hypertension, and heart failure has multiple assessment findings that require follow-up. A loss of appetite and abdominal pain in a client with atrial fibrillation and heart failure, who is taking several medications, requires follow-up.The client has orthostatic hypotension, a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more when changing from a lying to a standing position. This finding requires follow-up and can occur with dehydration. The tenting and slow return of the skin to normal when pinched is a sign of dehydration and requires follow-up. The client's heart rate is within normal range and does not require follow-up. The oxygen saturation level of 96% is within normal limits and does not require follow-up. The client's electrocardiogram (ECG) shows normal sinus rhythm and does not require follow-up. Summary Explanation: A 78-year-old female client with atrial fibrillation and heart failure is admitted to the telemetry unit with dizziness, loss of appetite, and abdominal pain for the past 2 days. Recognize the most serious cues that need immediate follow-up: dizziness, loss of appetite, abdominal pain, yellow-green halos, orthostatic hypotension, and self-medication with ginseng. Analyze these cues to compare different events related to serum drug levels. In this case study, digoxin toxicity and salicylate toxicity were compared.Identify and prioritize the most likely and the most serious hypotheses to prevent further harm in the client, and be able to establish a care plan. This client is at risk for dysrhythmias due to a digoxin level in the toxic range and hypokalemia. Generate solutions by anticipating

58. A client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? respiratory acidosis respiratory alkalosis metabolic alkalosis metabolic acidosis

metabolic acidosis Explanation: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) − (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

54. The nurse is preparing the client for discharge. Which assessment finding(s) indicates an effective outcome? Select all that apply. serum potassium level client verbalized the need to reduce potassium in diet client will use one pharmacy skin returns quickly when pinched serum digoxin level orthostatic blood pressure

orthostatic blood pressure skin returns quickly when pinched client will use one pharmacy serum digoxin level serum potassium level

9. Which orders would the nurse anticipate initially in a client admitted with unrelieved chest pain? Select all that apply. troponin level now cardiac diet morphine sulfate 4 mg intramuscularly as needed for chest pain electrocardiogram in 72 hours bed rest computerized tomography scan of chest

troponin level now cardiac diet bed rest Explanation: The nurse would expect troponin levels, cardiac diet, as well as bed rest. The other orders would not be anticipated for this client.

56. When assessing a client with heart failure, the nurse should immediately report which findings to the health care provider (HCP)? Select all that apply. 2-pound (0.9- Kg) weight gain in 5 days confusion O2 saturation 94% on room air bibasilar crackles blood pressure 108/62 mm Hg, heart rate 88 beats per minute urine output 20 mL/hr

urine output 20 mL/hr confusion The nurse reports signs of decreased tissue perfusion to the HCP; these include a decrease in urine output and confusion. Crackles, edema, and weight gain are monitored closely, but are not as high a priority as decreasing tissue perfusion. Vital signs and oxygen saturation are within normal limits.

47. The nurse interprets the rhythm strip (see figure) from a client's bedside monitor as which rhythm? normal sinus rhythm ventricular fibrillation ventricular tachycardia sinus tachycardia spaced some ST elevation

ventricular tachycardia Explanation: This rhythm is ventricular tachycardia, which is characterized by an absent P wave and a heart rate of 140 to 220 bpm. Ventricular tachycardia requires immediate intervention, usually with lidocaine.

61. The nurse caring for a client with an arterial line notes that the client's heart rate is 124 beats/min, temperature is 101.5°F (38.6°C), and has positive blood cultures and redness at the insertion site. Which situation does the nurse suspect? Arterial spasm Dislodgement of catheter Arterial line infection Embolism at tip of catheter

Arterial line infection Explanation: The nurse should suspect arterial line infection. The elevated temperature, elevated heart rate and positive blood cultures indicate an infection. In addition, the redness at the arterial line insertion site indicates that it might be infected.

5. An older adult is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations (see nurse's notes below). At 2015, the nurse places the client on the ECG monitor and identifies the following rhythm (see below). What should the nurse do? Select all that apply. Have the client sign consent for cardioversion as prescribed. Apply oxygen. Draw blood for a CBC count and thyroid function study. Monitor vital signs. Prepare to defibrillate the client. Teach the client about warfarin treatment and the need for frequent blood testing.

Apply oxygen. Monitor vital signs. Have the client sign consent for cardioversion as prescribed. Explanation: The client has atrial fibrillation and will have an irregularly irregular pulse and will commonly be tachycardic, with rapid ventricular responses (heart rates) typically in the 110 to 140 range, but rarely over 150 to 170. The goal of treatment is the restoration of sinus rhythm. With a heart rate greater than 150 and symptoms such as shortness of breath, dizziness and syncope, and chest pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled heart rates and more minor signs and symptoms, chemical conversion with drugs such as diltiazem and digoxin prior to other interventions such as synchronized cardioversion with appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent for cardioversion requires a prescription from a health care provider (HCP), but with the current heart rate, having cardioversion is a very strong possibility for this client. Defibrillation is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial fibrillation usually require some form of anticoagulation. Drawing labs for CBCs to detect anemia or infection, and thyroid function studies (to determine thyrotoxicosis, a rare, but not-to-be-missed cause, especially in older adults), serum electrolytes and BUN/creatinine (looking for electrolyte disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation; they are not an immediate action.

1. A client with chronic obstructive pulmonary disease (COPD) has a signed living will with a do not resuscitate (DNR) request. While the wife was visiting the client, he had a cardiac arrest. The wife requested the client be resuscitated immediately. When the nurse hesitated to start resuscitation procedures, the wife threatened to sue the hospital. What should the nurse do? Select all that apply. Call the chaplain to come and remain with the wife. Call the code for fear of being sued by the wife. Notify the health care provider (HCP). Carry out the written DNR request and client wishes. Notify the nurse manager of the situation. Calmly remind the wife of the client's wishes and DNR request.

Carry out the written DNR request and client wishes. Calmly remind the wife of the client's wishes and DNR request. Notify the nurse manager of the situation. Call the chaplain to come and remain with the wife. Notify the health care provider (HCP). Explanation: The nurse's role is to carry out the client's written wishes as indicated in the DNR and living will and the nurse should calmly remind the wife of the client's wishes. The nurse next should notify the HCP who will determine that the client has died. The HCP also should reaffirm the client's wishes with the wife. Chaplains are an important resource for families at times of loss. They will remain with the families if they wish and attend to their needs. The nurse manager needs to be notified of the wife's statement in order to notify risk management of a potential legal concern. Not carrying out the client's written directions and wishes places the nurse and the facility under legal liability.

40. The family of a client awaiting heart transplantation is concerned about the financial cost of lifelong antirejection medications following the procedure. Which intervention by the nurse is most appropriate? Discuss how the family might consider fund raising efforts to pay for the costs. Explain that all costs are covered if the client is unable to pay. Contact the social worker to discuss the client and family's financial concerns. Suggest the family discuss the cost with the health insurance provider.

Contact the social worker to discuss the client and family's financial concerns. Explanation: Transplantation requires a multidisciplinary team approach. A social worker is always included as part of that team. The nurse should contact the social worker to discuss the client's and family's financial concerns. The social worker would contact the health insurance provider to discuss the cost of the transplant. It is unlikely that the costs will be covered if the client is unable to pay. Although fund raisers have been used through social media to secure finances to pay for medical expenses, this suggestion is inappropriate for the nurse to make.

73. A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which actions? Select all that apply. Place a pillow under both legs. Prepare for modified postural drainage. Elevate head of bed to 90 degrees. Administer diuretics as ordered. Encourage deep breathing and coughing.

Elevate head of bed to 90 degrees. Administer diuretics as ordered. Explanation: Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.

12. A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? The oxygen concentration is above 44%. The water level in the humidifier reservoir is too low. The oxygen tubing is pinched. The client has a nasal obstruction.

The oxygen tubing is pinched. Explanation: Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

71. A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? increased fremitus Cheyne-Stokes respirations diminished or absent breath sounds on the affected side decreased sensation on the affected side

diminished or absent breath sounds on the affected side Explanation: Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration.

26. The nurse interprets the rhythm strip (see image) from a client's bedside monitor as which rhythm? atrial fibrillation normal sinus rhythm ventricular tachycardia sinus tachycardia

atrial fibrillation Explanation: This rhythm is atrial fibrillation. It is characterized by an irregular QRS interval, no definite P waves before the QRS waves, and a ventricular rate greater than100 bpm.

20. Complete the following sentence by using the list of drop-down options. The nurse determines that the client is at risk for __________ cranial hemorrhaging clotting paralysis if the client were to be administered tissue plasminogen activator (t-PA) when experiencing a(n) ______________ ischemic transiet hemorrhagic stroke because the blood vessels of the brain have already _________ ruptured clotted narrowed

cranial hemorrhaging hemorrhagic ruptured Explanation: The client has right-sided arm weakness, headache, and notable slurred speech, which are findings that indicate the client may be having a stroke. The heart rate and the respiration rate are within normal limits.

41. A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply. tracheal deviation to the opposite side bradypnea flattened jugular veins tracheal deviation to the affected side hypotension decreased cardiac output

decreased cardiac output hypotension tracheal deviation to the opposite side Explanation: Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not to escape on expiration. The air presses against the mediastinum, causing a tracheal shift to the unaffected side and decreased venous return (reflected by decreased cardiac output and hypotension). Neck veins bulge with tension pneumothorax. This also leads to compensatory tachycardia and tachypnea.

66. Which assessments would provide the nurse with the most valuable information to assess the breathing of a client with chronic obstructive pulmonary disease (COPD)? Select all that apply. inspection and palpation for vibrations auscultation and percussion inspection for pursed-lip breathing technique palpation of peripheral pulses exertional effects on breathing

inspection and palpation for vibrations auscultation and percussion exertional effects on breathing inspection for pursed-lip breathing technique Explanation: The nurse should conduct a thorough assessment to gauge the severity of the client's COPD, including inspection, palpation, percussion, and auscultation. The nurse should also observe the extent of the client's dyspnea on exertion. COPD would be unlikely to affect the client's peripheral pulses.

15. The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? respiratory alkalosis metabolic acidosis respiratory acidosis metabolic alkalosis

metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

42. A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber the nurse will mark to record the current drainage level. picture

middle column Explanation: A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the left.