Theory Exam 1 PrepU (F/E; A/B; G.E.)

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

"The ET tube will maintain your airway while you're under anesthesia."

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?

0 to 4 mm

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl

Which is considered an isotonic solution?

0.9% normal saline

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level?

115 mEq/L

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

275-300 mOsm/kg

The nurse is caring for the following group of clients. Select the client most likely to be diagnosed with respiratory alkalosis.

A 26-year-old female with anxiety who has been hyperventilating

What dietary recommendations should a nurse provide a client with a lung abscess?

A diet rich in protein

Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels?

A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use

Which of the following is accurate regarding status asthmaticus?

A severe asthma episode that is refractory to initial therapy

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about?

Absent distal pulses

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?

Administer small volumes of a hypertonic solution.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as

Atelectasis

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

Avoid sports activities for 6 weeks.

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned?

Calcium

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest pain

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Extracellular fluid volume deficit

A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations?

Fatigue, cramps, and weakness

You are speaking at a local PTO meeting about upper respiratory infections. Which preventive factor for rhinitis should you teach the attendees?

Get adequate rest and sleep.

The nurse is aware that the major role of the kidneys in regulating acid-base balance is to increase the production of:

HCO3−

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

Hoarseness of more than 2 week's duration

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia

A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?

Hypomagnesemia

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus

The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?

Increased intracranial pressure

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 38°C The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

The calcium concentration in the blood is regulated by which mechanism?

Parathyroid hormone (PTH)

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

Regular

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis

A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient?

Respiratory alkalosis

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

Restricting fluids to 800 ml/day

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?

Sinus aspirates

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:

Sleep with the head of bed elevated.

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis?

Sodium bicarbonate

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements?

They prolong bleeding.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished?

Vigilant handwashing by staff and residents

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

The nurse is caring for a client receiving an aminoglycoside (antibiotic) that can be nephrotoxic. Which will alert the nurse that the client may be experiencing nephrotoxicity?

a decrease in urine output

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

third-spacing

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

tingling sensation in the fingers

Clients diagnosed with hypervolemia should avoid sweet or dry food because it

increases the client's desire to consume fluid.

Which is the most common cause of symptomatic hypomagnesemia?

Alcoholism

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

A 58-year-old male patient with a 60 pack-year history of cigarette smoking and a history of heavy alcohol use has been diagnosed with laryngeal cancer following a physical examination and endoscopy. The patient has been scheduled for a partial laryngectomy and is highly anxious about the consequences of this surgery. What patient education should the nurse provide for this man?

"A partial laryngectomy has the advantage of having only a minimal effect on your speech."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

"Family members should continue to talk to the client."

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?

"I can use laxatives and enemas but only once a week."

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?

"I will not salt my food; instead I'll use salt substitute."

Which solution is hypotonic?

0.45% NaCl

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Aspiration pneumonia

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Do not eat or drink for 6 hours before the procedure.

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?

MRI can view soft tissues and can help stage cancers.

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?

Mast cells

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

On the cheeks below the eyes

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

280 mOsm/kg.

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be

155 mEq/L (155 mmol/L)

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be

7.50

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?

Low purine

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Metabolic acidosis

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

Partial laryngectomy

The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan?

Performing chest physiotherapy as ordered

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleurisy

In general, chest drainage tubes are not indicated for a client undergoing which procedure?

Pneumonectomy

A client with emphysema is at a greater risk for developing which acid-base imbalance?

chronic respiratory acidosis

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining?

1L

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care.

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

Apply an ice pack

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure.

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis

What would the instructor tell the students purulent fluid indicates?

Infection

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

Daily doses of isoniazid, 300 mg for 6 months to 1 year

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?

Dehydration

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?

Deviation from the midline

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?

Emphysema

Question 8 See full question13sReport this Question Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)?

Exposure to tobacco smoke

Which nerve is implicated in the Chvostek's sign?

Facial

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse.

Which is a true statement regarding severe acute respiratory syndrome (SARS)?

It is most contagious during the second week of illness.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?

Presence of Trousseau sign

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?

Ventilation exceeds perfusion.

You are speaking at a local PTO meeting about upper respiratory infections. Which preventive factor for rhinitis should you teach the attendees?

You are speaking at a local PTO meeting about upper respiratory infections. Which preventive factor for rhinitis should you teach the attendees?

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.

Question 10 See full question23sReport this Question A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

electrocardiogram (ECG) results

A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality?

free water loss

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?

furosemide

A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?

metabolic alkalosis

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

Which set of arterial blood gas (ABG) results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume cycled

Which of the following is not a primary symptom of COPD?

Weight gain