Care II Exam 3 Practice Questions

a. Initiate bag-valve-mask ventilation

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? a. Initiate bag-valve-mask ventilation b. Provide the client with a communication board c. Obtain a blood sample for ABG analysis d. Document the ventilator settings

a. Insulin glargine

A nurse is caring for a client who has type one diabetes mellitus and is in need of a long acting insulin. The nurse anticipates receiving a prescription for which of the following insulins? a. Insulin glargine b. Insulin lispro c. Insulin aspart d. NPH insulin

d. sudden onset of severe headache

Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes which of the following? a. sensory changes b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache

c. Can draw blood from the line **this allows the client to have less pokes

Which of the following is a benefit of a central line? a. Can administer TPN b. Can easily administer chemotherapy medication c. Can draw blood from the line d. Can be easily accessed with clean technique

b. Agnosia

Which of the following terms is defined by "the inability to recognize an object by sight, touch, or hearing"? a. Apraxia b. Agnosia c. Aphasia d. Hemiplegia

a. Dysarthria

While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as which of the following? a. Dysarthria b. Apraxia c. Alexia d. Dysphagia

c. Albuterol (Proventil HFA)

Which of the following medications would be most appropriate to administer to a patient experiencing an acute asthma attack? a. Montelukast (Singulair) b. Inhaled hypertonic saline c. Albuterol (Proventil HFA) d. Salmeterol (Serevent Diskus)

c. Streptococcus pneumoniae

Which of the following organisms most commonly causes community-acquired pneumonia in adults? a. Haemophilus influenzae b. Klebsiella pneumoniae c. Streptococcus pneumoniae d. Staphylococcus aureus

d. Inflammation

Which of the following pathophysiological mechanisms that occur in the lung parenchyma allow pneumonia to develop? a. Atelectasis b. Bronchiectasis c. Effusion d. Inflammation

a. impaired judgement d. left-sided weakness e. impulsive actions

Which of the following symptoms indicate a stroke on the right side of the brain? (Select all that apply) a. impaired judgement b. depression c. impaired speech d. left-sided weakness e. impulsive actions

b. The mucosa lining experiences severe inflammation c. The goblet cells within the mucosa lining produce excessive amounts of mucous

Select all the correct options that represent the pathophysiology of an asthma attack. a. The smooth muscle surrounding the alveoli constricts, limiting oxygenation b. The mucosa lining experiences severe inflammation c. The goblet cells within the mucosa lining produce excessive amounts of mucous d. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis

c. 7 days **most places policy is to change every 7 days

The dressing is changed on a central line at the time it is loose or saturated. If the dressing stays clean, dry, and intact, then the policy tells to change the dressing how often? a. 3 days b. 5 days c. 7 days d. 9 days

c. Superior vena cava

The end of a central line catheter usually sits where in the heart? a. Aorta b. Inferior vena cava c. Superior vena cava d. Right atrium

c. deliver a precise concentration of O2 **venturi is high flow, which can deliver a precise amount of O2

The major advantage of a Venturi mask is that it can do which of the following? a. deliver up to 80% O2 b. provide continuous 100% humidity c. deliver a precise concentration of O2 d. be used while a patient eats and sleeps

b. Latex **latex is a common allergy associated with spina bifida

The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons. The nurse would suspect that the child may have an allergy to which of the following? a. Bananas b. Latex c. Kiwifruit d. Color dyes

d. prolonged expiratory phase

The nurse assesses a patient admitted for an asthma exacerbation. Which of the following is a distinct assessment finding of asthma? a. prolonged inspiratory phase b. purulent sputum c. nasal polyps d. prolonged expiratory phase

d. Walk 15 to 20 minutes daily at least 3 times/week

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? a. Stop exercising when short of breath b. Walk until pulse rate exceeds 130 beats/minute c. Limit exercise to activities of daily living (ADLs) d. Walk 15 to 20 minutes daily at least 3 times/week

d. alpha-fetoprotein (AFP)

The nurse discusses with a client a prenatal test to screen for spinal anomalies done between 16 and 20 weeks' gestation, which is called the... a. Enzyme-linked immunosorbent assay (ELISA) b. VDRL c. BHCG d. alpha-fetoprotein (AFP)

c. patency of the cerebral blood vessels

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine what? a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerebrospinal fluid

b. Check for blood return

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? a. Administer 5 mL of a heparinized solution b. Check for blood return c. Flush the port with 10 mL of normal saline d. Palpate the port for stability

c. Agitation

The nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? a. Nausea b. Dysphagia c. Agitation d. Hypotension

b. The client's hemoglobin A1C **A1C shows a 90-day period of blood glucose

The nurse is assessing the glucose level of a client with a diagnosis of diabetes. Which of these is the most helpful in evaluating the client's long-term glucose management? a. The client's 24-hour urine output b. The client's hemoglobin A1C c. The client's food diary d. The client's fasting blood glucose

b. The client has weakness on the right side of the body, including the face and tongue

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs b. The client has weakness on the right side of the body, including the face and tongue c. The client has lost the ability to move the right arm but can walk independently d. The client has lost the ability to move the left arm but can walk independently

a. delayed capillary refill b. sunken fontanels d. decreased urine output

Which of the following is a sign of dehydration in a child diagnosed with bronchiolitis? (Select all that apply) a. delayed capillary refill b. sunken fontanels c. intercostal retractions d. decreased urine output

a. Increased mucus secretion

A nurse is teaching a client about the manifestations of an allergic reaction associated with asthma. The release of histamine causes which of the following reactions? a. Increased mucus secretion b. Bronchial dilation c. Bradycardia d. Vertigo

d. Albuterol

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? a. Beclomethasone b. Salmeterol c. Formoterol d. Albuterol

a. Diet and exercise regime

A 36-year-old male is newly diagnosed with Type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? a. Diet and exercise regime b. Metformin BID by mouth c. Regular insulin subcutaneous d. None, monitoring at this time is sufficient enough

a. Kussmaul's respirations and a fruity odor on the breath

A client is in diabetic ketoacidosis (DKA) secondary to infection. As the condition progresses, which of the following symptoms might the nurse see? a. Kussmaul's respirations and a fruity odor on the breath b. Shallow respirations and severe abdominal pain c. Decreased respiration and increased urine output d. Cheyne-stokes respirations and foul-smelling urine

b. "Your body has insulin resistance and decreased insulin secretion"

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make? a. "Your body is destroying the cells that secrete insulin" b. "Your body has insulin resistance and decreased insulin secretion" c. "An infection in your pancreas destroyed the cells that make insulin" d. "Your kidneys are not able to reabsorb water, which leads to Type 2 Diabetes Mellitus"

a. Elevated blood glucose level and a low plasma bicarbonate

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which finding would a nurse expect to note as confirming this diagnosis? a. Elevated blood glucose level and a low plasma bicarbonate b. Decreased urine output c. Increased respiration and an increase in pH d. Comatose state

d. Administer 50% dextrose intravenously per protocol

A client with diabetes has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the nurse is the priority? a. Administer acetaminophen to lower the client's temperature b. Administer the client's prescribed fast-acting insulin c. Administer oxygen via nasal cannula d. Administer 50% dextrose intravenously per protocol

b. Assess the client's respiratory status

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? a. Increase the oxygen flow to 3 L/min b. Assess the client's respiratory status c. Call emergency services for the client d. Have the client cough and expectorate secretions

d. Impaired gas exchange related to airflow obstruction

A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? a. Activity intolerance related to fatigue b. Anxiety related to actual threat to health status c. Risk for infection related to retained secretions d. Impaired gas exchange related to airflow obstruction

a. Establish the ability to communicate effectively **The left hemisphere is usually dominant for language --> this client had a left-side CVA, so the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication

A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebral accident CVA three weeks ago. Which of the following goals should the nurse include in the clients rehabilitation program? a. Establish the ability to communicate effectively b. Compensate for loss of depth perception c. Learn to control impulsive behavior d. Improve left-side motor function

c. Remind the client to look for food on the left side of the tray

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? a. Provide a nonskid mat to alleviate plate movement b. Encourage the client to use his right hand when feeding himself c. Remind the client to look for food on the left side of the tray d. Encourage the use of the wide grip utensils

b. Difficulty with speech

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-sided stroke. Which of the following findings should the nurse expect? a. Reduced left-sided motor function b. Difficulty with speech c. Impulsive behavior d. Neglect of the left side of the body

d. Albuterol (ProAir)

A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first? a. Budesonide (Pulmicort) b. Fluticasone (Flovent) c. Montelukast (Singulair) d. Albuterol (ProAir)

d. Administering a nebulized beta-adrenergic **The greatest risk to the client's safety is airway obstruction, and beta-adrenergic medications act as bronchodilators

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? a. Initiating oxygen therapy b. Providing immediate rest for the client c. Positioning the client in high-Fowler's d. Administering a nebulized beta-adrenergic

b. Stop the infusion of blood

A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and hives 30 minutes after the infusion begins. Which of the following actions should the nurse take? a. Maintain IV access with 0.9% NaCl b. Stop the infusion of blood c. Send the blood container and tubing to the blood bank d. Obtain a urine sample

d. Barrel

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? a. Pigeon b. Funnel c. Kyphotic d. Barrel

c. Bradykinesia

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? a. Pruritus b. Hypertension c. Bradykinesia d. Xerostomia

d. Clubbing of the fingers

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation? a. Restlessness b. Retractions c. Dependent edema d. Clubbing of the fingers

d. Low back pain

A nurse is assessing a client who is receiving a unit of blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? a. Bradycardia b. Paresthesia c. Hypertension d. Low back pain

a. Stop the infusion of blood

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? a. Stop the infusion of blood b. Inform the provider c. Obtain a urine specimen d. Notify the laboratory

a. lethargy **blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia --> nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion

A nurse is assessing a school age child whose blood glucose is 280 mg/dL. Which of the following findings should be expected? a. lethargy b. pallor c. tremor d. shallow respirations

a. Repeat auscultation after asking the client to breath deeply and cough

A nurse is auscultation get a client's lung and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? a. Repeat auscultation after asking the client to breath deeply and cough b. Instruct the client to limit fluid intake to less than 2000 ml/day c. Prepare to administer antibiotics d. Place the client on bed rest in semi-Fowler's position

a. Sweat chloride test

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis? a. Sweat chloride test b. A sputum culture c. A stool fat content analysis d. Pulmonary function tests

c. Administer humidified O2 d. Suction the nasopharynx as needed

A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (Select all that apply) a. Administer PO Prednisone b. Initiate chest percussion and postural drainage c. Administer humidified O2 d. Suction the nasopharynx as needed e. Administer oral penicillin

a. Administer a short-acting beta 2 agonist (SABA) **when using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? a. Administer a short-acting beta 2 agonist (SABA) b. Obtain a peak flow rating c. Administer an inhaled glucocorticoid d. Determine the cause of the acute exacerbation

d. Keep the client NPO **use ABC's --> keep the client NPO due to the risk of aspiration as a result of the stroke

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? a. Obtain coagulation laboratory studies from the client b. Apply pneumatic compression boots to the client c. Request a referral for a speech-language pathologist d. Keep the client NPO

a. Expressive aphasia **understands speech, but has difficulty with speaking and writing

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit, but does not respond verbally to questions. The nurse should document this as which of the following alterations? a. Expressive aphasia b. Dysarthria c. Receptive aphasia d. Dysphagia

a. Impulse control

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? a. Impulse control b. Vision deficits in the right eye c. Motor retardation d. Impaired speech

d. Decreased tremors

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine (benadryl) 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? a. Delay in disease progression b. Improved bladder function c. Relief of depression d. Decreased tremors

a. Assess and document the client's vitals c. Verify with another nurse the blood type and Rh of the packed RBCs e. Obtain informed consent from the patient **D is wrong because normal saline is the only solution compatible with blood transfusions

A nurse is caring for a client who has an upper GI bleed. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply) a. Assess and document the client's vitals b. Restart the IV with a 22-gauge needle c. Verify with another nurse the blood type and Rh of the packed RBCs d. Hang a bag of Lactated Ringer's IV solution e. Obtain informed consent from the patient

b. Manifestations preceded by a severe headache

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? a. Gradual onset of several hours b. Manifestations preceded by a severe headache c. Maintains consciousness d. History of neurologic deficits lasting less than 1 hour

d. Intellectual impairment **A client who had a stroke involving the left cerebral hemisphere is likely to have deficits that involve language, mathematical skills, and thinking

A nurse is caring for a client who has had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? a. Impaired sense of humor b. Loss of depth perception c. Poor judgement d. Intellectual impairment

b. Inability to recognize his family members

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? a. Difficulty reading b. Inability to recognize his family members c. Right hemiparesis d. Aphasia

d. raise the head of the bed **elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs

A nurse is caring for a client who has pneumonia. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? a. administer oxygen 2 L per minute b. administer prescribed analegestic medication c. encourage coughing and deep breathing d. raise the head of the bed

c. Encourage the client to increase fluid intake **Increasing fluid intake promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a. Encourage the client to ambulate frequently b. Encourage coughing and deep breathing c. Encourage the client to increase fluid intake d. Encourage regular use of the incentive spirometer

b. Monitor the client for hypoglycemia **The first action the nurse should take using the nursing process is to assess or collect data from the client --> the nurse should immediately check the client's blood glucose level, expecting it to be low because of the excessive dose of insulin

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? a. Give the client 15 to 20 g of carbohydrate b. Monitor the client for hypoglycemia c. Complete an incident report d. Notify the nurse manager.

b. Diaphoresis

A nurse is caring for a client who has type I diabetes and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? a. Kussmaul respirations b. Diaphoresis c. Decreased skin turgor d. Ketonuria

b. Increased urination

A nurse is caring for a client who has type II diabetes and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? a. Hunger b. Increased urination c. Cold, clammy skin d. Tremors

c. Weight loss

A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect? a. Hypertension b. Hematuria c. Weight loss d. Bradycardia

c. Encourage deep breathing and coughing **least invasive to most invasive

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? a. Provide chest physiotherapy b. Perform oropharyngeal suction c. Encourage deep breathing and coughing d. Assist the client with ambulation

a. Maintain the integrity of the sac

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? a. Maintain the integrity of the sac b. Promote maternal-infant bonding c. Educate the parents about the defect d. Provide age appropriate stimulation

d. 200mg **2.2lb/ 1kg=88 lb 88lb/2.2= 40 kg 5mg x 40kg = 200mg

A nurse is caring for an adolescent client with pneumonia and a prescription for cefpodoxime 5mg/kg PO every 12 hours for the next 5 days. The client weighs 88 lbs. How many mg should the nurse administer? a. 20 mg b. 2000 mg c. 2 mg d. 200 mg

d. Test water temperature with the wrist **diabetes can decrease sensory perception in the feet

A nurse is conducting discharge teaching about foot care for a client who has diabetes. Which of the following instructions should the nurse include? a. Wear nylon socks with shoes every day b. Trim toenails by rounding the edges of the nail c. Apply lotion between the toes after bathing d. Test water temperature with the wrist

d. Instruct the client to use pursed-lip breathing **Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation

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? a. Restrict the client's fluid intake to less than 2 L/day b. Provide the client with a low-protein diet c. Have the client use the early-morning hours for exercise and activity d. Instruct the client to use pursed-lip breathing

d. Bicarbonate level 12 mEq/L

A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following lab values is consistent with diabetic ketoacidosis? a. Blood glucose 30 mg/dL b. Negative urine ketones c. Blood pH 7.38 d. Bicarbonate level 12 mEq/L

b. Addressing the client's perception of the disease process and what might have triggered past attacks

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. Eliminating environmental triggers that precipitate attacks b. Addressing the client's perception of the disease process and what might have triggered past attacks c. Overviewing the client's medication regimen d. Explaining manifestations of respiratory infections

c. Determine what the client knows about managing diabetes **The first action the nurse should take is to assess or collect data from the client, so the nurse should find out what the client knows before proceeding with the plan

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first? a. Establish short-term, realistic goals for the client b. Give the client access to a video about diabetes c. Determine what the client knows about managing diabetes d. Evaluate the effectiveness of the client's admission teaching plan

c. Encourage the client to take small bites **the family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking

A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instruction should the nurse include? a. Encourage brief exercise before meals to promote appetite b. Place food in the affected side of the mouth c. Encourage the client to take small bites d. Place the client with the head reclined back to facilitate swallowing

a. Stopping the transfusion

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority? a. Stopping the transfusion b. Covering the client with a blanket c. Notifying the provider d. Assessing the client's skin for a rash

b. Bronchiolitis

A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are associated with which of the following diagnoses? a. Influenza b. Bronchiolitis c. Croup d. Epiglottis

d. head circumference measurement

A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (myelomeningocele). A priority nursing assessment for this newborn is which of the following? a. pulse rate b. palpation of the abdomen c. specific gravity of the urine d. head circumference measurement

a. Eat high-calorie foods first

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. Eat high-calorie foods first b. Increase intake of water at meal times c. Perform active range-of-motion exercises d. Keep saltine crackers nearby for snacking

d. Nasal cannula

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of COPD. Which of the following oxygen-delivery methods should the nurse plan to use for this client? a. Simple face mask b. Nonrebreather mask c. Bag-valve-mask device d. Nasal cannula

c. Provide a latex-free environment **Children who have spina bifida have a very high risk of developing a latex allergy, which can be life threatening

A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Which of the following interventions should the nurse include in the plan of care? a. Maintain the infant in the supine position b. Initiate contact precautions c. Provide a latex-free environment d. Limit visitors to immediate family members

c. Palpate the abdomen for bladder distension **a neurogenic bladder is the most common complication of a myelomeningocele --> D is wrong because dressings should be moist

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? a. Fasten the diaper loosely b. Cleanse the meningeal sac with iodine daily c. Palpate the abdomen for bladder distension d. Cover the sac with a dry, sterile gauze

b. Ask the client to identify the types of food she prefers **involving the client in the planning will promote her adherence to the dietary plan

A nurse is planning dietary teaching for a client who has diabetes. Which of the following action should the nurse plan to take first? a. Obtain sample menus from the dietician to give to the client b. Ask the client to identify the types of food she prefers c. Identify the recommended range of the client's blood glucose level d. Discuss long-term complications that can result from non-adherence to the dietary plan

a. High risk for deficient fluid volume **Increased blood glucose will cause the kidneys to excrete the glucose on the urine --> glucose is accompanied by fluids and electrolytes, leading to dehydration

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing diagnosis would be which of the following? a. High risk for deficient fluid volume b. Deficient knowledge: disease process and treatment c. Imbalanced nutrition: less than body requirements d. Disabled family coping: compromised

b. 50 gtt/min **the quantity of those available is 20 GTT/min. The total infusion time is 20 minutes. The volume the nurse should infuse at is 50 mL. There is no need to convert the units of measurement. 20 gtt/1 mL x 50ml/20 min = 50 gtt/min

A nurse is preparing to administer antibiotic X over 20 minutes. Available is antibiotic X in 50 mL of 0.9% sodium chloride (NSS). The drop factor of the manual IV tubing is 20 GTT/ML. The nurse should set the manual IV infusion to deliver how many GTT/min? a. 0.5 gtt/min b. 50 gtt/min c. 2.5 gtt/min d. 25 gtt/min

c. 75 mL/hr

A nurse is preparing to administer total parenteral nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? a. .75 mL/hr b. 7.5 mL/hr c. 75 mL/hr d. 750 mL/hr

a. 10 **1 hr/60 min = 4 hr/X min X = 240 min 250 mL/240 min x 10 gtt/mL = X gtt/min X = 10.4 gtt/min

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hours. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Round to the nearest whole number) a. 10 b. 100 c. 1 d. 1000

c. Witness the informed consent document **must have consent before blood can be prepared to be given

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client with anemia. Which of the following actions should the nurse take first? a. Hang an IV infusion of 0.9% NaCl with the blood b. Compare the client's identification number with the number on the blood c. Witness the informed consent document d. Obtain pretransfusion vital signs

a. "We will give our child pancreatic enzymes with snacks and meals"

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching? a. "We will give our child pancreatic enzymes with snacks and meals" b. "We will restrict the amount of salt in our child's food" c. "I will limit my child's fluid intake" d. "I will prepare low-fat meals with limited protein for my child"

b. "My son might complain of feeling shaky when he has a low blood glucose"

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes. Which of the following statements by the parents indicates an understanding of the teaching? a. "The onset of low blood glucose usually occurs slowly" b. "My son might complain of feeling shaky when he has a low blood glucose" c. "Sweating can occur with hyperglycemia" d. "My son might have nausea and vomiting with hypoglycemia"

b. check the cannula position on a regular basis c. check the tops of the ears for skin breakdown d. post no smoking signs in a prominent location in the home **A is not correct because the flow rate should be checked DAILY

A nurse is providing discharge teaching's to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply) a. verify the oxygen flow rate every other day b. check the cannula position on a regular basis c. check the tops of the ears for skin breakdown d. post no smoking signs in a prominent location in the home

b. Promotes carbon dioxide elimination

A nurse is providing instructions about pursued lip breathing for a client who has COPD with emphysema. This breathing technique accomplishes which of the following? a. Increases oxygen intake b. Promotes carbon dioxide elimination c. Uses the intercostal muscles d. Strengthens the diaphragm

b. "Wear a medical alert identification tag when you exercise"

A nurse is providing teaching about exercise to a client who has type I diabetes. Which of the following statements should the nurse include? a. "You should exercise during a peak insulin time" b. "Wear a medical alert identification tag when you exercise" c. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase" d. "You will get the most benefit from exercise when your glucose levels are higher than normal"

a. Total lung capacity

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. Total lung capacity b. Vital lung capacity c. Functional residual capacity d. Residual volume

c. Levodopa/carbidopa

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client? a. Piperacillin/tazobactam b. Levothyroxine c. Levodopa/carbidopa d. Carbamazepine

b. Blurred vision d. Tachycardia e. Moist, clammy skin

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply) a. Polyuria b. Blurred vision c. Polydipsia d. Tachycardia e. Moist, clammy skin

b. "Try to drink at least 2 to 3 liters of fluid per day" **helps to loosen secretions and improve breathing

A nurse is providing teaching to a client who has emphysema. Which of the following instructions should the nurse include? a. "Be sure to take cough medicine to avoid coughing" b. "Try to drink at least 2 to 3 liters of fluid per day" c. "Try to reduce your smoking to 2 cigarettes per day" d. "Be sure to eat 3 full meals each day"

a. "My cells are resistant to the effects of insulin"

A nurse is providing teaching to a client with type II diabetes. Which of the following statements by the client indicates an understanding of the teaching? a. "My cells are resistant to the effects of insulin" b. "My body breaks down sugars too efficiently" c. "My pancreas does not produce insulin" d. "My body produces antibodies against pancreatic beta cells"

a. Hip **exercise can enhance the absorption of insulin from an involved insulin, so we don't want to administer it in any of the extremities in this case

A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? a. Hip b. Upper arm c. Thigh d. Lower leg

a. Provide client supervision **Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? a. Provide client supervision b. Limit client physical activity c. Speak loudly to the client d. Leave the television on continuously

a. Place the client in the prone position b. Diapering is contraindicated due to infection risk

A nurse is providing teaching to the parents of a child with spina bifida. Which of the following should the nurse include in the teaching? (Select all that apply) a. Place the client in the prone position b. Diapering is contraindicated due to infection risk c. Place a dry, sterile dressing over the sac d. Spina bifida is the abnormal development of the coccyx

c. Fasting blood glucose 155 mg/dL **a fasting blood glucose above 126 mg/dL meets the criteria for a diagnosis of diabetes mellitus

A nurse is reviewing the lab results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus? a. HbA1c 5.5% b. 2 hr blood glucose 170 mg/dL c. Fasting blood glucose 155 mg/dL d. Casual blood glucose 180 mg/dL

a. The client holds his breath for 10 seconds after inhaling the medication

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? a. The client holds his breath for 10 seconds after inhaling the medication b. The client takes a quick inhalation while releasing the medication from the inhaler c. The client exhales as the medication is released from the inhaler d. The client waits 10 min between inhalations

1. Inhale deeply and then exhale completely 2. Place her lips firmly around the mouthpiece 3. Breathe in deeply over 2 to 3 seconds while pushing down on the canister 4. Hold her breath for 10 seconds 5. Exhale slowly through pursed lips 6. Wait 60 seconds between each puff

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). Put the following steps in the sequence that the client should follow. Inhale deeply and then exhale completely Place her lips firmly around the mouthpiece Breathe in deeply over 2 to 3 seconds while pushing down on the canister Hold her breath for 10 seconds Exhale slowly through pursed lips Wait 60 seconds between each puff

c. "I'll check my feet every day for sores and bruises."

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll wear sandals in warm weather." b. "I'll put lotion between my toes after drying my feet." c. "I'll check my feet every day for sores and bruises." d. "I'll soak my feet in cold water every night before I go to bed."

b. Difficulty voiding **the nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of benztropine

A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? a. Excess salivation b. Difficulty voiding c. Diarrhea d. Slow pulse

c."To collect a sample for testing, hold the test strip next to the blood on the fingertip."

A nurse is teaching a client who was recently diagnosed with type one diabetes mellitus how to check blood glucose levels. Which of the following instructions should the nurse include in her teaching? a. "Blood can be smeared from the fingertip onto the test strip." b. "Use a syringe and needle to collect and transfer blood to the test strip." c."To collect a sample for testing, hold the test strip next to the blood on the fingertip." d. "Use a capillary tube to collect and transfer the blood from the fingertip."

c. Test the urine for ketones **test urine for ketones and report the presence of them in the urine --> ketonuria can indicate the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells ***B is wrong b/c provider should be notified when blood glucose levels are greater than 250 mg/dL

A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? a. Withhold insulin dose if feeling nauseous b. Notify the provider if blood glucose levels are over 350 c. Test the urine for ketones d. Limit fluid intake during meal time

d. "I give the insulin injection in my abdominal area." **The client should give insulin injections in the abdomen, if possible, as it is the area for fastest absorption

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? a. "I am to take my blood sugar reading after meals." b. "Insulin allows me to eat ice cream at bedtime." c. "A weight reduction program will make me hypoglycemic." d. "I give the insulin injection in my abdominal area."

d. Spina bifida

A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect? a. Cerebral palsy b. Hydrocephalus c. Muscular dystrophy d. Spina bifida

d. Race

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? a. History of smoking b. Obesity c. History of hypertension d. Race

d. "Maintain stable blood glucose levels"

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? a. "Have an eye examination once per year" b. "Examine your feet carefully every day" c. "Wear compression stockings daily" d. "Maintain stable blood glucose levels"

c. "My child will take the enzymes to help digest the fat in foods." **pancreatic enzymes help the body to digest fat in foods

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? a. "My child will take the enzymes to improve her metabolism." b. "My child will take the enzymes following meals." c. "My child will take the enzymes to help digest the fat in foods." d. "My child will take the enzymes 2 hours before meals."

b. "The spacer increases the amount of medication delivered to the lungs"

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? a. "The spacer increases the amount of medication delivered to the oropharynx" b. "The spacer increases the amount of medication delivered to the lungs" c. "Inhale rapidly using the spacer with the MDI" d. "Cover exhalation slots of the spacer with lips when inhaling"

b. Signs of hypoglycemia earlier than expected

A nurse went to a patient's room to do routine vital signs monitoring and found out that the patient's bedtime snack was not eaten. This should alert the nurse to check and assess for: a. Elevated serum bicarbonate and decreased blood pH b. Signs of hypoglycemia earlier than expected c. Symptoms of hyperglycemia during the peak time of NPH insulin d. Sugar in the urine

c. Call emergency services **the client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? a. Obtain the telephone number of the client's provider b. Find a location for the client to sit c. Call emergency services d. Drive the client to the nearest emergency department

a. 6.3% **the goal for a client who has diabetes mellitus is to keep the HbA1c values at 6.5% or less

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? a. 6.3% b. 7.8% c. 8.5% d. 10%

b. Confusion on date, time, and place d. Unilateral neglect f. Impulsive g. Short attention span

A patient has right side brain damage from a stroke. Which of the following signs and symptoms occur with this type of stroke? (Select all that apply) a. Right side hemiplegia b. Confusion on date, time, and place c. Aphasia d. Unilateral neglect e. Aware of limitations f. Impulsive g. Short attention span h. Agraphia

b. Ischemic embolism

A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? a. Ischemic thrombosis b. Ischemic embolism c. Hemorrhagic d. Ischemic stenosis

a. Allergic rhinitis c. Cough, especially at night d. History of chronic sinusitis

A patient is concerned that he may have asthma. Of the symptoms that he describes to the nurse, which ones suggest asthma or risk factors for asthma? (Select all that apply) a. Allergic rhinitis b. Prolonged inhalation c. Cough, especially at night d. History of chronic sinusitis

c. fever, chills, flank pain

A patient is receiving a blood transfusion. Within five minutes, the patient begins to have symptoms of a transfusion reaction. The assessment findings include which of the following? a. wheezing, cough, hoarse voice b. nausea, vomiting, diarrhea c. fever, chills, flank pain d. agitation, dizziness, hallucinations

a. Status asthmaticus

A patient is rushed to the emergency department during an acute, severe, prolonged asthma attack and is unresponsive to usual treatment. The condition is referred to as which of the following? a. Status asthmaticus b. Reactive airway disease c. Intrinsic asthma d. Respiratory distress syndrome

c. Hospital-acquired pneumonia

A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia? a. Aspiration pneumonia b. Ventilator acquired pneumonia c. Hospital-acquired pneumonia d. Community-acquired pneumonia

c. Bradykinesia

A patient with Parkinson's Disease has slow movements that affects their swallowing, facial expressions, and ability to coordinate movements. As the nurse you will document the patient has which of the following manifestations? a. Akinesia b. "Freeze up" tremors c. Bradykinesia d. Pill-rolling

c. Percentage of hemoglobin carrying oxygen

A pulse oximetry gives what type of information about the client? a. Amount of carbon dioxide in the blood b. Amount of oxygen in the blood c. Percentage of hemoglobin carrying oxygen d. Respiratory rate

c. tachycardia

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the blood glucose and it is 55 mg/dL. Which of the findings should the nurse expect? a. dry, flushed skin b. deep, rapid respirations c. tachycardia d. polyuria

b. Ineffective breathing pattern related to airway inflammation and increased secretions

An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is which of the following? a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear and/or anxiety related to dyspnea and hospitalization

c. contact precautions **RSV is transmitted through droplets

An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires which of the following types of isolation? a. reverse isolation b. airborne isolation c. contact precautions d. universal precautions

c. Applying moist saline dressings

Appropriate nursing interventions for a newborn's myelomeningocele sac prior to surgery include using sterile technique and which of the following? a. Leaving the sac open to air b. Applying petrolatum to cover the sac c. Applying moist saline dressings d. Applying dry dressings

c. 500 mg **Calculate the child's weight in kg: 44/2.2 = 20 kg Calculate the appropriate daily dose according to the drug text: 50 mg/kg/day = 50 mg x 20 kg = 1,000 mg/day BID means twice daily, so 1,000 divided by 2 equals 500 mg

Archie who weighs 44 lb has been given an order for amoxicillin 500 mg BID The drug text notes that the daily dose of amoxicillin is 50 mg/kg/day in two divided doses. What dose in milligrams is safest for this child? a. 1000 mg b. 750 mg c. 500 mg d. 250 mg

c. dopamine

As the nurse you know that Parkinson's Disease tends to affect the substantia nigra of the midbrain, which leads to the depletion of which neurotransmitter? a. acetylcholine b. norepinephrine c. dopamine d. serotonin

a. Pulmonary secretions are abnormally thick

Betty is a 9-year-old girl diagnosed with cystic fibrosis. Which of the following must the nurse keep in mind when developing a care plan for the child? a. Pulmonary secretions are abnormally thick b. Elevated levels of potassium are found in the sweat c. CF is an autosomal dominant hereditary disorder d. Obstruction of the endocrine glands occurs

d. Mechanical obstruction caused by increased viscosity of mucous gland secretions

Cystic fibrosis may affect singular or multiple systems of the body. The primary factor responsible for possible multiple clinical manifestations is which of the following? a. Hyperactivity of sweat glands b. Hypoactivity of autonomic nervous system c. Atrophic changes in mucosal wall of intestines d. Mechanical obstruction caused by increased viscosity of mucous gland secretions

d. "It is several conditions including hypertension and diabetes that increases the risk of cardiovascular disease."

Dave says, "The nurse practitioner said that I have metabolic syndrome. Can you tell me what that is?" What is the best response? a."It is a condition that impairs your ability to maintain a normal metabolic rate; causing added weight around the belly." b. "It is a syndrome that occurs with pre-diabetes and can't be avoided." c. "It is another name for pre-diabetes." d. "It is several conditions including hypertension and diabetes that increases the risk of cardiovascular disease."

b. time at which stroke symptoms first appeared

For a patient who is suspected of having a stroke, the most important piece of information that the nurse can obtain is which of the following? a. time of the patient's last meal b. time at which stroke symptoms first appeared c. patient's hypertension history and management d. family history of stroke and other cardiovascular diseases

c. Using a high-flow venturi mask to deliver oxygen as prescribed

For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the patient to drink three glasses of fluid daily b. Keeping the patient in semi-Fowler's position c. Using a high-flow venturi mask to deliver oxygen as prescribed d. Administering a sedative, as prescribed

b. 5.7-6.4%

Glycosylated hemoglobin (HbA1C) test measures the average blood glucose control of an individual over the previous three months. Which of the following values is considered a diagnosis of pre-diabetes? a. 6.5-7% b. 5.7-6.4% c. 5-5.6% d. >5.6%

c. 4 hours after the onset of stroke symptoms

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, when must it be administered? a. 10 hours after the onset of stroke symptoms b. 7 hours after the onset of stroke symptoms c. 4 hours after the onset of stroke symptoms d. 12 hours after the onset of stroke symptoms

c. Slowed growth

Inhaled corticosteroids are currently the recommended first-line therapy for children over the age of 5 years. Children with asthma who are taking long-term inhaled steroids should be assessed frequently because which of the following may develop? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome

b. a 48-year-old patient with a smoking history of one pack daily

Of the following patients, who is more at risk for COPD? a. a 55-year-old patient with a history of asthma and a rescue inhaler b. a 48-year-old patient with a smoking history of one pack daily c. a 67-year-old patient with lung cancer who wears 2L NC d. a 71-year-old patient with dysphagia diagnosed with aspiration pneumonia

b. A PICC line in the patient's right upper arm

Of the following, which line would be considered a central line? a. An 18-gauge in the patient's external jugular vein b. A PICC line in the patient's right upper arm c. A midline IV in the patient's left upper am d. A 16-gauge in the patient's brachial vein

a. Prone

Prior to surgery for a myelomeningocele, the nurse would place the baby in which of the following positions? a. Prone b. Trendelenburg c. Lateral d. Supine

c. Sac formation containing meninges and spinal fluid

Spina bifida is one of the possible neural tube defects that can occur during early embryological development. Which of the following definitions most accurately describes meningocele? a. Complete exposure of spinal cord and meninges b. Herniation of spinal cord and meninges into a sac c. Sac formation containing meninges and spinal fluid d. Spinal cord tumor containing nerve roots.

c. "It is best for you to let your mother dress herself for as long as she​ can." **the nurse should tell the caregiver​ that, by allowing independence in​ dressing, the client will have an improved sense of​ well-being and lessened depression

The daughter of an older adult client with advancing Parkinson disease tells the nurse that they need to dress their mother each​ morning, because the mother is​ "not fast​ enough." Which is the most appropriate response from the​ nurse? a. "It is important for you to get to work on​ time." b. "Can you let her dress​ herself? c. "It is best for you to let your mother dress herself for as long as she​ can." d. "That is really quite​ normal."

a. Measure the circumference of both upper arms **The first action the nurse should take using the nursing process is to assess the client --> nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider

The nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? a. Measure the circumference of both upper arms b. Notify the provider who inserted the PICC line c. Remove the PICC line d. Apply a cold pack to the client's upper arm.

c. Inspiratory wheezing and respiratory rate greater than 30

The nurse is caring for a client with an acute asthma exacerbation. What priority assessment would concern the nurse the most? a. Shortness of breath and temperature above 100 F b. An oxygen saturation of 90% and pulse rate greater than 80 c. Inspiratory wheezing and respiratory rate greater than 30 d. Tachycardia and pursed lip breathing

b. 90%

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent? a. 85% b. 90% c. 80%% d. 75%

b. Keep the head of the bed elevated

The nurse is instructing an unlicensed assistive personnel (UAP) regarding the care of a male client with a diagnosis of COPD. What is the highest priority nursing action to share with the UAP? a. Encourage the client to ambulate as much as possible b. Keep the head of the bed elevated c. Never leave the client alone when he is out of bed d. Offer to help the client with activities of daily living

a. Respiratory rate of 18 breaths/min

The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client's condition? a. Respiratory rate of 18 breaths/min b. Pulse oximetry of 88% c. Pulse rate of 110 beats/min d. Productive cough with rapid breathing

b. Recognize risk factors for respiratory infections

The nurse is planning care for a client with a diagnosis of cystic fibrosis (CF) living in the community. What is the priority goal to be included? a. Increase activity level 20 minutes per day b. Recognize risk factors for respiratory infections c. Family members will support the client's care d. Genetic testing will be considered in the future

b. Immediately removing the client's venous access device (VAD) when it is no longer needed c. Thorough hand hygiene d. Using chlorhexidine for skin disinfection

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply) a. During insertion, draping the area around the site with a sterile barrier b. Immediately removing the client's venous access device (VAD) when it is no longer needed c. Thorough hand hygiene d. Using chlorhexidine for skin disinfection

c. Completing the sentences that the client cannot finish

The nurse is trying to communicate with a client who had a stroke and now has aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech

a. reduced peak flow meter readings c. wheezing with exercise

The nurse provides discharge education to the parents of a child diagnosed with asthma. The education focuses heavily on early warning signs of an asthma exacerbation. Which of the following clinical manifestations should be included as early warning signs? (Select all that apply) a. reduced peak flow meter readings b. fatigue at rest c. wheezing with exercise d. chest retractions

a. infection

The nurse provides education to the parents of a child diagnosed with cystic fibrosis. She describe to the parents the most common complication from cystic fibrosis is which of the following? a. infection b. infertility c. malnutrition d. dyspnea

a. Assess the insertion site

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do first? a. Assess the insertion site b. Check connections c. Check the infusion rate d. Discontinue the IV and start another

d. Wheezes

The nurses auscultating the breath sounds of a client who has asthma. when the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? a. Crackles b. Rhonchi c. Stridor d. Wheezes

b. Monitor the glucose more frequently than usual while she is sick

The parent of a 6-year-old child with type 1 diabetes calls the clinic to report that her child has been running a low grade fever and not eating well since yesterday. What information should the nurse include in her education? a. Increase the frequency of blood glucose checks but stop giving insulin until the fever resolves b. Monitor the glucose more frequently than usual while she is sick c. Decrease her baseline insulin dosing because the fever will cause her to be more hypoglycemic than usual d. Push fluids and continue to check her glucose on the same schedule as you do every day

a. exercise such as walking d. breathing exercises, such as pursed-lip breathing

The plan of care for the patient with chronic obstructive pulmonary disease (COPD) should include (Select all that apply) a. exercise such as walking b. high flow rate of O2 administration c. use of peak flow meter to monitor the progression of COPD d. breathing exercises, such as pursed-lip breathing

d. all of the above

Treatment for a COPD exacerbation includes which of the following medications? a. short-acting bronchodilators b. corticosteroids c. antibiotics d. all of the above

d. Type O-

What blood type is known as the "universal donor"? a. Type A+ b. Type B+ c. Type AB d. Type O-

c. Type AB

What blood type is known as the "universal recipient"? a. Type A b. Type B c. Type AB d. Type O

c. Low hemoglobin levels cause reduced oxygen-carrying capacity

What effect does hemoglobin amount have on oxygenation status? a. No effect b. More hemoglobin reduces the client's respiratory rate c. Low hemoglobin levels cause reduced oxygen-carrying capacity d. Low hemoglobin levels cause increased oxygen-carrying capacity

a. Proper hand hygiene **D is wrong because sterile technique should be used whenever accessing the central line

What is the best way to prevent a CLABSI? a. Proper hand hygiene b. Strict contact precautions c. Putting the client in isolation d. Using clean technique when accessing the central line

d. 1.7

What level of INR indicates that administration of tPA is contraindicated for that patient? a. 0.9 b. 0.2 c. 1.4 d. 1.7

a. Normal saline

What solution or solutions below are compatible with a transfusion of red blood cells (RBCs)? a. Normal saline b. Dextrose solutions c. Lactated Ringer's d. No solutions are compatible with blood

b. Regular insulin **regular insulin is a short-acting insulin

When a client is experiencing diabetic ketoacidosis, the insulin that would be administered is: a. NPH insulin b. Regular insulin c. Insulin lispro injection d. Insulin glargine injection

c. Bronchopulmonary dysplasia (BPD) **close monitoring of inspiratory pressure and O2 concentration is necessary to prevent BPD, which is related to the use of high inspiratory pressures and O2 concentrations

When caring for a very-low-birth-weight neonate, the nurse carefully monitors inspiratory pressure and oxygen (O2) concentration to prevent which of the following? a. Respiratory distress syndrome (RDS) b. Respiratory syncytial virus (RSV) c. Bronchopulmonary dysplasia (BPD) d. Meconium aspiration syndrome

d. Tremors are an expected side effect of rapidly acting bronchodilator

Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs b. Inhale slowly and deeply when using the dry power inhaler (DPI) c. Hold your breath for 5 seconds after using the bronchodilator inhaler d. Tremors are an expected side effect of rapidly acting bronchodilator

b. Headaches c. Polyuria

Which of the following are symptoms of hyperglycemia? (Select all that apply) a. Confusion b. Headaches c. Polyuria d. Irritability e. Tremors

c. Daily weight

Which of the following is NOT a part of daily care for a client with type II diabetes? a. Daily foot inspection b. Blood glucose diary c. Daily weight d. Oral medication and/or insulin

b. Clients should wear flip flops

Which of the following is NOT a part of diabetic foot care education? a. Clients should inspect feet daily b. Clients should wear flip flops c. Clients should wear white socks d. Clients should keep nails trimmed

c. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago

Which patient below is at most risk for a hemorrhagic stroke? a. A 65 year old male patient with carotid stenosis b. A 89 year old female with atherosclerosis c. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago d. A 55 year old female with atrial flutter

a. "I use my corticosteroid inhaler when I feel short of breath."

Which statement indicates the patient with asthma requires further teaching about self-care? a. "I use my corticosteroid inhaler when I feel short of breath." b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection." c. "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies." d. "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath."

b. Airway clearance techniques d. Inhaled tobramycin to combat Pseudomonas infection

Which treatments would the nurse expect to implement in the management plan of a patient with cystic fibrosis? (Select all that apply) a. IV corticosteroids on a chronic basis b. Airway clearance techniques c. Take-home oxygen tank d. Inhaled tobramycin to combat Pseudomonas infection

d. Beta cells, pancreas

Which type of cells secrete insulin, and where are they located? a. Alpha cells, liver b. Alpha cells, pancreas c. Beta cells, liver d. Beta cells, pancreas

c. Subarachnoid stroke

Which type of stroke is often referred to as the "silent killer"? a. Embolic stroke b. Intracerebral stroke c. Subarachnoid stroke d. Thrombotic stroke

c. Speech

Which type of therapy is used to manage problems with eating and​ swallowing associated with Parkinson's ? a. Physical b. Occupational c. Speech d. Nutritional

a. The client should rotate injection sites for insulin administration **can lead to lipodystrophy if sites not rotated = buildup of scar tissue

You are a nurse caring for a client who receives insulin therapy as part of their diabetes management. Which of the following is a priority teaching point for this client? a. The client should rotate injection sites for insulin administration b. The client should take their short-acting insulin immediately following meals c. The client should take their insulin less frequently on days they are sick d. The client should give a dose of insulin when they are feeling diaphoretic

a. Aphasia c. Impaired math skills d. Issues with seeing on the right side f. Depression and anger

You are educating a group of nursing students about left side brain damage. Which of the following signs and symptoms are noted with this type of stroke? (Select all that apply) a. Aphasia b. Denial about limitations c. Impaired math skills d. Issues with seeing on the right side e. Disoriented f. Depression and anger g. Impulsive

a. risk of infection

You are the nurse caring for a patient who is on the surgical floor, post-op from abdominal surgery. The patient had a central venous line placed in surgery for pain medications, IV antibiotics, blood products, and TPN (IV nutrition). Which of the following is a priority nursing diagnosis? a. risk of infection b. impaired tissue integrity c. risk of altered nutrition d. impaired physical mobility

b. Check for pouching of food in the right cheek

You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to do which of the following? a. Keep the head of bed less than 30° b. Check for pouching of food in the right cheek c. Prevent aspiration by thinning the liquids d. Have the patient extend the neck upward away from the chest while eating

b. TIAs produce signs and symptoms that can last for several weeks to months d. TIAs don't require medical treatment **TIA symptoms produce signs and symptoms that can last a few minutes to hours and resolve, and they do require medical treatment

You're educating a patient about transient ischemic attacks (TIAs). Which of the following are incorrect about this condition? (Select all that apply) a. TIAs are caused by a temporary decrease in blood flow to the brain b. TIAs produce signs and symptoms that can last for several weeks to months c. A TIAs is a warning sign that an impending stroke may occur d. TIAs don't require medical treatment

c. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales

You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device? a. Encourage the patient to use it twice a day b. The patient exhales into the device rapidly and then coughs c. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales d. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds

c. The patient is unable to wink or move his arm to scratch his skin **apraxia = inability to perform particular purposive actions as a result of brain damage

You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? a. The patient is unable to read b. The patient has limited vision in half of the visual field c. The patient is unable to wink or move his arm to scratch his skin d. The patient doesn't recognize a pencil or television