3070 Final

Which person is at greatest risk of developing a community-acquired pneumonia? -An older adult who smokes and has a substance abuse problem -An older adult with exercise-induced wheezing -Young adult who eat a vegetarian diet -Middle-aged teacher who eats a diet of Asian food

An older adult who smokes and has a substance abuse problem

The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3 22, PCO2 28, PO2 98? -Diabetic ketoacidosis and emphysema -Diarrhea and vomiting for 36 hours -Chronic obstructive pulmonary disease -Anxiety induced hyperventilation

Anxiety induced hyperventilation

The nurse is caring for a client who has sepsis. After administering oxygen, what is the priority intervention for this client? -Administer IV fluids -Administer a diuretic -Initiate a heparin drip -Administer a vasoconstrictor

Administer IV fluids

A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? -30 pack-year history of smoking -Age 58 years -BMI 37 -Primary HTN

BMI 37

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? -Gangrene of the gallbladder -Pain and drowsiness -Acidosis and hypoglycemia -Bleeding and perforation of the hepatobiliary

Bleeding and perforation of the hepatobiliary

A nurse is caring for a client who has HIV. Which following laboratory values is the nurse's priority? -Platelets of 175,000/mm3 -Positive Western Blot test -CD4 count of 180 cells/mm3 -WBCs of 6,000/mm3

CD4 count of 180 cells/mm3

A nurse is assessing a client who has been diagnosed with cholecystitis and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? -Left upper chest -Neck or jaw -Inguinal region -Right shoulder

Right shoulder

A client admitted with IBS asks the nurse for help with menu selections. What menu selection is most likely to be the best choice for this client? -Salmon -Fresh blueberries -Raw spinach -Multigrain bagel

Salmon

A nurse is teaching a female client who has a new diagnosis of SLE. The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? -Infection -Stress -Moderate exercise -Sunlight

Moderate exercise

A client is scheduled for an intravenous pyelogram. Before the procedure, the nurse learns that the client has an allergy to shellfish. What should the nurse do next? -Keep the client on NPO status -Administer a laxative to empty the colon -Notify the healthcare provider -Administer an antiflatulent to relieve gas

Notify the healthcare provider

A client is entering the rehabilitation phase of a burn injury. What nursing action should be prioritized during this phase of treatment? -Regulating body temperature -Providing education to the client and family -Monitoring fluid and electrolyte imbalance -Treating infection

Providing education to the client and family

A client who is receiving antiretroviral therapy tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response? -You are not as contagious as you were before -The antiretroviral medications are working well right now -You are developing an opportunistic infection -Your HIV infection is becoming resistant to your medication

The antiretroviral medications are working well right now

A client comes for his yearly PPD. Which statement by the nurse is best made to the client who returns to the clinic 48 hours later with a 16mm area of redness and induration? -Your PPD is negative. No follow up is necessary -You will need to be evaluated further -You will need a second PPD -You will need to have titers drawn

You will need to be evaluated further

The nurse enters the client's room for the first time and observes the manifestations shown below. What action should the nurse take first? (picture of woman with swelling in face, eyes almost shut, lips swollen) -Get a full set of vitals -Prepare to administer epinephrine -Prepare to administer Benadryl -Assess the client's respiratory status

Assess the client's respiratory status

The nurse reviews an ABG report for a client with COPD. The results are as follows: pH 7.36, PCO2 62, PO2 70, HCO3 34. What should the nurse do first? -Assess the vital signs -Apply a non rebreather mask -Prepare for mechanical ventilation -Reposition the patient

Assess the vital signs

A client has the following arterial blood gases: pH 7.30, HCO3 22, PCO2 55, PO2 86. Which intervention by the nurse takes priority? -Administer bronchodilators -Administer mucolytics -Assessing the airway -Providing oxygen

Assessing the airway

A client is being discharged and needs to monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client? -Ensuring an oral intake of at least 3L/day -Assessing the radial pulse for a full minute twice a day -Weighing themselves at the same time every day -Restricting sodium and potassium intake

Assessing the radial pulse for a full minute twice a day

The nurse is caring for a client who is recovering from full-thickness burns is aware of the client's risk for contractures and scarring. How does the nurse best reduce the risk? -Encourage physical activity and range-of-motion exercises regularly -Administer oral or IV steroids as prescribed -Apply lotion after granulation has occurred -Don't allow the patient to move at all

Encourage physical activity and range-of-motion exercises regularly

Which client does the nurse assess to be at the greatest risk for pressure ulcer development? -Client with hypertension taking multiple medications -Client who requires assistance with ambulation -Client with incontinence and limited mobility -Client who has pneumonia

Client with incontinence and limited mobility

The nurse is assessing the respiratory status of a client experiencing an exacerbation of COPD secondary to a respiratory infection. Which finding is expected? -Coarse crackles -Prolonged inspiration -Normal breath sounds -Unlabored chest movement

Coarse crackles

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which intervention does the nurse anticipate? -Application of a transparent dressing -Drainage management -Application of a hydrocolloid dressing -Debridement

Debridement

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which organs are responsible for regulatory processes and compensation? -Heart and liver -Heart and lungs -Lungs and kidneys -Pancreas and stomach

Lungs and kidneys

What nursing intervention is most important in preventing sepsis and septic shock? -Monitoring RBCs for elevation -Administering IV fluid replacement as prescribed -Obtaining vital signs every 4 hours for every client -Maintaining asepsis of indwelling urinary catheters

Maintaining asepsis of indwelling urinary catheters

Which is the highest priority goal to set for a client with pneumonia? -Maintenance of SaO2 of 95% or higher -Walking 20 feet three times daily -Absence of cyanosis -Absence of confusion

Maintenance of SaO2 of 95% or higher

Which instruction is the most accurate for the nurse to give a client who has a PCA device after surgery? -Instruct your visitors to push the button for you when you are sleeping. -Try to go as long as you possibly can before you press the button -Push the button when you first feel pain instead of waiting until the pain is severe. -Push the button every 15 minutes whether you feel pain at that time or not.

Push the button when you first feel pain instead of waiting until the pain is severe.

A nurse is reviewing laboratory values for a client who has SLE. Which of the following values should give the nurse the best indication of the client's renal function? -Serum creatinine -Serum sodium -BUN -Urine-specific gravity

Serum creatinine

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which topic? -Appropriate use of prescribed pancreatic enzymes -Signs and symptoms of intra-abdominal complications -The need for blood glucose monitoring for the next week -Management of fluid balance in the home setting

Signs and symptoms of intra-abdominal complications

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks and criticized her technique. How should the nurse best interpret this client's behavior? -The client may be experiencing inconsistencies in the care he is being provided -The client may be experiencing an adverse drug reaction that is affecting cognition and behavior -The client may be experiencing anger about his circumstances that he is directing toward the nurse -The client may be experiencing neurologic complications of the injury

The client may be experiencing anger about his circumstances that he is directing toward the nurse

What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia? (SATA) -Daily breaks from sedation to assess readiness for extubation -Administer prophylactic antibiotics -Maintain good hand hygiene -Provide frequent oral care -Perform chest percussion frequently -Keep HOB elevated

-Daily breaks from sedation to assess readiness for extubation -Maintain good hand hygiene -Provide frequent oral care -Keep HOB elevated

The nurse is working on an orthopedic floor. Which client should the nurse assess first after receiving change of shift report? -64 year old with a left total knee replacement and new onset confusion -88 year old post op total hip replacement with an abduction pillow -84 year old in traction for a fractured femoral neck -50 year old post op total knee replacement with a continuous passive motion machine

64 year old with a left total knee replacement and new onset confusion

The nurse has four patients with pressure ulcers. For one patient, the nurse leaves the wound open to air and does not apply a dressing. To which of the following patients did the nurse provide care? -A patient with a clean stage I on the right heel -A patient with a clean stage II on the coccyx -A patient with a draining stage III on the left hip -A patient with a clean, tunneling stage IV on the coccyx

A patient with a clean stage I on the right heel

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of UTIs among older adults. What action has the greatest potential to prevent UTIs in this population? -Limit the use of indwelling urinary catheters -Toilet immobile residents on a scheduled basis -Encourage frequent mobility and repositioning -Administer prophylactic antibiotics

Limit the use of indwelling urinary catheters

The nurse is performing a home visit to an 84 year old client recovering from hip surgery. The woman seems confused and has dry mucous membranes. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? -It is normal to be a little confused after surgery and it is not safe to urinate at night. -Limiting your fluids can create an imbalance that can result in confusion. Maybe we need to adjust the timing of your fluids. -If you build up too much urine in your bladder it can cause confusion, especially when your body is under stress. -I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup.

Limiting your fluids can create an imbalance that can result in confusion. Maybe we need to adjust the timing of your fluids.

The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (SATA) -Assist the client with good oral care after meals and at bedtime -Use N95 respirator masks anytime staff is in the client's room -Provide an incentive spirometer to encourage coughing and deep breathing -Use sterile gloves and gowns whenever staff is in contact with the client -Keep a blood pressure cuff, thermometer and stethoscope in the client's room for their use only -Request that family take home the fresh flowers that are at the client's bedside

-Assist the client with good oral care after meals and at bedtime -Provide an incentive spirometer to encourage coughing and deep breathing -Keep a blood pressure cuff, thermometer and stethoscope in the client's room for their use only -Request that family take home the fresh flowers that are at the client's bedside

The nurse administers 650 mg of aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing the client for which desired outcomes? (SATA) -Decreased temperature -Decreased pain when breathing -Prolonged clotting time -Increased RR -Thickened respiratory secretions

-Decreased temperature -Decreased pain when breathing

A nursing student is providing education on the signs of hypovolemia to a group at a senior center. Which of the following does the student include? (SATA) -Dizziness -Elevated pulse -Elevated BP -Dry mucous membranes -Confusion

-Dizziness -Elevated pulse -Dry mucous membranes -Confusion

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate (Select all that apply)? -Implement turning schedule every 4 hours -Keep the client's skin clean and dry -Minimize exposure to moisture -Massage over reddened bony prominences -Use pillows to keep heels off the bed surface

-Keep the client's skin clean and dry -Minimize exposure to moisture -Use pillows to keep heels off the bed surface

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (SATA) -Keep the client from bathing on a daily basis -Dispose of all linin in the trash after use -Prohibit visitors who have active infections -Instruct the client to eat well cooked meals -Wear an N95 respirator mask and shoe covers at all times when with client

-Prohibit visitors who have active infections -Instruct the client to eat well cooked meals

The nurse is assessing a client's skin for local signs of infection. Which sign does the nurse assess for? (SATA) -Warmth -Fever -Redness -Pain -Elevated WBCs -Swelling

-Warmth -Redness -Pain -Swelling

The nurse is assessing clients in the ED. Which client is at highest risk for developing septic shock? -82 year old taking antihypertensive medications -68 year old being treated with chemotherapy -37 year old who is 20% above ideal body weight -25 year old who has IBS

68 year old being treated with chemotherapy

The nurse caring for the following group of clients considers which client to be at highest risk of developing deficient fluid volume? -A thin 52 year old receiving steroid therapy for bronchitis -A 60 year old who had a left inguinal hernia repair 12 hours ago -A 68 who is NPO for a cardiac catheterization the next day -A 76 year old who has an NG to suction following a colon resection

A 76 year old who has an NG to suction following a colon resection

When instructing a client on how to decrease the risk of developing COPD, the nurse should emphasize which instruction? -Avoid exposure to people with respiratory infections -Participate regularly in aerobic exercises -Abstain from cigarette smoking -Maintain a high protein diet

Abstain from cigarette smoking

A client with burns is to have a dressing change. What should the nurse do 30 minutes before the intervention? -Slit the dressing with blunt scissors -Soak the dressings in normal saline -Administer an analgesic -Remove the dressings

Administer an analgesic

Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a burn injury? -Beginning parenteral nutrition high in calories -Providing a low-protein, high-fat diet -Including 3000 kcal/day of calories with meals -Allowing the client to eat whenever he or she wants

Allowing the client to eat whenever he or she wants

An elderly patient developed pneumonia. The nurse is aware that the initial symptom the patient manifest is: -Fever and chills -Altered mental status -Pleuritic chest pain and cough -Hemoptysis and dyspnea

Altered mental status

A client is receiving fluid replacement with lactated ringers after 40% of the body was burned 10 hours ago. The assessment reveals temp 97.1 F, HR 122 bpm, BP 84/42, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/hr. Which of the following prescriptions should the nurse request from the healthcare provider? -A decrease in the IV infusion rate -An order for oral fluids -An increase in the IV infusion rate -A diuretic

An increase in the IV infusion rate

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? -Dinner roll -Tapioca pudding -Mashed potatoes -Fried chicken

Fried chicken

The nurse is caring for a client whose IBS has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? -Antiemetics on PRN basis -Vitamin B12 injections to prevent pernicious anemia -Give an antidiarrheal medication 30 mins before a meal -Beta blockers to increase bowel motility

Give an antidiarrheal medication 30 mins before a meal

The nurse is caring for a client diagnosed with pneumonia. The nurse should perform which of the following interventions to help loosen thick secretions: -Place the patient in the prone position -Administer antibiotics as ordered -Limit fluids to prevent fluid overload -Have the patient use the incentive spirometer every hour while awake

Have the patient use the incentive spirometer every hour while awake

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? -Have the client use the early morning hours to exercise and activity. -Provide the client with low protein diet. -Instruct the client to use pursed-lip breathing. -Restrict the client's fluid intake to less than 2L/day

Instruct the client to use pursed-lip breathing.

A client returns to the med-surg unit after a total hip replacement with a large wedge-shaped pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response? -It will prevent climbing out of bed if he becomes confused -It will help prevent nerve damage and foot drop -It will help keep the new hip from becoming dislocated -It will help prevent pressure ulcers from developing

It will help keep the new hip from becoming dislocated

A nurse is caring for several clients at risk for hypovolemia. The nurse assess the older client with which finding first? -Has had diabetes mellitus for 12 years -Had abdominal surgery and has an NG tube -Just received 3 units of packed red blood cells -Uses antacids frequently

Just received 3 units of packed red blood cells

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? -Keep catheter tubing free of kinks and/or dependent loops -Clean the perineal area with hot water daily -Irrigate the catheter once each shift -Replace the catheter every 3 days

Keep catheter tubing free of kinks and/or dependent loops

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the X-ray department. Which of the following actions should the nurse take? -Clamp the chest tube prior to transferring the client to a wheelchair. -Empty the collection chamber prior to transport. -Disconnect the chest tube from the drainage system during transport. -Keep the drainage system upright and below the level of the client's chest at all times.

Keep the drainage system upright and below the level of the client's chest at all times.

What is the rationale that supports multidrug treatment for clients with TB? -Multiple drugs potentiate the drugs actions -Multiple drugsallow reduced dosages to be given -Multiple drugs reduce development of resistant strains of the bacteria

Multiple drugs reduce development of resistant strains of the bacteria

The nurse is caring for a client admitted with a serious infection. The prescriber has ordered cultures and a broad-spectrum antibiotic. How should the nurse proceed? -Obtain the culture samples, then administer the antibiotic -Delay administration of antibiotic until the culture results are available -Administer acetaminophen for fever -Administer antibiotic then obtain the culture sample

Obtain the culture samples, then administer the antibiotic

The nurse is assessing the client who is post op for a total knee replacement. Which assessment data warrant immediate intervention? -Diffuse, crampy abdominal pain -Pain and tenderness in the calf of the unaffected leg -T 99F, HR 80, RR 20, and BP 128/76 -Intermittent bowel sounds in all 4 quadrants

Pain and tenderness in the calf of the unaffected leg

A nurse is preparing to provide care for a client whose exacerbation of UC has required hospital admission. During an exacerbation of this health problem, the nurse would expect that the client's stools will have what characteristics? -Watery with blood and mucous -Hard or black and tarry -Dry and streaked with blood -Loose with visible fatty streaks

Watery with blood and mucous

A nurse is caring for a client receiving nasogastric suctioning. Which of the following ABG values does the nurse anticipate? -pH 7.48 pO2 89 pCO2 30 HCO3 26 -pH 7.26 pO2 84 pCO2 38 HCO3 20 -pH 7.51 pO2 94 pCO2 36 HCO3 31 -pH 7.31 pO2 77 pCO2 52 HCO3 23

pH 7.51 pO2 94 pCO2 36 HCO3 31

Which of the following symptoms would the nurse expect to see in a client with a pleural effusion? (SATA) -Dry cough -Dyspnea -Purulent sputum -Vomiting -Chest pain

-Dry cough -Dyspnea -Chest pain

A nurse is assessing a client follwoing a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (SATA) -Dyspnea -Decreased use of accessory muscles -Tachypnea -Deviation of trachea -Chest pain -Bradycardia

-Dyspnea -Tachypnea -Deviation of trachea -Chest pain

The UAP reports to the RN that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vitals in the chart obtained by the UAP. The nurse should do which of the following? (SATA) 800: T 100.9F, 90bpm, 16 RR, BP 112/74, SpO2 93% 1000: 104bpm, 18 RR, BP 110/58, SpO2 92% 1200: T101.8F, 118bpm, 24 RR, BP 96/64, SpO2 92% -Call a code -Encourage client to drink more fluid -Administer acetaminophen as prescribed -Assure the client is maintaining strict bedrest -Check urine output

-Encourage client to drink more fluid -Administer acetaminophen as prescribed -Check urine output

Which interventions should be included in the discharge teaching of a client who had a total hip replacement? (SATA) -Explain the importance of increasing activity gradually -Discuss the client's weight-bearing limitations -Request that the client demonstrate use of assistive devices -Tell the client to ambulate barefooted for comfort -Instruct the client not to take any medications before ambulating

-Explain the importance of increasing activity gradually -Discuss the client's weight-bearing limitations -Request that the client demonstrate use of assistive devices

The client with which conditions requires immediate nursing intervention? (SATA) -Stridor -RR of 4 bpm -Arterial blood gas pH 7.36 -Occasional expiratory wheeze -Retractions of the sternum -Pulse ox reading of 95%

-Stridor -RR of 4 bpm -Retractions of the sternum

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? -A client who has incisional pain 72 hours after pacemaker insertion -A client with a broken femur and report of hip pain -A client who has episodic back pain following a fall 1 year ago -A client who has food poisoning and reports abdominal cramping

A client who has episodic back pain following a fall 1 year ago

A client who has hyponatremia is receiving a regular diet. To encourage foods high in sodium, the nurse would recommend which of the following foods for lunch? -A ham and cheese sandwich -Chicken salad on lettuce -White fish and plain baker potato -Green salad with vinegar dressing

A ham and cheese sandwich

The nurse works in a long-term care facility. Which resident does the nurse assess most carefully for manifestations of infection? -A resident with long-standing dementia -A resident whose family won't allow a pneumonia vaccine -A resident with both fecal and urinary incontinence -A resident who eats a diet high in carbs

A resident with both fecal and urinary incontinence

Which intervention in a client with hypovolemia-induced confusion is most likely to relieve the confusion? -Applying oxygen by mask or nasal cannula -Measuring intake and output every 4 hours -Placing the client in high-fowler's position -Decreasing the IV flow rate

Applying oxygen by mask or nasal cannula

The nurse is caring for a postoperative client following a total left hip replacement the previous day. During the assessment, the nurse notes that the client's left leg is cool with weak pedal pulses. What is the nurse's first action? -Check for bilateral Homan's signs -Measure leg circumference at the calf -Notify the surgeon immediately -Assess circulatory status of the right leg

Assess circulatory status of the right leg

The client is receiving an IV infusion at 150 mL/hr as prescribed. After 4 hours of the infusion, the client reports SOB and develops a cough. Which intervention should be the nurse's first action? -Elevate client's legs -Notify prescriber -Continue to monitor the patient -Assess the client's lungs

Assess the client's lungs

A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? -Increase oxygen flow to 3L/min -Assess the client's respiratory status -Call emergency services for the client -Have the client cough and expectorate secretions

Assess the client's respiratory status

A nurse is caring for several clients. Which client does the nurse assess most carefully for the development of hyperkalemia? -Client taking NSAIDs -Client taking furosemide (lasix) for HTN -Client with type 2 diabetes taking an oral hypoglycemic agent -Client with HF using a salt substitute

Client with HF using a salt substitute

A nurse is assessing a patient with respiratory acidosis. Which of the following findings does the nurse anticipate? -Facial flushing -Hyperactive reflexes -Peripheral edema -Confusion

Confusion

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a drainage system with suction. The nurse should intervene for which of the following: -Continuous bubbling in the water-seal chamber. -Fluid-level fluctuation in the water-seal chamber with inspiration and exhalation. -Bloody drainage in the collection chamber. -Continuous bubbling in the suction control chamber.

Continuous bubbling in the water-seal chamber.

Which intervention is most important for the nurse to teach the client who is recovering from an anaphylactic reaction to a bee sting? -How to use an Epi pen -Wearing a medical alert bracelet -Avoiding contact with the allergen -Keeping diphenhydramine (Benadryl) available

How to use an Epi pen

Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound infection by which statement? -If my temperature elevates, I should increase my dose of antibiotic -I should take the antibiotic until my temperature is normal -If the drainage is clear, I do not need the antibiotic -I need to take the medication until the prescription is finished

I need to take the medication until the prescription is finished

A client states he is "allergic" to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? -Drinking 3 L of water a day will prevent kidney damage -I will always wear a medical alert bracelet for this allergy -I should carry Benadryl with me at all times -I need to try to avoid coming into contact with poison ivy

I need to try to avoid coming into contact with poison ivy

A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates understanding of the teaching? -I will limit my fluid intake to 2-3 glasses of water a day -I should conserve my energy by limiting my activity -I will wait until my pain is at least a 6 out of 10 before I use my PCA button -I will use my incentive spirometer every hour while I am awake

I will use my incentive spirometer every hour while I am awake

A patient with HIV will be receiving care in the home setting. What aspect of self-care will the nurse emphasize during discharge education to prevent infection? -Signs and symptoms of wasting syndrome -Appropriate use of prophylactic antibiotics -Strategies for adjusting antiretroviral meds -Importance of personal hygiene

Importance of personal hygiene

A nurse is caring for a patient with metabolic alkalosis knows to assess for the primary compensatory mechanism of: -Decreased PCO2 -Decreased HCO3 -Increased PCO2 -Increased HCO3

Increased PCO2

The nurse is assessing a client with a pressure ulcer. Which indicates the client has a stage II pressure ulcer? -Loss of epidermis with dermis visible -Loss of epidermis and dermis, subcutaneous tissue visible -Presence of a dark, leathery substance over the wound -Non-blanchable erythema with intact skin

Loss of epidermis with dermis visible

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan to help with the client's confusion? -Make sure that a clock and calendar are easily visible -Feed the client when she will not do it herself -Remove locks from bathrooms and bedrooms -Do not allow the client to smoke when he is alone

Make sure that a clock and calendar are easily visible

A patient with a productive cough, chills and night sweats is suspected of having active TB. The most important initial intervention by the nurse would be: -Administer the PPD ordered by the physician -Prepare the client to be discharged on bed rest -Place the client on airborne isolation -Administer the prescribed rifampin before discharge

Place the client on airborne isolation

The client is undergoing a thoracentesis for a pleural effusion. After the procedure, the nurse will monitor for which of the following possible complications of the procedure? -Pneumothorax -Coagulopathy -Metabolic acidosis -Pulmonary fibrosis

Pneumothorax

Which factor puts the older adult at the greatest risk for impaired wound healing? -Well-controlled hypertension -History of one minor heart attack -Poorly controlled diabetes -Age over 70

Poorly controlled diabetes

The nurse is caring for a patient with a stage III pressure ulcer. Which nutrient will the nurse most likely increase to best facilitate healing? -Fat -Protein -Carbohydrates -Fiber

Protein

A client with Chron's disease has concentrated urine, decreased urinary output, dry skin, hypotension and weak, thready pulse. What should the nurse do first? -Turn and reposition every 2 hours -Provide IV rehydration as prescribed -Monitor vitals every shift -Encourage the client to drink at least 1 L of fluids

Provide IV rehydration as prescribed

A nurse is assessing a client using a PCA following a hip surgery. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The ABG results are pH 7.52, PO2 89, PCO2 28, and HCO3 24. Which of the following actions does the nurse take initially? -Discontinue the PCA -Instruct the client to cough forcefully -Assist the client with ambulation -Provide calming interventions

Provide calming interventions

The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has: -Reduced sensation of pressure -Impaired visual acuity -Impaired hearing ability -Altered balance

Reduced sensation of pressure

The healthcare provider is preparing a patient on the med-surg unit for thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? -Prone with arms extended above the head -The HOB elevated 45 degrees with patient lying on unaffected side -Sitting up, leaning over bedside table and feet supported on ground

Sitting up, leaning over bedside table and feet supported on ground

What intervention does the nurse implement to provide for client safety during intradermal allergy testing? -Apply oxygen by mask or nasal cannula before infecting the test agent -Cover the examination table and pillow with plastic or an ultrafine mesh -Stay with the client and ensure that emergency equipment is available -Pretreat the skin are to be tested with a cortisone-base cream

Stay with the client and ensure that emergency equipment is available

A client has been in an automobile accident and the nurse is assessing for possible pneumothorax. What finding should the nurse immediately report to the HCP? -Cough with clear sputum -Some wheezes heard over the affected side -Sudden, sharp chest pain -Oxygen saturation of 93%

Sudden, sharp chest pain

A client with a pneumothorax has a chest tube inserted that is connected to a chest drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? -There is a leak in the system -An obstruction is present in the chest tube -The system is functioning properly -The client has pulled the chest tube out

The system is functioning properly

The nurse is caring for an HIV positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS? -HIV positive status for 8 years -Thick white patches on the client's tongue -Generalized lymphadenopathy -Low-grade fever for the last 10 days

Thick white patches on the client's tongue

A nursing assistant asks the nurse if respiratory isolation is needed for a client with pneumocystis jiroveci pneumonia. What is the nurse's best response? -This type of pneumonia is an opportunistic infection so the staff are not at risk -Yes, please institute respiratory isolation because this is very contagious -You should wear a mask and gown to provide care -You are not at risk for this infection if you have had a vaccination

This type of pneumonia is an opportunistic infection so the staff are not at risk

Which of the following does the nurse expect as an outcome of pursed lip breathing for patients with COPD? -To strengthen the intercostals -To promote oxygen intake -To promote carbon dioxide elimination -To strengthen the diaphragm

To promote carbon dioxide elimination

A client has a history of chronic hypocalcemia. What intervention is most important for the nurse to add to this client's plan of care? -Encourage fluid intake of 2L/day -Strain all urine output -Use of nonslip footwear to get out of bed -Position the client supine twice a day

Use of nonslip footwear to get out of bed

Which information does the nurse include in a teaching plan for the client newly diagnosed with COPD? (SATA) -Get the influenza vaccine yearly -The pneumonia vaccine is contraindicated for clients with lung disease -A short acting bronchodilator should always be readily available -Smoking cessation is important to slow or stop disease progression -Pulmonary rehab programs offer very little benefit

-Get the influenza vaccine yearly -A short acting bronchodilator should always be readily available -Smoking cessation is important to slow or stop disease progression

A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors of delayed wound healing (Select all the apply)? -Impaired circulation -Poor diet -Type II diabetes mellitus -Smoking -Migraines -Advanced age

-Impaired circulation -Poor diet -Type II diabetes mellitus -Smoking -Advanced age

Which interventions should a nurse include in the plan of care for a client who is diagnosed with pneumonia and respiratory acidosis (Select all that apply)? -Place the client in a mid to high fowler's position -Administer bronchodilators and antibiotics as ordered -Increase fluid intake to thin secretions -Position the client supine with the head of bed flat -Maintain strict bedrest -Auscultate breath sounds every 2 hours and as needed

-Place the client in a mid to high fowler's position -Administer bronchodilators and antibiotics as ordered -Increase fluid intake to thin secretions -Auscultate breath sounds every 2 hours and as needed

The nurse is admitting an intravenous opioid medication to a client. Which interventions should the nurse implement for client safety? (SATA) -Reassess vitals 15-30 minutes after administration of medications -Clarify every pain medication order with prescriber -Assess the client's vitals prior to administration -Ask the client's name and DOB comparing it to the ID bracelet -Have a witness verify the wasted portion of the opioid after administration -Determine if the client has any allergies to medications

-Reassess vitals 15-30 minutes after administration of medications -Assess the client's vitals prior to administration -Ask the client's name and DOB comparing it to the ID bracelet -Determine if the client has any allergies to medications

A client is in the acute phase of a burn injury. One of the patient problems identified in the care plan is impaired coping. What interventions by the nurse appropriately address this diagnosis (Select all that apply)? -Teach the client some coping strategies -Promote open and honest communication -Avoid asking the client to make any decisions -Provide positive reinforcement -Administer sedative medications around the clock

-Teach the client some coping strategies -Promote open and honest communication -Provide positive reinforcement

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? -Difficulty moving the upper extremities -A reddened area over the sacrum -Stiffness in the lower extremities -Difficulty hearing some types of sounds

A reddened area over the sacrum

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? -Clean and dress the wounds -Administer a tetanus booster -Administer IV fluids -Administer pain medications

Administer IV fluids

A client has been diagnosed with hypervolemia and is confused. Which intervention is a priority to relieve the confusion? -Administer a diuretic as prescribed. -Slowing the IV flow rate to 50mL/hr -Placing the client in Trendelenburg position -Measuring intake and output every shift.

Administer a diuretic as prescribed.

Which statement indicates that the client with COPD who has been discharged home understands the care plan? The client: -Agrees to call the provider if dyspnea on exertion increases -Can state actions to reduce pain -Will use oxygen via a nasal cannula at 6L/min -Plans to avoid direct contact with family and friends

Agrees to call the provider if dyspnea on exertion increases

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? -Request the prescription for the insertion of an indwelling urinary catheter -Apply a moisture barrier ointment to the client's skin -Check the client's skin every 8 hours for signs of breakdown -Clean the client's skin and perineum with hot water after each episode of incontinence

Apply a moisture barrier ointment to the client's skin

A patient has just experienced a 90 second tonic-clonic seizure and has the following ABG values: pH 6.88, HCO3 22, PCO2 60, PO2 50. Which intervention by the nurse is the priority? -Administer 50 mL of 50% dextrose and 20 units of regular insulin -Apply oxygen by mask or nasal cannula -Administer 50 mL of sodium bicarbonate intravenously -Apply a paper bag over the client's nose and mouth

Apply oxygen by mask or nasal cannula

The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to an UAP? -Making adjustments to flow rates based on evaluation of client responses -Assisting a client with adjusting the position of his nasal cannula -Monitoring a client for adverse effects of oxygen therapy -Assessing a client for the best method of oxygen delivery

Assisting a client with adjusting the position of his nasal cannula

A client who has suffered a burn injury is drooling and having difficulty swallowing. Which action does the nurse take first? -Assess level of consciousness and pupillary reactions -Auscultate breath sounds over the trachea and main airways -Measure abdominal girth and auscultate bowel sounds -Determine when the client last ate or drank

Auscultate breath sounds of the trachea and main airways

The patient with COPD states that he feels "full after eating just a little food." What will the nurse teach the patient to assist with this problem? -Avoid drinking fluids just before and during meals -Use a bronchodilator inhaler 30 minutes before meals -Practice diaphragmatic breathing 4 times/day

Avoid drinking fluids just before and during meals

What strategy will the nurse adopt to best assist an older adult in learning about a therapeutic regimen involving wound care? -Delegate the dressing changes to a trusted family member -Verbally instruct to patient how to change a dressing and check for comprehension -Provide a detailed pamphlet on a dressing change -Demonstrate a dressing change and allow the patient to practice

Demonstrate a dressing change and allow the patient to practice

A female client has been experiencing recurrent UTIs. What health education should the nurse provide to this client? -Void at least every 7-8 hours -Drink plenty of fluids each day -Take hot baths to keep the perineal region clean -Avoid voiding immediately after sex

Drink plenty of fluids each day

The client is taking an opioid pain medication at home after surgery. What instruction does the nurse give this client? -Drink plenty of water and eat foods high in fiber -Avoid taking aspirin while you are on the medication -Weigh yourself daily to determine whether you are retaining fluid -Stop this medication after 3 days whether there is still pain or not

Drink plenty of water and eat foods high in fiber

The nurse is instructing an older adult about ways to promote skin integrity. Which health maintenance behavior by the client is most helpful? -Walking for 10 minutes three times a week -Sleeping 6 hours a night -Consuming a calorie restricted diet -Drinking an adequate amount of fluids daily

Drinking an adequate amount of fluids daily

A client has been admitted with pyelonephritis. A review of the client's I&O records reveal that the client has been consuming between 3 and 3-5 L of oral fluid each day since admission. How does the nurse best respond to this finding? -Supplement the client's fluid intake with a high calorie diet -Obtain an order for a high sodium diet to prevent dilutional hyponatremia -Emphasize the need to limit intake to 2 L of fluid daily -Encourage the client to continue this pattern of fluid intake

Encourage the client to continue this pattern of fluid intake

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? -Administering oxygen via nasal cannula at 2L/mins -Helping the client select a low-salt diet -Maintaining a semi-Fowler's position as often as possible -Encouraging the client to drink plenty of fluids every day.

Encouraging the client to drink plenty of fluids every day.

Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound? -Restrict the client's movement with bedrest -Apply hydrocortisone cream as ordered -Ensure that the client is well oxygenated -Cover the wound with a tight dressing

Ensure that the client is well oxygenated

A client with COPD is experiencing dyspnea and has a low PO2 level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administration to a client with COPD? -High oxygen concentrations may inhibit the stimulus to breathe -Increase oxygen use will cause the client to become dependent on the oxygen -High oxygen concentrations will cause cough and worsening dyspnea -Administration of oxygen is contraindicated in clients who are using bronchodilators

High oxygen concentrations may inhibit the stimulus to breathe

What does the nurse prioritize teaching the client with COPD? -How to treat respiratory infections without antibiotics -How to assess the pulse and RR -How to recognize when a change is needed in oxygen therapy -How to prevent respiratory infections

How to prevent respiratory infections

The nurse expects to find renal compensation for an acid-base imbalance in which situation? -Hypoxemia for 4 days from pneumonia -Food poisoning with vomiting for 12 hours in a middle-aged woman -Acute asthma attack with wheezing of 6 hours duration in an older man -Mild to moderate dehydration in a middle-aged client who jogged for 2 hours

Hypoxemia for 4 days from pneumonia

A client is being discharged and is at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective? -I'll drink at least three glasses of milk a day -I will avoid excess use of antacids -I will not add salt to my food during meals -I will avoid medications containing aspirin

I will avoid excess use of antacids.

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? -I will inhale slowly through pursed lips to help me breathe better. -I will follow a daily diet high in calories and protein. -I will lie on my stomach to practice abdominal breathing every day. -I will avoid getting a flu shot.

I will follow a daily diet high in calories and protein.

A nurse is teaching a client who has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching? -I will take my bronchodilators after meals. -I will eat five or six small meals each day. -I will choose foods that are not gas-forming. -I will rest for at least 30 minutes before eating.

I will take my bronchodilators after meals.

In the acute phase of a burn injury, which pain medication is most likely to be prescribed for the patient? -Intramuscular opioids -Intravenous opioids -Oral NSAIDs like ibuprofen -Oral antianxiety medications like xanax

Intravenous opioids

A client is admitted to the hospital with a serum potassium level of 2.8 mEq/L. Which of the following assessments would warrant immediate intervention by the nurse? -Respiratory rate of 18 with clear breath sounds and 2 loose stools this morning. -Irregular pulse and shallow respirations

Irregular pulse and shallow respirations

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? -Respiratory acidosis -Metabolic acidosis -Metabolic alkalosis -Respiratory alkalosis

Metabolic acidosis

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below the reference range. The nurse should assess for signs and symptoms of what imbalance? -Respiratory alkalosis -Respiratory acidosis -Metabolic alkalosis -Metabolic acidosis

Metabolic alkalosis

For a client admitted with severe hyponatremia, which should be the priority intervention to achieve the goal "client will remain free from injury"? -Adhere to the sodium restriction as prescribed -Perform daily weights at the same time each day -Monitor neurologic status and initiate seizure precautions -Maintain accurate intake and output records

Monitor neurologic status and initiate seizure precautions

Which statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury? -My goal is to achieve the highest level of functioning that I can -Recovery from a burn injury will never occur -I am fully recovered when all the wounds are closed -I will eventually be able to perform all my former activities

My goal is to achieve the highest level of functioning that I can

Which assessment finding, obtained while taking a client history, alerts the nurse that the client should be assessed for fluid imbalance? -I am often cold and need to wear a sweater. -In the summer I feel thirsty more often. -My rings seem to be tighter this week. -I seem to urinate more when I drink coffee.

My rings seem to be tighter this week.

Which client is at a greatest risk for hypovolemia? -Younger adult client on bedrest -Younger adult client receiving hypertonic IV fluid -Older adult with cognitive impairment -Older adult receiving hypotonic IV fluids

Older adult with cognitive impairment

The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis? -Allergic rhinitis and sinusitis on sulfa antibiotics -Emphysema and undergoing nasogastric (NG) tube suctioning -On patient controlled analgesia after abdominal surgery -Type 1 diabetes and urinary tract infection

On patient controlled analgesia after abdominal surgery

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears restless. Which of the following values does the nurse anticipate to be outside the reference range? -Bicarb -PO2 -PCO2 -Sodium

PCO2

For a client with rib fractures and pneumothorax, the health care provider prescribes morphine sulfate 1-2 mg IVP every 2 hours PRN for pain. The nursing care goal is to provide adequate pain control so the client can breathe effectively. Which finding indicates this goal has been met? -Patient reports decreased anxiety -PO2 of 72 on an ABG -RR of 26 breaths per minutes -Patient rates pain as 0-1 on scale of 10

Patient rates pain as 0-1 on scale of 10

A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? -pH 7.32 -Potassium of 7.5 mEq/L -Hematocrit 52% -Sodium 132 mEq/L

Potassium of 7.5 mEq/L

During the acute phase of a burn injury, which of the following goals does the nurse establish as a priority? -Prevention of infection -Promotion of a positive self image -Promotion of hygiene -Education on care of the graft site

Prevention of infection

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client for prevention? -Check your radial pulse twice a day. -Bake or grill meat rather than frying it. -Weight yourself every morning and night. -Read food labels to determine sodium content.

Read food labels to determine sodium content.

A nurse is caring for a client admitted with an exacerbation of a neuromuscular disease. Upon assessment of the client, the nurse notes that the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? -Respiratory alkalosis -Respiratory acidosis -Metabolic acidosis -Metabolic alkalosis

Respiratory acidosis

The nurse is caring for a client who experienced a traumatic injury in a workplace accident. The client is reporting dyspnea because of abdominal pain. An ABG reveals the following results: pH 7.28, pCO2 50, and HCO3 23. The nurse should recognize the likelihood of what acid-base disorder? -Metabolic acidosis -Respiratory acidosis -Metabolic alkalosis -Respiratory alkalosis

Respiratory acidosis

A client is being discharged from the emergency department with several broken ribs. For which acid-base imbalance does the nurse provide discharge teaching? -Respiratory acidosis from inadequate ventilation -Metabolic alkalosis from taking base-containing analgesics -Respiratory alkalosis from anxiety and hyperventilation -Metabolic acidosis from calcium loss from broken bones

Respiratory acidosis from inadequate ventilation

The nurse is administering the pneumonia and influenza vaccines to clients with COPD. A client asks why these vaccines are recommended. What is the nurse's best response? -Respiratory infections can be more serious in patients with COPD and should be prevented. -These vaccines help reduce the tachypnea that you experience -These vaccines are recommended for all clients -These vaccines promote bronchodilation and improve oxygenation

Respiratory infections can be more serious in patients with COPD and should be prevented.

The nurse is assessing a client with COPD. Which finding requires immediate intervention? -Use of purse lip breathing -Clubbed fingernails -Diminished breath sounds -SOB causing an inability to speak

SOB causing an inability to speak

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? -Talk with the client during wound care -Keep family members aware of his condition -Assign assistive personnel to keep his room neat and clean -Rotate nursing staff so he can have varied interactions

Talk with the client during wound care

The nurse is assessing a client wit COPD. Which symptoms is a priority for the nurse's intervention? -The client has new bilateral dependent leg edema -The client has pale, pink skin -The client's anterior/posterior to transverse ratio is 1:1 -The client has clubbing of the fingernails

The client has new bilateral dependent leg edema

A nurse is caring for 4 hospitalized clients. Which of the following clients should the nurse identify as being at risk of fluid volume deficit? -The client who has left-sided HF and has a BNP of 600pg/mL. -The client who has end stage renal failure and is scheduled for dialysis today. -The client who has gastroenteritis and has a fever. -The client who has been NPO since midnight for an endoscopy.

The client who has gastroenteritis and has a fever.

Which client is at greatest risk for developing hypercalcemia? -The client with hyperparathyroidism -the client taking furosemide (Lasix) -The woman who is pregnant with twins -The client with long-standing osteoarthritis

The client with hyperparathyroidism

A family member of a patient diagnosed with a pleural effusion asks why the patient hasn't been "coughing up any of the fluid"? Which of the following is the nurse's best answer? -The fluid is outside of the airways in the pleural space -The effusion has most likely resolved -The pressure of the fluid is restricting the airway -The fluid will be excreted through the lung circulation

The fluid is outside of the airways in the pleural space

A client has the following arterial blood results: pH 7.12, HCO3 22, PCO2 65, PO2 56. The nurse correlates these values with which clinical situation? -Diabetic ketoacidosis in a person with emphysema -Tracheal obstruction related to aspiration -Anxiety induced hyperventilation -Diarrhea for 36 hours in an older frail woman

Tracheal obstruction related to aspiration

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? -Alginate dressing -Hydrogel dressing -Wet to dry dressing -Transparent dressing

Transparent dressing

A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this client? -Heart rate 130 bpm -Hematocrit 60% -Urine output of 50 mL/hr -Increased peripheral edema

Urine output of 50 mL/hr

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? -Elevate the head of the bed no more than 45 degrees -Massage the skin over bony prominences -Apply cornstarch to keep sensitive skin areas dry -Use a transfer device to lift the client up in bed

Use a transfer device to life the client up in bed

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? -Treat skin lesions with antibiotics and cover any open lesions -Wash the perineum with warm water and soap, cleaning from front to back -Treat fungal infections such as athlete's foot immediately -Have a pneumonia immunization to prevent streptococcal infection

Wash the perineum with warm water and soap, cleaning from front to back