260 Test 1
A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem?
bronchospasm
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?
conceal iv with gauze
The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?
consistent seatbelt use
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds?
crackles
hypoventilation
decreased rate or depth of air movement into the lungs
hypoxia
deficiency in the amount of oxygen reaching the cells
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
determines if client is getting enough oxygen
Dyspnea
difficulty breathing
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?
ensure that two fingers can be inserted in between the restraints and the client extremities
The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting?
exhale in counts of 4
A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should prioritize what action?
fill out an incident report with the goal of preventing it from reoccurring
A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?
"I am placing the new linens under the rolled, soiled linens to avoid contamination."
An 8-year-old child fell off their bicycle. They were not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?
"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."
risk for injury
A- age 85+ B- brittle bones 4 C- coagulant meds S- surgical post op
Which guideline should the nurse follow when removing contact lenses from a client's eyes?
Before removing hard lenses, use gentle pressure to center the lens on the cornea.
A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?
Breaks in skin integrity and fungal nail infection.
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?
Breathing through your nose first will warm, filter, and humidify the air you are breathing
The nurse is caring for a client with conjunctivitis and is assisting the client with eye care. What is the nurse's most appropriate action?
Cleanse each eye with a separate washcloth.
diffusion
Exchange of respiratory gases in the alveoli and capillaries
PASS acronym to use
Pull, Aim, Squeeze, Sweep
The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?
Launder gowns, linens, and towels separate from other clients' items.
Which modification to bathing should be implemented for a client who is incontinent?
Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?
Monitor the amount of oxygen saturation in the blood.
in a fire what is the course of action
R-rescue A-activate alarm C-contain/confine E- extinguish
The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply.
Provide a bedpan and pericare. Obtain, record, and report vital signs.
A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?
She has motivation to participate in self-care..
perfusion
The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which action should the nurse take first?
The nurse should question the client about the source of the bruises.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.
Hyperventilation
Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism
A nurse is providing oral care for a client who has been in a coma for 2 weeks. Which statement should guide the nurse's care plan?
White patches may be present that indicate a fungal infection called thrush.
priority to see the patient first
airway, breathing, circulation
site of gas exchange
alveoli
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
ambu bag
The nurse is participating in the investigation of a series of Centers for Medicare & Medicaid Services (CMS) "never events" that have taken place over the past several months. Which clinical event will the nurse most likely investigate?
an increase in the incidence and prevalence of pressure injuries experienced by clients
warfin is what kind of drug
anticoagulant, blood thinner
surfactant
any substance that interferes with the hydrogen bonding between water molecules and thereby reduces surface tension helps to keep alveoli open.
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?
having a bath helps to remove bacteria from your skin which is causing that rash
myocardial infarction
heart attack
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
high respiratory rate
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?
hypoxia
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
instruct patient to inhale deeply then cough
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
is you mask causing you discomfort
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
low pitched and soft heard over breath fields
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?
maintain the clients oxygenation and notify the health care provider immediately
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR)
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:
motor vehicle accidents
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?
nasal cannula
seizure precautions
never put a finger in persons mouth
A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?
normal saline
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?
notify health care provider
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?
obtain a three prong plug
A kindergarten student is sent to the school nurse because they have been vigorously scratching their scalp for a few hours. What is the nurse's priority action?
pediculosis
Types of Restraints Used for Adults and Children
physical: restraining limbs, belts, vests environmental: secluded room mechanical: bed rails, chair with locking table pharmalogic: sedatives
The nurse working at a long-term care facility supervises while the unlicensed assistive personnel (UAP) bathes an older adult client. The nurse determines the UAP requires intervention when the UAP:
places a large amount of soap on wash cloth
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
pleural effusion
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?
providing a back rub before bed
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
pulse oximetry
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?
rapid respiration
The nurse has provided a family with education related to car seat safety for a 9-month-old infant. Which statement indicates an understanding of the teaching?
rear facing car seat in the back
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?
remove the airway, turn the client to the side, and provide mouth suction, if necessary.
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
residual volume
A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan?
restrain baby in a car seat
The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?
risk related to injury
A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?
store in cold water when not in use
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.
teamwork and collaboration Quality improvement client-centered care
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of completing the recommended treatment
perfusion
the process by which oxygenated capillary blood passes through body tissues
ventilation
the process of moving gases into and out of the lungs
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
trachostemy collar
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
true
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:
using chest muscle to help him breathe
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?
warm clients hands and try again
Myocardial ischemia
when the blood flow through one or more coronary arteries are decreased
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
you should never smoke when oxygen is in use