240 Exam 4 PrepU Content & Notes

A 4-year-old with bronchiolitis has been admitted to the hospital with respiratory compromise. The father asks the nurse why the physician won't prescribe an antibiotic, "My child just keeps getting worse." What is the best response by the nurse?

"Bronchiolitis is almost always caused by the respiratory syncytial virus (RSV). Unfortunately, antibiotics don't work on viruses."

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?

"Lately, I have this cough that just never seems to go away."

A nurse is performing discharge teaching for an older adult client diagnosed with osteoporosis. Which statement about home safety should the nurse include?

"Most falls among older adults occur in the home. You should remove throw rugs and install bathroom grab bars."

The nurse is working with a group of caregivers of children diagnosed with asthma. Which statement made by the caregivers is most accurate regarding the triggers that may cause an asthmatic attack?

"My sister and her family love animals, and when we go to their house my daughter always has an asthma attack."

A male patient newly diagnosed with COPD tells the nurse, "I can't believe I have COPD, I only had a cough; are there other symptoms I should know about"? Which of the following is the nurse's best response?

"Other symptoms you may develop are shortness of breath on exertion, and sputum production."

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?

A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

The nurse is assessing the heart rate of a healthy 6-month-old. In which range should the nurse expect the infant's heart rate?

90 to 160 bpm

The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient?

A barrel chest

A group of students are reviewing information about bone healing in children. The students demonstrate understanding of this information when they state:

A child's bones heal more quickly than those of an adult.

Which of the following would be LEAST likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning patient care.

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete?

ABG

Which ethnic group is more likely to develop severe hypertension?

African

A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. The nurse knows this would probably be

Albuterol

A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast?

Assess the fingers for warmth, pain, and function

The experienced licensed practical/vocational nurse (LPN/VN) under the supervision of the registered nurse (RN) team leader is providing nursing care for an infant with respiratory syncytial virus. Which tasks are appropriate for the RN to delegate to the LPN/VN? Select all that apply.

Auscultate breath sounds. Check oxygen saturation using pulse oximetry. Administer prescribed aerosolized medications.

Which of the following is a key diagnostic indicator of heart failure?

BNP (Brain natriuretic peptide)

Signs/symptoms include a pale/dusky appearance, delayed cap refill, cool skin temperature, paresthesia, pain with passive ROM and no improvement in pain regardless of interventions of the affected extremity. Treatment is aimed at restoring blood flow and tissue perfusion.

Compartment Syndrome

In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient?

Compartment syndrome

Which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg?

Complaints of numbness and tingling in toes of affected leg

A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?

Confine the client to bed rest in a darkened room.

The nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. Which nursing interdisciplinary intervention is recommended to help prevent these adverse conditions?

Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion.

Which of the following are general nursing measures for a patient with a fracture reduction?

Encourage participation in ADLs

The nurse is caring for a child with a fractured femur in traction. Which action will the nurse complete while caring for this client?

Ensure traction weights are hanging freely, not touching the bed or floor

This risk factor for a fracture increases every year and can be considered preventable; Can occur in the community and in the hospital setting. This risk factor also results in increased healthcare costs, increased health complications and even mortality

Falls

This can be a serious complication from a fracture; a triad of symptoms includes hypoxemia, neurologic compromise and petechial rash. Interventions include immobilization, surgical fixation/manipulation and respiratory support.

Fat embolism

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit; heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:

Fat embolism syndrome

This fracture complication can result from hemorrhage, more frequently in pelvic and open or femoral fractures. Interventions include: Stabilizing and immobilizing the fracture, restoring volume/circulation and preventing further injury.

Hypovolemia/Shock

This can result in complications on major body systems. Interventions are aimed at maintaining overall health and functional status.

Immobility

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

Which of the following measures may increase complications for a patient with COPD?

Increased oxygen supply

In caring for the child with asthma, the nurse recognizes that which nursing diagnosis would be the highest priority in this child's plan of care?

Ineffective airway clearance related to the diagnosis

The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure?

Jugular vein distention (JVD)

Which of the following terms refers to failure of fragments of a fractured bone to heal together?

Nonunion

This is the most common joint disease; Risk factors include: older age, female, obesity, occupational hazards and a history of previous joint injuries. Management is aimed at reducing pain, improving mobility, weight loss and aerobic exercises.

Osteoarthritis

This fracture complication is a type of infection that can result from external fixation; prevention includes frequent pin care and assessment of each pin site for redness, swelling and pain.

Osteomyelitis

The nursing student recalls that the underlying pathophysiology of chronic obstructive pulmonary disease (COPD) includes the following components: (Select all that apply.)

Overinflated alveoli impair gas exchange. Inflamed airways obstruct airflow. Mucus secretions block airways.

This complication can be prevented post-operatively with the use of an anticoagulant agent, intermittent compression devices and early mobilization.

PE/VTE (thromboembolism)

This complication can result from immobility in general as well as use of an immobilization device (casts, splints or braces) or the use of traction.

Pressure Ulcer

The nurse enters the room of Molly, who has pneumonia. Molly has a low oxygen level and is working hard to breathe. The nurse raises the head of the bed and has Molly tilt her head back. What is the next appropriate action by the nurse?

Provide oxygen therapy to Molly.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

A client has been diagnosed with heart failure. One of the main overall objectives of management of heart failure is which of the following?

Reduce the workload on the heart.

A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing?

Take prescribed medications as scheduled.

What instruction should the nurse's discharge teaching plan for the client with heart failure include?

obtaining daily weights at the same time each day

The client has had hypertension for 20 years. The nurse should assess the client for?

Renal insufficiency and failure.

A nurse is giving instructions to a client who's going home with a cast on his leg. Which teaching point is most critical?

Reporting signs of impaired circulation

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD?

Respiratory failure

Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

Risk for injury related to altered mobility

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

Serum potassium level

A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position?

Sitting upright, leaning forward slightly

When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated?

Smoking cessation

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or a flame is dangerous near oxygen

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

The child will need the blood pressure checked two more times.

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate.

The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. Their friend's child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with:

a bronchodilator and mast cell stabilizers.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.

Which of the following is the strongest predisposing factor for asthma?

allergy

The nurse is teaching the parents about medications for their 9-year-old boy who has a respiratory disorder. The nurse would be alert for an increased need for medications if the child was exposed to second-hand smoke and has which condition?

asthma

Which of the following is the most common chronic disease of childhood?

asthma

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical?

blood pressure elevation

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication?

bone fracture

To help prevent osteoporosis, what should a nurse advise a young woman to do?

consume at least 1,000 mg of calcium daily

This is a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. Nursing interventions are aimed at helping to restore function/mobilization, control pain, control edema, and maintaining health

fracture

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

hemolysis, elevated liver enzymes and low platelet count

The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to:

prevent edema

The nurse is caring for a child who has been admitted with a diagnosis of asthma. What laboratory/diagnostic tool would likely have been used for this child?

pulmonary function test

During a community health fair, a nurse is teaching a group of seniors about health promotion and infection prevention. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?

receive vaccinations

Which action would be most helpful in preventing pressure ulcer formation in an at-risk client?

repositioning every hour

Health promotion activities to reduce the incidence of osteoporosis include:

teaching women to maintain adequate calcium intake.

A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:

visual disturbances

The nurse is caring for a child admitted with asthma. Which clinical manifestations would likely have been noted in the child with this diagnosis?

wheezing

A physician diagnoses primary osteoporosis in a client who has lost bone mass. In this metabolic disorder, the rate of bone resorption accelerates while bone formation slows. Primary osteoporosis is most common in:

elderly postmenopausal women.

A client hospitalized for treatment of hypertension is being prepared for discharge. Which teaching topic should the nurse should be sure to cover?

Maintaining a low-sodium diet

What statement is the most accurate regarding the structure and function of the newborn's respiratory system?

Most infants are nasal breathers rather than mouth breathers.

A 78-year-old client is in the emergency department following involvement in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of her upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma?

Immobilization

This type of surgical intervention could be a result of osteoarthritis, trauma or a congenital deformity. Post-operative preventions include: infection, dislocation and VTE/PE. Overall, the goal is to improve mobility, functional status and quality of life.

Joint replacment

During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition?

mild preeclampsia

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?

mobility status

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating

orthopnea.

A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child?

Lower extremities

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the patient's oxygen saturation.

A client is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications?

Take NSAIDs with food.

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?

diminished reflexes

Which of the following is an important assessment parameter for the patient diagnosed with congestive heart failure?

distended veins

A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse should anticipate using:

diuretics

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

echo cardiogram

The plan of care for a client with hypertension taking propranolol hydrochloride should include:

instructing the client to notify the health care provider of irregular or slowed pulse rate.

A female client who is 32 years of age has been diagnosed with stage 1 hypertension. The client's height is 5 feet 5 inches (165 cm), and her weight is recorded as 125 pounds (56.6 kg); she reports that she frequently eats at "fast food" restaurants and enjoys a glass of wine to relax on weekends. In developing a teaching plan for this client, the nurse should address which topic?

low-sodium food choices

One of the most prevalent bone disorders; most commonly develops after menopause in women. Can result in fractures, as bones become brittle and weak. Interventions include increasing dietary calcium/vitamin D, low aerobic exercises and avoid smoking, caffeine, and carbonated beverages.

osteoprosis

What is the No. 1 treatment for hypoxemia?

oxygen