Comprehensive Quiz

An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first?

Check the resident's oxygen saturation

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation?

Checks for orthostatic blood pressure changes

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax?

Chest asymmetry and jugular vein distention are present

The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion?

Cigarette smoking

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?

Client behavior that changes from anxious to lethargic

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record?

Client has a 96 pack-year history

The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)?

Client has developed restlessness over the last hour

The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse?

Client on warfarin (Coumadin) with epistaxis with brisk bleeding

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client?

Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)

Client who had 1200 mL of pleural fluid removed by thoracentesis

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse?

Client who is speaking in three-word sentences and has an SpO2 of 90%

The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure?

Client with a brainstem tumor Client with acute pancreatitis Client with a C5 spinal cord injury Client using client-controlled analgesia

The medical-surgical unit nurse should call the Rapid Response Team to assess which client?

Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis

The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit?

Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask

The RN has received report about four clients. Which client needs the most immediate assessment?

Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry

The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients?

Client with aspiration pneumonia

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first?

Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule?

Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%

The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation?

Client with hypoventilation and decreased breath sounds

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room?

Client with possible H5N1 influenza who currently has epistaxis

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN?

Client with pulmonary tuberculosis who is receiving multiple medications

The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. what action will the nurse take next

Collaborate with the provider to lower the FiO2 level.

Which important aspect of coordinating care within the interdisciplinary team is facilitated by use of the "SBAR" and "PACE" procedures?

Communication

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess?

Confusion

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care?

Contacting the health care provider (HCP) if drooling occurs

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend?

Continuous capnography

When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)?

Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client

Which action does the nurse implement for a client with wound evisceration?

Cover the wound with a sterile, warm, moist dressing.

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess?

Crackles

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider?

Crackles ½ way up the lung fields

The nursing student asks the supervising nurse whether a certain fall protocol used on the nursing unit is effective. To demonstrate effectiveness, what does the supervising nurse identify?

Data about the number of falls after the protocol was introduced compared with previous fall rates

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess?

Decreased loss of bicarbonate through the kidney

Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?"

Decreasing nighttime disruptions

The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention?

Decreasing respiratory rate

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish?

Develop the discharge teaching plan in conjunction with the client.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?

Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? (Select all that apply.)

Dizziness and syncope Inspiratory chest pain Tachycardia

When caring for a client who had a lobectomy the nurse notes small bubbles in the water seal chamber of the disposable chest drainage device during coughing. Which of these reflects the appropriate action by the nurse?

Document the finding in the medical record.

Bedside computers are an example of informatics used in health care primarily for which purpose?

Documenting interdisciplinary care

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first?

Draw aerobic and anaerobic blood cultures.

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these?

Early recognition and quarantine of affected persons

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?

Elevates the head of the bed

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first?

Encourage fluid intake

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis?

Encourage the client to ask questions and verbalize concerns.

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem?

Encourage use of incentive spirometer.

The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time?

Ensure a tracheostomy tray is at the bedside

The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis?

Ensure adequate oxygenation

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize?

Ensure the client does not smoke for 6 hours before the test.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure?

Ensure the client has had nothing by mouth.

A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?

Ensures that the tubing is patent and that oxygen flow is high

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication?

Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution Use an IV pump to deliver the medication

The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively?

Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these?

Evaluating pneumonia vaccine status

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?

Excessive swallowing

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest?

Expiratory wheezing not cleared by coughing

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?

Face tent

The nurse is providing teaching for a client who has been newly diagnosed with lung cancer and will be undergoing radiation therapy. Which of these points would be covered in the teaching session?Select all that apply.

Fatigue may occur . Changes in taste may occur Do not expose the site to sun.

Which nursing activity is best for the charge nurse on the medical-surgical unit to delegate to staff members who are unlicensed assistive personnel (UAPs)?

Feeding a client whose hands are affected by rheumatoid arthritis

Which principal nursing actions best support a focus on client safety?

Handwashing Preoperative checklists Five rights of drug administration

A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present?Select all that apply.

Harsh cough Stridor

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? Select all that apply.

Headache Shallow breathing Fatigue

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?

Heart Rate

The nurse has recently been assigned to a medical-surgical clinical rotation. According to the scope of medical-surgical nursing, what type of client assignments does the nurse expect to see?

Hospitalized adults with acute and chronic illnesses

The nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover?

Hypercalcemia

The client with which condition is in greatest need of immediate intubation?

Hypoventilation and decreased breath sounds

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority?

Hypoxemia related to ventilation-perfusion mismatch

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse?

Inability to state name and date of birth

Which of these findings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation?

Increasing somnolence

What pain management does a client who has been admitted to the post-anesthesia care unit typically receive?

Intravenous opioid analgesics

The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan?

It is important to have good oral hygiene using an irrigating device such as Waterpik.

The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)?

Keep the head of the bed elevated

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first?

Listen to the client's breath sounds.

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first?

Listen to the client's breath sounds.

The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care?

Maintain the client upright for 30 minutes after eating Provide small, frequent meals Teach the client to "tuck" the chin down in the forward position to swallow.

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority?

Make sure he always carries the wire cutters with him

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide?

Measurement of the client's weight

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)?

Monitor blood pressure and pulse.

A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care?

Monitor the platelet count daily.

The nurse is providing education to a client with chronic bronchitis who has a new prescription for a mucolytic. Which of these will the nurse teach the client about the purpose of the medication?

Mucolytics thin secretions, allowing for easier expectoration.

The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do?

Notify the surgeon about possible wound dehiscence.

The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority?

Observing the dressing for bright-red blood

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)?

Offering fluids to drink every hour

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first?

Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)

Which value indicates clinical hypoxemia and the need to increase oxygen delivery?

PaO2 of 65 mm HgPao2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is termed hypoxemia.

An older client who has had a total hip replacement will be transferred to a rehabilitation center for continuing care before going home. The Joint Commission, along with National Patient Safety Goal standards, mandates communication between hospital nurses and other providers to ensure adequate transition management. Which aspects of this client's care plan are most important for the nurse to communicate to the rehabilitation center care team?

Pain medication needs

The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action?

Perform the abdominal thrust maneuver.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period?

Picture board

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action?

Place a respiratory mask on the client.

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate?

Place the client on a cardiac monitor

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first?

Place the client on a cardiac monitor.

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?

Place the client on bed rest Evaluate the electrolyte levels assess for orthostatic hypotension initiate cardiac monitoring

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform?

Plan client and family teaching regarding upcoming pulmonary function testing.

After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant?

Position the client on the left side.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do?

Provides the visitor with a surgical mask

The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis?

Providing frequent explanations and reassurance

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)?

Providing oral care every 1 to 2 hours

Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client?

RN who has 5 years of experience in the delivery room

The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her?

RN who has floated from the intensive care unit

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern and should be reported to the surgeon?

Redness and swelling around the incision

When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety?

Remain with the client and provide oxygen in a calm manner.

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)?

Remain with the client and provide oxygen in a calm manner.

The nurse is educating the client with COPD who requires home oxygen therapy for discharge. Which of these teaching points takes the highest priority?

Removing combustion hazards present in the home

When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances?

Respiratory acidosis

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention?

Respiratory rate of 6 breaths/min

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first?

Schedule an immediate chest x-ray

The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation?

Self-determination

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess?Select all that apply.

Sensation of air hunger Tracheal deviation Blue discoloration of the lips

The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client?

Severe coughing spasms

How does the nurse position a client with postoperative nausea and vomiting?

Side-lying, with the head in a neutral position

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia care unit?

Snoring sounds when inhaling

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority?

Start an IV line and begin intravenous hydration.

The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider?

Stridor

The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care?

Suction the client if needed cleanse the inner cannula with a mixture of peroxide and saline Replace the dressing with sterile, folded 4 × 4 gauze.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?

Suction the tracheostomy using sterile technique.

Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?

Suctioning the tracheostomy tube

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client?

Supplemental pain reduction is needed.

The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care?

Swallow twice to clear the airway

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care?Select all that apply.

Take a supplement containing B vitamins.Avoid alcohol containing beverages.Report changes in vision to the health care provider.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment?

The client has been afebrile for 48 hours

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective?

The client is free from adventitious breath sounds.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?

The client is receiving oxygen at 4 L/min.

The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision?

The client is unable to cough and protect the airway.

The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia?

The client who has metabolic acidosis

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first?

The client whose potassium is 6.2 mEq/L (6.2 mmol/L)

A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best?

The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse?

The client with pink, frothy sputum

Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury?

The nurse responsible for the client's case management

A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse?

The oxygen reservoir deflates during inspiration.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question?

The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth?

They prevent radiation scatter from metal in the mouth.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target?Select all that apply.

Those in the local prisonHomeless adultsRecent immigrants to the United States

A client has just been admitted to the intensive care unit after having a left lower lobectomy via video-assisted thorascopic surgery. Which of these prescriptions will the nurse implement first?

Titrate oxygen flow rate to keep O2 saturation at or greater than 93%

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl?

Use a potassium infusion prepared by a registered pharmacist. Assess for burning or redness during infusion. Infuse at a rate of no more than 10 mEq per hour.

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client?

Use of aspirin or salicylates

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make?

Use of salt substitute Use of an ACE inhibitor Potassium-sparing diuretics

A client with COPD calls the pulmonary clinic reporting the last 24 hours the peak flow meter readings have been in the yellow range. Which of these interventions by the nurse is appropriate at this time?

Use your prescription for rescue medication and retest yourself.

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function?

Walk as tolerated each day

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant?

Washing the skin with plain soap and water

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client?

Wearing a disposable particulate mask respirator

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?

Weigh the client daily, at the same time.

The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg

apply oxygen

A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next?

assess for adequate oxygenation

The nurse educator is instructing newly hired registered nurses about patient-centered care. Which competency categories are included in this content?

attitudes knowledge skills

When caring for the client with chronic bronchitis, which of these interventions will assist the client in mobilizing secretions?

consume at least 2 liters of fluid daily

The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube?

hyperoxygenate before and after suctioning

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?

instructing the client not to ambulate without assistance

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription?

insulin

When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease?

pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia. The nurse recognizes that a positive outcome to therapy has been achieved by which of these

the oxygen saturation is between 88% and 90%.

The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use?

translation phone service

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan?

"Are you allergic to iodine or shellfish?"

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?

"Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask?

"Did you take metformin today?"

The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response?

"Do you have a light scarf that you could place over it?"

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications?

"I am here to receive the yearly pneumonia shot again."

The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care?

"I can only take baths, no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will be unable to wear a necklace."

Which statement by a client with a laryngectomy indicates a need for further discharge teaching?

"I can't put anything over my stoma to cover it."

The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective?

"I may need to restrict my activities for several months."

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions?

"I must have my emergency inhaler with me at all times."

Which statement by a client with chronic obstructive pulmonary disease (COPD) and a 10 pound (4.5 kg) weight loss indicates the need for additional follow-up instruction?

"I should consume plenty of fluids with my meal."

The nursing student has been assigned to the hospital's Rapid Response Team (RRT). Which statement by the student indicates a correct understanding of the RRT member's purpose?

"I will be caring for clients in the hospital."

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure?

"I will have to take special care not to aspirate while eating."

The nurse is evaluating understanding of the treatment regimen for a client newly diagnosed with asthma. Which of these statements by the client indicates understanding of the regimen?

"I will take the long acting beta agonist even when my breathing seems OK."

A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question?

"Ibuprofen 800 mg every 8 hours as needed for pain."

A client recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the client has correct understanding of the use of an inhaler with a spacer when the client states which of these?Select all that apply.

"If the spacer makes a whistling sound, I am breathing in too rapidly." "I should hold my breath for at least ten seconds after inhaling the medication."

The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement?

"Inverted T waves and a U wave may appear on the ECG."

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session?

"Offer fluids that they prefer frequently and on a regular schedule."

The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?

"Paralysis and sedatives help decrease the demand for oxygen."

The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate?

"Paralytics and sedatives help decrease the demand for oxygen."

The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners?

"Rapid breathing is a way to compensate for acidosis caused by his condition"

When transferring a client who was admitted with chest pain from the emergency department (ED), which information is essential for the ED nurse to communicate to the nurse on the medical-surgical unit?

"The client is being admitted for ongoing monitoring of pain and vital signs." "Nitroglycerin and morphine sulfate were given to relieve the pain. "Frequent reassurance is needed because the client has a high anxiety level." The client has a family history of heart disease and hypertension." "A coronary arteriogram should be scheduled as soon as possible.

The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance?

"The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats"

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching?

"The intranasal vaccine can be given to everybody in the family."

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements?

"Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3."

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF?

"Weighing myself daily can reveal increased fluid retention."

The client says, "I hate this stupid COPD." What is the best response by the nurse?

"You sound fed up with managing your illness."

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan?

"You will not pose an increased risk of disease to the people you have been living with."

The nurse is providing preoperative teaching for the client with lung cancer for whom a lobectomy is planned. Which of these does the nurse include in the preoperative education session?Select all that apply.

"You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." "Plan to request pain medication before your pain becomes severe." "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing."

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?

"let's discuss why smoking around oxygen is dangerous."

The nurse is caring for a client who has had a lobectomy and placement of a chest tube 8 hours ago. When performing an initial assessment, which of these requires immediate follow up?

200 mL red drainage from chest tube over 2 hours

A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client?

4, 2, 1, 3

Which client has the highest risk for developing a pulmonary embolism (PE)?

A 25-year-old woman who frequently flies to different countries

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first?

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing

Which client is at greatest risk for slow wound healing?

A 47-year-old obese man with diabetes

Which client needs immediate attention by the nurse?

A 54-year-old who is mechanically ventilated and has tracheal deviation

Which nursing action demonstrates use of the principle of justice?

A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN?

A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg)

the nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first?

A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?

A client admitted yesterday with heart failure with dependent pedal edema

After receiving change-of-shift report, which client does the RN assess first?

A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg

When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse?

A client receiving mechanical ventilation who has tracheal deviation

The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)?

A client returning from an open reduction and internal fixation of the tibia

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)?

A client returning from an open reduction and internal fixation of the tibia

When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed?

A nonsteroidal anti-inflammatory drug

The nurse is working in the intensive care unit. When does the nurse call the Rapid Response Team (RRT)?

A postoperative client's blood pressure suddenly drops.

The nurse on a medical surgical unit is planning bed assignments for a new admission who has cystic fibrosis (CF) and is infected with Burkholderia cepacia. Which of these room assignments is most appropriate for this client?

A private room with a bathroom

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care?

Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia

A previously stable postoperative client on the medical-surgical unit now has a blood pressure of 88/40 mm Hg and a heart rate of 124 beats/min. After placing the client in Trendelenburg position, which action does the nurse perform next?

Activate the Rapid Response Team

The nurse is assessing a client admitted with status asthmaticus. The nurse finds a sudden absence of wheezing in the lung fields and sets which of these as the priority action?

Activation of the rapid response team to secure an airway

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?

Adjust the position of the oxygen tubing.

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg

Administering an antiemetic

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit?

Administering preoperative antibiotics and anxiolytics

A client with acute exacerbation of asthma has been admitted to the medical surgical unit for treatment. The client is reporting increased shortness of breath with inspiratory and expiratory wheezes. When planning care for this client, which medication will the nurse administer first?

Albuterol-2 inhalations

The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session?

Alcohol and smokeless tobacco use

The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority?

Apply oxygen.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment?

Arrange for a health care worker to observe the client take the medication.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?

Ask the client whether the mask fits tightly over the mouth and nose.

Which action does the nurse take first when preparing to do discharge teaching for the 73-year-old client who is being discharged after prostate surgery?

Ask what the client knows about self-care after prostate surgery.

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care?

Assess daily weights. Encourage consumption of citrus fruits. Monitor serum potassium.

The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action?

Assess flow to the area using a Doppler device.

A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next?

Assess for adequate oxygenation.

The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make?

Assess for tachypnea

When caring for the client returning from thoracotomy and placement of a chest tube, the client reports severe pain. What does the nurse do first?

Assess location and quality of pain.

The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? (Select all that apply.)

Assess the client's color and respirations. Confirm alarms and ventilator settings. Ensure that the tube cuff is inflated and is in the proper position. Auscultate for bilateral breath sounds.

The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?

Assess the client's respiratory status.

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?

Assessing the blood pressure hourly

The nurse is appointed to a hospital committee whose goal is to "improve the safety of nursing practice." Which areas of practice are included in the committee's task?

Attentiveness/surveillance of clients Mandatory reporting Medication administration Prevention of errors or complications

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first?

Auscultate lung sounds

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target?Select all that apply.

Bakers Coal miners Furniture refinishers Potters

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously?

Bananas ACE inhibitors Salt substitute

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority?

Beta agonist

the nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation?

Bi-level positive airway pressure (BiPAP)

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy?

Blood pressure Pulse rate and quality Urinary output Urine specific gravity

In conducting a postoperative assessment of a client, what is important for the nurse to examine first?

Breathing pattern

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse?

Bronchial breath sounds heard at the bases

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN?

Calcium level of 9.5 mg/dL (2.4 mmol/L)

Which role of the medical-surgical nurse is demonstrated when writing a plan of care for a client who is newly admitted to the hospital?

Caregiver

The nurse is asked to collaborate with others to implement an interdisciplinary plan of care for a client. Which health care team members are essential for the client's daily care regimen?

Case manager Health care provider