240 Exam 3

62. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics containing base products

1. Respiratory acidosis from inadequate ventilation

30. The patient is receiving IV piggyback doses of genta- micin every 12 hours. Which would be the nurse's pri- ority for monitoring during the period that the patient is receiving this drug? 1. Serum creatinine and blood urea nitrogen levels 2. Patient weight every morning 3. Intake and output every shift 4. Temperature

1. Serum creatinine and blood urea nitrogen levels

The nurse is admitting a patient for whom a diagnosis of a pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child a year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle crash.

630. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 5 seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds

2. 10 seconds

29. Which patient will the charge nurse assign to an RN floated to the acute care unit from the surgical intensive care unit (SICU)? 1. A patient with kidney stones scheduled for litho- tripsy this morning for renal 2. A patient who has just undergone surgery stent placement 3. A newly admitted patient with an acute urinary tract infection (UTI) 4. A patient with chronic kidney failure who needs teaching on peritoneal dialysis

2. A patient who has just undergone surgery for renal stent placement

671. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

2. Acute kidney injury

41. The client has portal hypertension and hepatic enceph- check first to see if the medication is having the desired with lactulose. Which laboratory result will the nurse alopathy secondary to liver disease and is being treated effect? 1. White blood cell count 2. Ammonia level 3. Potassium level 4. Platelet count

2. Ammonia level

201. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Clamp the chest tube and notify the health care provider immediately.

2. Check for an air leak, because the bubbling should be intermittent.

669. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles

21. The nurse notifies the emergency department (ED) health care provider (HCP) about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later the nurse sees that the cli- ent is to be discharged with a follow-up appointment in the morning. The nurse reexamines the client and the symptoms seem worse. What should the nurse do first? 1. Contact the nursing supervisor and express concerns. 2. Express findings and concerns to the HCP. 3. Discharge the client but stress the importance of follow-up. 4. Follow the discharge orders and write an incident report.

2. Express findings and concerns to the HCP.

198. While changing the tapes on a newly inserted tra- cheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

2. Grasp the retention sutures to spread the opening.

722. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia

54. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse mon- itors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis

719. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5 °C (101.2 °F). Which nursing action is most appropriate? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

2. Notify the health care provider.

194. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system immediately. 4. Place a sterile dressing over the disconnection site.

2. Place the tube in a bottle of sterile water.

61. The nurse is caring for a client who is on a mechan- ical ventilator. Blood gas results indicate a pH of 7.50 and a Paco, of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L (145 mmol/L) 2. Potassium level of 3.0 mEq/L (3.0 mmol/L) 3. Magnesium level of 1.3 mEq/L (0.65 mmol/L) 4. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

2. Potassium level of 3.0 mEq/L (3.0 mmol/L)

1. The risk for urinary nurse is reviewing the lab values for a problems. Which finding patient with is of most concern to the nurse? 1. Blood urea nitrogen (BUN) of 10 mg/mL (3.6 mmol/L) 2. Presence of glucose and protein in urine 3. Serum creatinine of 0.6 mg/mL (53 mcmol/L) 4. Urinary pH of 8

2. Presence of glucose and protein in urine

57. The nurse is caring for a client with diabetic ketoaci- dosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallowad 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

2. Respirations that are increased in rate 4. Respirations that are abnormally deep

53. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3 of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated

29. The following clients come to the ment triage desk reporting acute abdominal pain. emergency depart- Which client has the most severe condition? 1. A 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. An 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 4. A 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night

3. A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant

604. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.

3. Ask the client to extend the arms.

36. The disease after hemodialysis. Which patient care action nurse is caring for a patient with chronic kidney should the nurse delegate to the experienced unli- censed assistive personnel (UAP)? 1. Assess the patient's access site for a thrill and bruit. of postdialysis 2. Monitor for signs and symptoms bleeding. and 3. Check the patient's postdialysis blood pressure and weight. 4. Instruct the patient to report signs of dialysis disequilibrium syndrome immediately.

3. Check the patient's postdialysis blood pressure and weight.

The nurse is caring for a client who was admitted to the medical-surgical unit for observation after being eval- uated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to unlicensed assistive personnel (UAP)? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check urometer every hour and observe for red- or pink-tinged urine. 3.Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

3. Check vital signs every hour and report all of the values.

639. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3. Chest pain that occurs suddenly

196. The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assess- ment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

37) The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventila- tion through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3.Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

3. Maintain the head of bed at a 30- to 45-degree angle.

633. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

3. Paradoxical chest movement

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

3. Pasta with sauce

35, The nurse is caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. Which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing with baseline

3. Performing daily weights with the same amount of clothing

6. The nurse is providing care for a patient after a kidne, biopsy. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) Select all that apply. 1. Check vital signs every 4 hours for 24 hours. 2. Remind the patient about strict bed rest for 2 to 6 hours. 3. Reposition the patient by log-rolling with support- ing backroll. 4. Measure and record urine output. 5. Assess the dressing site for bleeding and check complete blood count results. 6. Teach the patient to resume normal activities after 24 hours if there is no bleeding.

3. Reposition the patient by log-rolling with supporting backroll.

55. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) moni- tor displays tachycardia, with a heart rate of 120 beats/ minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PACO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3 4. An increased pH and an increased HCO3

4. An increased pH and an increased HCO3

26. Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles

24. After emergency endotracheal intubation, the health care team and the nurse must verify tube placement before securing the tube. What is the most accurate bedside assessment that can be performed immediately after the tube is placed? 1. Visualize the movement of the thoracic cage. 2. Auscultate the chest during assisted ventilation. 3. Confirm that the breath sounds are equal and bilateral. 4. Check exhaled carbon dioxide levels with capnography.

4. Check exhaled carbon dioxide levels with capnography.

588. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

725. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syn- drome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4. Headache, deteriorating level of consciousness, and twitching

635. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate

720. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of head- ache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP).

632. The nurse is assessing the respiratory status of a cli- ent who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4. Pain, especially with inspiration

197. The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4. Perform the Valsalva maneuver.

7. The nurse is providing nursing care for a 24-year-ol female patient admitted to the acute care unit with a diagnosis of cystitis. Which intervention should t nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient how to secure a clean-catch urine sample 2. Assessing the patient's urine for color, odor, and sediment 3. Reviewing the nursing care plan and add nursing interventions 4. Providing the patient with a clean-catch urine sample container

4. Providing the patient with a clean-catch urine sample container

58. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco, is 90 mm Hg (90 mm Hg), and HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation

4. The nurse has delegated collection of a urinalysis spec- imen to an experienced unlicensed assistive personnel (UAP). For which action must the nurse intervene? 1. The UAP provides the patient with a specimen cup. 2. The UAP reminds the patient of the need for the specimen. 3. The UAP assists the patient to the bathroom. 4. The UAP allows the specimen to sit for more than 1 hour.

4. The UAP allows the specimen to sit for more than 1 hour.

56. The nurse is caring for a client having respiratory distress related to an values are pH=7.53, anxiety attack. Recent arterial blood gas Pao2=72 mm Hg (72 mm Hg), Pac02=32 mm Hg Which conclusion about the client should the (32 mm Hg), and HCO3=28 mEq/L (28 mmol/L). nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating.

4. The client is probably hyperventilating.

What needs to be kept at bedside when a pt has an endotracheal tube placed?

A resuscitation (Ambu) bag needs to be kept at the bedside of a client with an endotracheal tube or a tracheostomy tube at all times.

Liver biopsy Pre-procedure

A. Assess results of coagulation tests (prothrombin time, partial thromboplastin time, platelet count). b. Administer a sedative as prescribed. C. client is placed in the supine or left lateral position during the procedure to expose the right side of the upper abdomen

Heart failure and pulmonary edema: Positioning?

Heart failure and pulmonary edema: Position the client upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion.

Liver biopsy post procedure

a. Assess vital signs. b. Assess biopsy site for bleeding. c. Monitor for peritonitis d. Maintain bed rest for several hours as prescribed. e. Place the client on the right side with a pillow under the costal margin for 2 hours to decrease the risk of bleeding, and instruct the client to avoid coughing and straining. f. Instruct the client to avoid heavy lifting and strenuous exercise for 1 week.

Nasotracheal tubes

a. Inserted through a nostril; this smaller tube increases resistance and the client's work of breathing. b. Its use is avoided in clients with bleeding disorders. C. It is more comfortable for the client, and the client is unable to manipulate the tube with the tongue.

Liver biopsy description

sample for biopsy abdominal wall to the A needle is inserted through the abdominal wall to the liver to obtain a tissue sampl for biopsy and microscopic examination.

28. An unlicensed assistive personnel (UAP) reports to the RN that a patient with acute kidney failure had a urine output of 350 mL over the past 24 hours after receiving furosemide 40 mg IV push. The UAP asks the nurse how this can happen. What is the nurse's best response? 1. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." 2. "There must be some sort of error. Someone must have failed to record the urine output." 3. "A patient with acute kidney failure retains sodium and water, which counteracts the action of the furosemide." 4. "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium."

1. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics."

Cirrhosis description

1. A chronic progressive disease of the liver characterized by diffuse degeneration in destruction of hepatocytes. 2. Repeated destruction of hepatic cells causes the formation of scar tissue 3. Cirrhosis has many causes and is due to chronic damage and injury to liver cells; the most common are chronic hepatitis C, alcoholism, non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis.

31. The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assess- ment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse

1. A deviated trachea

707. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority -sm nursing actions? Select all that apply. 1. Administer oxygen to the client. 2. Continue dialysis at a slower rate after check- ing the lines for air. 3. Notify the health care provider (HCP) and Rapid Response Team. 4. Stop dialysis, and turn the client on the left side with head lower than feet. Bolus the client with 500 mL of normal 5. saline to break up the air embolus.

1. Administer oxygen to the client. 3. Notify the health care provider (HCP) and Rapid Response Team. 4. Stop dialysis, and turn the client on the left side with head lower than feet.

668. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the suspects pulmonary edema. The nurse immediatly asks another nurse to contact the health care provider and prepares to implement which priority intervention? select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intrave- nously 5. Transporting the client to the care unit coronary 6. Placing the client in a low Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intrave- nously

S2. A patient on the medical-surgical unit with acute kid- ney failure is to begin continuous arteriovenous hemo- filtration (CAVH) as soon as possible. What is the priority collaborative action at this time? 1. Call the charge nurse and arrange to transfer the patient to the intensive care unit. 2. Develop a teaching plan for the patient that focuses on CAVH. 3. Assist the patient with morning bath and mouth care before transfer. 4. Notify the health care provider (HCP) that the patient's mean arterial pressure is 68 mm Hg. admitted antidiuretic gravity value

1. Call the charge nurse and arrange to transfer the patient to the intensive care unit.

718. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Increased number of white blood cells in the urine

1. Elevated creatinine level

35. The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply. 1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise. of less than 3. Immediately report a urine output 2 mL/kg/hr. and weigh patients daily. 4. Record intake and output 5. Question any prescriptions for potentially nephro- toxic drugs. 6. Monitor laboratory values that reflect kidney function.

1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise. 4. Record intake and output and weigh pts daily 6. Monitor laboratory values that reflect kidney function.

27. The nurse is providing nursing care for a patient with acute kidney failure for whom volume overload has gate to an been identified. Which actions should the nurse delegate ti the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a stand- ing scale 3. Administering furosemide 40 mg orally twice a day 4. Reminding the patient to save all urine for intake and output measurement 5. Assessing breath sounds 4 hours every 6. Ensuring that the patient's urinal is within reach

1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 4. Reminding the patient to save all urine for intake and output measurement 6. Ensuring that the patient's urinal is within reach

30, The nurse is the preceptor for an RN who is undergo- ing orientation to the intensive care unit. The RN is distress syndrome providing care for a patient with acute respiratory (ARDS) who has just been intu- bated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetri- cal chest movement 2. Uses an end-tidal carbon dioxide detector to con- firm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

(3. Marks the tube 1 cm from where it touches the incisor tooth or nares

The nurse is caring for a client who was admitted to the medical-surgical unit for observation after being eval- uated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to unlicensed assistive personnel (UAP)? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check urometer every hour and observe for red- or pink-tinged urine. 3.Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

(3.) Check vital signs every hour and report all of the values.

Orotracheal tubes

a. Inserted through the mouth; allows use of a larger diameter tube and reduces the work of breathing b. Indicated when the client has a nasal obstruction or a predisposition to epistaxis C. Uncomfortable and can be manipulated by the tongue, causing airway obstruction; an oral airway may be needed to keep the client from biting on the tube.

38. The critical care charge receiving mechanical ventilation. nurse is responsible for the care of four patients Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68 year old patient with a history of smoking and emphysema. 2. A 57 year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

1. A 68 year old pr with a history of smoking and emphysema

34. A client has been admitted with chest trauma after a MVC and has undergone subsequent intubation. The nurse Checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1. Right pneumothorax

the inflow. Which actions should the nurse take? dialysis notes that the client's outflow is less than 716. The nurse monitoring a client receiving peritoneal Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system kinks.

199. The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right

1. Stridor

Liver Biopsy priority Nursing actions

1. Explain the procedure to the client. 2. Ensure that informed consent has been obtained. 3. Position the client supine, with the right side of the upper abdomen exposed; the client's right arm is raised and extended behind the head and over the left shoulder. 4. Remain with the client during the procedure. 5. After the procedure, assist the client into a right lateral (side-lying) position and place a small pillow or folded towel under the puncture site. 6. Monitor vital signs closely after the procedure and mon- itor for signs of bleeding. 7. Document appropriate information about the procedure, client's tolerance, and postprocedure assessment findings. For the client undergoing liver biopsy (or any invasive procedure), the procedure is explained to the client and informed consent is obtained by the health care provider performing the procedure. Since the liver is located on the right side of the upper abdomen, the client is positioned supine, with the right side of the upper abdomen exposed. In addition, the right arm is raised and extended behind the head and over the left shoul- der. This position provides for maximal exposure of the right intercostal spaces. The nurse remains with the client during the procedure to provide emotional support and comfort. After the procedure, the client is assisted into a right lateral (side- lying) position and a small pillow or folded towel is placed under the puncture site for at least 3 hours or as prescribed, to provide pressure to the site and prevent bleeding. Vital signs are monitored closely after the procedure and the client is monitored for signs of bleeding. The nurse documents appro- priate information about the procedure, the client's tolerance, and postprocedure assessment findings.

602 The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as pre- scribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as pre- scribed for pain.

59. The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco, of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1. Nausea 2. Confusion 4. Tachycardia 6. Lightheadedness

711. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemo- dialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1. Palpation of a thrill over the fistula

29.) A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

PRACTICE QUESTIONS e 706. A client with acute kidney injury has a serum potas- sium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if contain or retain potassium. any 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 4. Review the client's medications to determine if contain or retain potassium. any

Cirrhosis complications

1. Portal hypertension: a persistent increase in pressure in a portal vein that develops as a result of obstruction to flow 2. Ascites a. Accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries b. Capillary congestion leads to plasma leaking directly from the liver surface and portal vein 3. Bleeding esophageal varices: fragile, thin walled, distended esophageal veins that become irritated and rupture 4. Coagulation defects a. Decreased synthesis of bile fats in the liver prevents the absorption of fat soluble vitamins b. Without vitamin K and clotting factors II, VII, IX, and X, The patient is prone to bleeding

27. A patient with a pulmonary embolus is receiving anticoagulation with IV Heparin. What instructions would the nurse give the UAP who will help the patient with activities of daily living ? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2 Use an electric razor when shaving the patient each day. 3.Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3.Use a soft-bristled toothbrush or tooth sponge for oral care. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

3. The nurse is caring for a patient with risk for kidney disease for whom a urinalysis has been ordered. What time would the nurse instruct the unlicensed assistive personnel is best to collect this sample? 1. With first morning void 2. Before meal any 3. At bedtime 4. Immediately

1. With first morning void

60. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respi- ratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Paco2 50 mm Hg (50 mm Hg) 2. pH 7.35, Paco2 40 mm Hg (40 mm Hg) 3. pH 7.50, Paco2 52 mm Hg (52 mm Hg) 4. pH 7.52, Paco2 28 mm Hg (28 mm Hg)

1. pH 7.25, Paco2 50 mm Hg (50 mm Hg)

40. The RN is supervising a nursing student who will su tion a patient on a mechanical ventilator. Which actions indicate that the student has a correct under standing of this procedure? Select all that apply. 1.The student nurse uses a sterile catheter and glove 2. The student nurse applies suction while inserting the catheter. 3The student nurse applies suction during catheter removal. 4 The student nurses uses a twirling motion when withdrawing the catheter. 5 The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.

1.) The student nurse uses a sterile catheter and glove 2. The student nurse applies suction while inserting the catheter. 3The student nurse applies suction during catheter removal. 4 The student nurses uses a twirling motion when withdrawing the catheter 5 The student nurse uses a no. 12 French catheter.

26. The nurse is teaching a patient how best to prevent renal trauma after an injury that required a left nephrectomy. Which points would the nurse include in the teaching plan? Select all that apply. 1. Always wear a seat belt. 2. Avoid contact sports. 3. Practice safe walking habits. 4. Wear protective clothing if you participate in contact sports. 5. Use caution when riding a bicycle. 6. Always avoid use of drugs that may damage the kidney.

1.Always wear a seat belt. 2. Avoid contact sports. 3. Practice safe walking habits. 5. Use caution when riding a bicycle.

31 The nurse is assigned to provide nursing care for a mechanical ventilation. Which action patient receiving should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2) Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2) Taking vital signs and pulse oximetry readings every 4 hours

31. A patient diagnosed with acute kidney failure had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient under the RN's supervision asks how a patient with kidney failure can ha such a large urine output. What is the RN's best response? 1. "The patient's kidney failure was caused by hypovolemia, and we have given him IV fluids to correct the problem." 2. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." 3. "With that much urine output, there must have been a mistake in the patient's diagnosis." 4. "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure.'

2. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day."

34.) The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is up. struggling to sit Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (FI02) on the ventilator to 100% in preparation for endotra- cheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2.) Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

2. For which patient is the nurse most concerned about the risk for developing kidney disease? 1. A 25-year-old patient who developed a urinary tract infection (UTI) during pregnancy 2. A 55-year-old patient with a history of kidney stones 3. A 63-year-old patient with type 2 diabetes 4. A 79-year-old patient with stress urinary incontinence

3. A 63-year-old patient with type 2 diabetes

631. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreas ing. Which nursing intervention is appropriate? 1. Continue to suction. 2. Notify the health care provider immediately. 3. Stop the procedure and reoxygenate the client. 4. Ensure that the suction is limited to 15 seconds.

3. Stop the procedure and reoxygenate the client.

The low pressure alarm sounds on a ventilator. The nurses assess the client and then attempt to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check vital signs 3. Ventilate the patient manually 4. Start CPR

3. Ventilate the pt manually

37) A client with end-stage liver disease is talking to the nurse about being on the transplant list. Which state- ment by the client is cause for greatest concern? 1. "I have a family history of diabetes." 2. "I had symptoms of asthma when I was a kid." 3."I guess I should cut back on my alcohol consumption." 4. "I am not very good about taking prescribed medication."

3."I guess I should cut back on my alcohol consumption."

33.) The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assess- ment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3.The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.

3.)The patient is unable to remember her husband's first name.

32 After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive per- sonnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min of 168/90 mm Hg 3. Blood pressure 4 Tympanic temperature of 101.4°F (38.6°C)

4 Tympanic temperature of 101.4°F (38.6°C)

39. After extubation of a patient, which finding would the nurse report to the health care provider IMMEDIATLY? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4Crowing noise during inspiration

4) Crowing noise during inspiration

35.) When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/ min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (F102) and call the health care provider to discuss the patient's status.

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (F102) and call the health care provider to discuss the patient's status.

Interventions for tubes

a. Placement is confirmed by chest x-ray film (correct placement is 1 to 2 cm above the carina). b. Assess placement by auscultating both sides of the chest while manually ventilating with a resuscitation (Ambu) bag (if breath sounds and chest wall movement are absent in the left side, the tube may be in the right main stem bronchus). c. Perform auscultation over the stomach to rule out esophageal intubation. ai zirfT d. If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distention will be present. e. Secure the tube with adhesive tape immediately after intubation. f. Monitor the position of the tube at the lip or nose. g. Monitor skin and mucous membranes. h. Suction the tube only when needed. i. The oral tube needs to be moved to the oppo- site side of the mouth daily to prevent pres- sure and necrosis of the lip and mouth area, ssl prevent nerve damage, an ilitate inspec- tion and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by 2 HCPS.

Endotracheal tube description

a. The endotracheal patent airway. tube is used to maintain b. Endotracheal tubes are indicated when the c. If the client needs mechanical ventilation. client requires an artificial longer than 10 to 14 days, a tracheostomy may be created to avoid cord damage that can be mucosal and vocal airway for caused by the endotracheal tube. d. The cuff (located at the distal end of the tube), when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used; an inflated cuff also prevents air from passing to the vocal cords, nose, or mouth. e. The pilot balloon permits air to be inserted into the cuff, prevents air from escaping, and is used as a guideline for determining the presence or absence of air in the cuff. f. The universal adapter enables attachment of the tube to mechanical ventilation tubing or other types of oxygen delivery systems. g. Types of tubes: orotracheal and nasotracheal