B260 (O2/AB/F&E/Blood/IV/Pt. Ed) FA23

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances? Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic Acidosis

Clients who have nausea and vomiting are at risk for metabolic alkalosis due to loss of metabolic acid.

A nurse is caring for a client who is postoperative. Morphine 8 mg subcutaneous q 3 hr PRN pain Temperature 37.5° C (99.5° F) Respirations 10/min Pulse oximetry 87% on room air Pupils are 3 mm, equal and reactive to light

The nurse should follow-up on: - respiratory rate of 10/min - pulse oximetry of 87% on room air [b/c the client is experiencing hypoxia due to the morphine. The nurse should report these findings to the charge nurse and provide the client with supplemental oxygen. The client might require naloxone to reverse the effects of the morphine.] The client's temperature and pupils are within the expected reference range and do not require further action by the nurse.

A nurse is assessing a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an allergic transfusion reaction? Wheezing Distended neck veins Flank pain Elevated blood pressure

Wheezing is a manifestation of an allergic reaction. The nurse should stop the transfusion and notify the provider.

A nurse is caring for a client who has anemia. Select the 4 findings that require immediate follow-up. IV site Oxygen saturation Temperature Back pain Breath sounds Urine color Blood pressure

When analyzing cues, the nurse should identify that the client's temperature, back pain, urine color, and blood pressure should be reported to the provider. The client's temperature at 1015 is greater than the expected reference range, and the client's blood pressure at 1015 is less than the expected reference range, indicating hypotension. Fever, hypotension, flank back pain, and reddish or dark brown urine are manifestations of an acute hemolytic transfusion reaction and require interventions to reduce the risk for further injury. The nurse should stop the transfusion, notify the provider, and send a urine sample to the laboratory.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? Tape the connections on the client's chest tube. Strip the client's chest tube every 2 hrs. Loop the tubing of the chest tube on the client's bed. Place the chest tube drainage system above the level of the client's heart.

a. The connections on the chest tube should be securely taped to reduce the risk of disconnection which can cause air to enter the client's pleural cavity.

A nurse is caring for a client who has a history of angina. Which of the following findings require follow-up by the nurse? BP Anxiety Oxygen Sat. Breath Sounds Irregular HR Chest Tightness

BP Anxiety Irregular HR Chest Tightness

A nurse is caring for a client who has a history of angina. 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. Which of the following findings require follow-up by the nurse? Blood pressure Anxiety Oxygen saturation Breath sounds Breath sounds Irregular heart rate Chest tightness

BP Anxiety Irregular Heart Rate Chest Tightness

A nurse is caring for a client. Diagnostic Results History and Physical Diagnostic Results 1000 Cholesterol 275 mg/dL (<200 mg/dL) Fasting glucose 90 mg/dL (70 to 110 mg/dL) History of hypertension History of smoking Daily exercise History of rheumatoid arthritis Cholesterol level Fasting glucose level

History of hypertension History of smoking Cholesterol level

A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing? Role-play Discussion Return demonstration Question-and-answer

Return demonstration --is an active teaching method based on the psychomotor domain of learning. The nurse demonstrates a procedure, and the client returns the demonstration.

Client has an NG tube in the right nare, placed to intermittent low wall suction, draining moderate green-brown drainage. The client is at risk for developing (Condition) due to (Finding).

When analyzing the cues of a pH value above the expected reference range of 7.35 to 7.45, an HCO3- value above the expected reference range of 21 to 28 mEq/L, and a PCO2 level within the expected reference range of 35 to 45 mm Hg. client is at risk for developing metabolic alkalosis due to nasogastric suctioning. Nasogastric suctioning results in loss of metabolic acid, which can cause metabolic alkalosis. Because the client is at risk for developing metabolic alkalosis, they are also at risk for muscle twitching, lethargy, and lightheadedness. The nurse should monitor the client's respiratory and neuromuscular status and place the client on fall precautions.

A nurse is creating a teaching plan for a client who has a new diagnosis of diabetes mellitus. Which of the following teaching methods is based on the cognitive domain of learning? -Give the client printed information describing diabetes mellitus. -Engage in a question-and-answer session with the client. -Ask the client how they feel about checking their blood glucose. -Ask the client to demonstrate checking their blood glucose level. -Give the client a fill-in-the blank quiz. -Ask the client to describe the manifestations of hypoglycemia and hyperglycemia.

When taking actions, the nurse should identify that giving the client printed information describing diabetes mellitus, engaging in a question-and-answer session with the client, giving the client a fill-in-the blank quiz, and asking the client to describe the manifestations of hypoglycemia and hyperglycemia are teaching methods based on the cognitive domain of learning. A client who is thinking through, comprehending, and applying information is engaging in the cognitive domain of learning.

A nurse is writing a teaching plan using the Specific, Measurable, Attainable, Relevant, and Timed outcome (SMART) goals for a client who is learning to walk with crutches.

When taking actions, the nurse should identify that the timed component of SMART outcome goals are measurable outcomes based upon a specific time frame by which the client should accomplish the outcome. Day1, in one day, by day 2, and by day 3, are all measurable time frames to assist the nurse in evaluating whether outcome goals are achieved.

A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood? Lymphocytes Platelets Neutrophils Hemoglobin

a. Hemoglobin is part of the red blood cell and transports oxygen in the blood throughout the body.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Lethargy Numbness of fingers Dry skin Abdominal pain

a. Manifestations of respiratory acidosis can include anxiety, confusion, and lethargy.

A nurse is teaching a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include? Store oxygen tanks upright. Keep oxygen tanks 4 feet away from an electric stove. Use petroleum-based ointments to moisturize lips. Choose a wool blanket when using oxygen.

a. Oxygen tanks should be stored upright and attached to a fixed object to prevent them from falling over.

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take? Place the client on continuous cardiac monitoring. Have the client breath into a paper bag. Plan to administer sodium bicarbonate to the client. Obtain a prescription for insulin for the client.

a. The client who has metabolic alkalosis is at risk for dysrhythmias. The nurse should place the client on continuous cardiac monitoring to monitor the client for dysrhythmias.

A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning? Describe the steps of walking with crutches for the client. Ask the client to demonstrate walking with crutches. Show the client a video on walking with crutches. Encourage the client to ask questions about walking with crutches.

b. Having the client demonstrate walking with crutches utilizes the development of physical movement and coordination associated with the psychomotor domain of learning.

A nurse is assessing a client who is experiencing anxiety. Which of the following findings should the nurse expect? Peripheral vasodilation Hyperventilation Bradycardia Drowsiness

b. Manifestations of anxiety can include hyperventilation.

A nurse is teaching a client how to perform a dressing change. The nurse asks the client to explain the information in their own words. Which of the following types of teaching methods is the nurse utilizing? Role-play Teach-back Question-and-answer Lecture

b. Teach-back is an active teaching method based on the cognitive domain of learning. During teach-back, the nurse can evaluate the client's understanding of the education and determine whether further instruction is indicated.

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include? The reservoir bag on a nonrebreather mask should collapse with exhalation. A nonrebreather mask should fit snugly over a client's face. A nonrebreather mask dries a client's mucous membranes. Use a nonrebreather mask to deliver low-flow oxygen.

b. The nonrebreather mask should fit snugly over a client's face to ensure the client is receiving the prescribed amount of oxygen.

A nurse is caring for a client who is receiving a continuous IV infusion through a short-peripheral device. Which of the following actions should the nurse take? Ensure the client's IV solution is changed every 48 hr Change the client's IV tubing every 96 hr. Replace the client's transparent IV dressing every 24 hr. Check the client's IV site every 8 hr.

b. The nurse should change the client's IV tubing every 96 hr to reduce the risk of infection.

A nurse is caring for a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take? Plan to administer insulin to the client. Have the client breath into a paper bag. Have the client place their head between their knees. Plan to administer sodium bicarbonate to the client.

b. The nurse should have a client who is experiencing hyperventilation to breath into a paper bag to slow their respiratory rate and increase their CO2 levels.

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take? Plan to administer sodium bicarbonate to the client. Place the client on seizure precautions. Encourage the client to breath slowly. Have the client breath into a paper bag.

b. The nurse should initiate seizure precautions because the client who has metabolic alkalosis is at risk for seizure activity.

A nurse is preparing to teach a client who has impaired cognition. Which of the following actions should the nurse include in the plan? Avoid making eye contact with the client during the educational session. Involve the client's family in the educational session. Provide long educational sessions. Speak quickly to the client.

b. The nurse should involve the client's family in the educational session to promote learning.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take? Preoxygenate the client for 10 seconds prior to tracheostomy care. Perform tracheostomy care for the client every 4 hr. Place the client in a lateral recumbent position prior to tracheostomy care. Clean the tracheostomy stoma with a chlorhexidine solution.

b. The nurse should perform tracheostomy care every 4 hr to reduce the risk of infection.

A nurse is caring for a client who receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take? Place a pressure dressing over the IV site. Aspirate fluid from the IV cannula. Place the affected extremity below the level of the client's heart. Slow the IV infusion.

b. The nurse should try to aspirate fluid from the IV cannula to remove any solution that might cause further injury.

A nurse is planning to calculate a client's cardiac output. Which of the following data should the nurse obtain to calculate the cardiac output? Blood pressure Heart rate Temperature Respiratory rate

b. The nurse should obtain the client's heart rate to calculate the cardiac output. Cardiac output is calculated by multiplying the heart rate by the stroke volume. It is the measurement of the volume of blood pumped by the left ventricle in 1 min.

A nurse is teaching a newly licensed nurse about client education. The nurse should include that which of the following is the role of the nurse in client education? Describe the steps of a surgical procedure Prescribe medications Diagnose client illnesses Encourage clients to advocate for themselves.

c. Client education should provide the client with feelings of empowerment and assist clients in taking control of managing their own care.

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances? Metabolic Acidosis Respiratory alkalosis Respiratory acidosis Metabolic alkalosis

c. Clients who have COPD, atelectasis, pneumonia, or central nervous system depression, are at risk for respiratory acidosis due to an increased PCO2 from hypoventilation.

A nurse is planning to provide preoperative teaching for a client. Which of the following actions should the nurse plan to take? Dim the lights in the client's room. Start with the least important information. Ensure privacy for the client. Provide educational material written at an eighth-grade reading level.

c. The nurse should ensure privacy for the client to reduce distractions and promote learning.

A nurse is assisting with the care of a client who has metabolic alkalosis. Which of the following actions should the nurse take? Encourage the client to breath slowly. Plan to administer sodium bicarbonate to the client. Place the client on seizure precautions. Have the client breath into a paper bag.

c. The nurse should initiate seizure precautions because the client who has metabolic alkalosis is at risk for seizure activity.

A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first? Return the unit of blood to the blood bank. Infuse 0.9% sodium chloride. Stop the transfusion. Obtain a blood sample from the client.

c. When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to stop the transfusion to reduce the risk of further injury to the client.

A nurse is caring for a client who has a new colostomy and states they are not ready to look at the stoma. The nurse encourages the client to share their feelings about the colostomy. Which of the following teaching strategies is the nurse utilizing? Return demonstration Question-and-answer Role-play Discussion

d. Discussion is an active teaching method using the expression of feelings and application of the material. It is based on the affective or the cognitive domain of learning.

A nurse is teaching a client who has a new colostomy. Which of the following outcomes should the nurse expect? Report of anxiety Increase in length of care in the health care facility Increase in need for pain medication Report of empowerment

d. Education about the colostomy should provide the client with feelings of empowerment and assist the client in taking control of their care.

A nurse is teaching a client who wishes to stop smoking cigarettes. Which of the following teaching methods uses the affective domain of learning? Create short term goals to assist the client in smoking cessation. Discuss the benefits of smoking cessation with the client. Review strategies for smoking cessation with the client. Encourage the client to share their feelings about smoking cessation.

d. Encouraging the client to share their feelings about smoking cessation involves exploring the client's emotions and is associated with the affective domain of learning.

A nurse is assessing a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia? Wheezing Hypoactive bowel sounds Cerebral edema Decreased deep tendon reflexes

d. Hyperkalemia can cause decreased deep tendon reflexes, paralysis, and dysrhythmias.

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia? Hyperactive bowel sounds Hypertension Cerebral edema Muscle weakness

d. Hypokalemia can cause muscle weakness, hypotension, and dysrhythmias.

A nurse is providing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make? "Hold your breath for 5 seconds." "Exhale through your nose." "Inhale through your mouth." "Repeat your breathing exercise every 2 hrs."

d. The client should repeat the breathing exercise every 1 to 2 hrs to increase lung expansion and reduce the risk for atelectasis and pneumonia.

A nurse is planning to insert a short-peripheral IV device into the arm of a client who has a bleeding disorder. Which of the following actions should the nurse plan to take? Elevate the client's arm above the heart. Apply a tourniquet to the client's arm. Apply friction to the selected insertion site. Apply a warm compress over the selected insertion site.

d. The nurse should apply a warm compress over the selected insertion site to promote vascular distention

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take? Place the affected extremity below the level of the client's heart. Place a pressure dressing over the IV site. Slow the IV infusion Apply a warm compress to the IV site.

d. The nurse should apply a warm compress to the IV site to decrease inflammation and promote comfort.

A nurse is planning to administer a unit of PRBCs for a client. Which of the following actions should the nurse plan to take? Stay with the client for the first 10 min after starting the transfusion. Flush the transfusion tubing with 5% dextrose in water. Administer the blood transfusion over 1 hr. Ensure 2 nurses check the label on the unit of blood.

d. Two nurses should check and compare the label on the unit of blood with the client's identification. The two nurses should ensure compatibility of the unit with the client's blood type to reduce the risk of a transfusion reaction.