first 75 questions

the nurse is planning to suction a client through tracheostomy tube. which is the amount of time for application of suction during withdrawal of the catheter.

10 seconds

the nurse uses the glasgow coma scale to assess a client with a head injury. which glasgow coma scale score indicates that the client is in a coma?

6

a client with no history of respiratory disease is admitted to the hospital with respiratory failure. the nurse reviews the arterial blood gas reports for which results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

after a head injury a client develops a deficiency of antidiuretic hormone (ADH). what should the nurse consider before assessing the patient about the response to secretion of ADH?

Tubular reabsorption of water increases

the nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardia which action should the nurse take?

discontinue suctioning until the client is stabilized and monitor vital signs.

initially after a brain attack CVA. a client's pupils are equal and reactive to light. four hours the nurse identifies that one pupil reacts more slowly than the other. the client's systolic blood pressure is beginning to increase. on which condition should the nurse be prepared to focus on?

increased intracranial pressure

a client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone.(SIADH) the nurse will expect to see which clinical findings upon assessment? SATA

nausea and vomiting increased weight decreased serum sodium decreased level of consciousness

a client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after supraglottic laryngectomy. The LPBN nurse should perform which action

notify the registered nurse

the nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. which equipment should the nurse plan to have at the bedside when the client returns from surgery

obturator

the nurse is assisting in caring for a client with newly inserted tracheostomy. the nurse documentation of an airway problem because of thick respiratory secretions. the nurse should monitor for which item as the best indicator of an adequate respiratory status?

respiratory rate of 18 breaths per minute.

the nurse provides education during the discharge of a client who has a diagnosis of multiple sclerosis. which priority statement does the nurse include in the teaching?

schedule the occupational therapist to do a safety assessment of your home

the low exhaled volume (low pressure) alarm sounds on a ventilator. the nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. which would be the next immediate nursing action.

ventilate the client with a resuscitation bag

the nurse is assisting a health care provider with the insertion of an endotracheal tube. the nurse should plan to ensure that which is done as a final measure to determine correct tube placement?

verify placement by a chest x ray

the nurse is assisting in caring for a postoperative client who had a pneumonectomy. the nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema

frothy sputum

the nurse is caring for a client at home who has had a tracheostomy tube for several months. the nurse monitors the client for complications associated with the long term tracheostomy and suspects trachesophageal fistula if which observation is noted for the client?

abdominal distention

the nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when the high pressure alarm sounds. the nurse checks the client and system for which most likely?

accumulation of secretions in the client's lung

the nurse is is caring for a client with an endotracheal tube attached to a ventilator. the high pressure alarm sounds on the ventilator.the nurse prepares to perform which priority nursing intervention?

suction the client

a client is scheduled for a computed tomography of the brain with contrast. when reviewing the clients medical record what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure

the client takes metformin daily

a client is at risk for increased intracranial pressure. Which assessment finding reflects an increase in ICP?

unequal pupil size

what interventions should the nurse implement in caring for a client with diabetes insipidus(DI) following a head injury?SATA

providing adequate fluids within easy reach assessing for and reporting changes in neurologic status monitoring for constipation, weight loss, hypotension, and tachycardia

the nurse cares for an older adult client with congestive heart failure following a myocardial infarction. the client reports having difficulty breathing and states " i feel as if i am drowning when I lie down which complication does the nurse recognize as contributing to the assessment finding?

pulmonary edema

a client is diagnosed with a brain attack CVA. The baseline vital signs are a pulse rate of 78 bpm and a blood pressure of 120/80. the nurse continues to monitor the vital signs and recognize which changes in vital signs indicate increased intracranial pressure?

pulse 50bpm and BP 140/60 mm Hg

Which findings are typical of end stage renal disease

iron deficient anemia decreased creatinine clearance metabolic acidosis

a nurse is caring for a child with a diagnosis of meningitis. what clinic findings indicate an increase in intracranial pressure?

irritability bradycardia

the nurse is performing nasotracheal suctioning of a client. the nurse determines that the client is adequately tolerating the procedure if which observation is made?

breath sounds are clear

the nurse is performing tracheal suctioning on an assigned client. the nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?

breath sounds are clear

the nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. which action should the nurse implement?

check the amount of suction pressure being applied

a client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. which is the nurse's priority intervention

check the client for spontaneous breathing

the nurse is teaching the parent of an infant client about common pediatric conditions. which statement by the nurse about otitis media is correct?

otitis media usually occurs before your child experiences a primary bacterial infection

the nurse is performing nasotracheal suctioning of a client. the nurse interprets that the client is adequately tolerating the procedure if which observation is made?

coughing occurs with suctioning

the nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. the nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs

aspiration of gastric contents occurs when suctioning

the nurse cares for 4 clients. which activity demonstrates the nurse's understanding of how ethnicity influences the client's health?

assess a 5 month old african american client for sickle cell

the nurse is suctioning a client through a tracheostomy tube. during the procedure, the client begins to cough and the nurse notes the presence of an audible wheeze. the nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. what is the nurse's priority response ?

disconnected the suction source from the catheter

the nurse is told to that an assigned client will have a fenestrated tracheostomy tube inserted. the nurse should provide the client with which information about this type of tube?

enables the client to speak

the nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation at 6 cm. which actions by the nurse are important during this stage?

encouraging the client to void monitoring the condition of the fetus staying at the bedside until the client delivers

the nurse reviews the nurses notes from 1300, 1500,2000, and 2020. Based on the the information which is the priority action by the nurse?

ensure the endotracheal is ready at the bedside

the nurse is preparing to suction an adult client through the client's left tracheostomy tube. which interventions should the nurse perform for this procedure select all that apply.

hyperoxygenate the client before suctioning apply suction while gently inserting the catheter advance the catheter until resistance is met and then pull the catheter back 1 cm

the nurse is caring for a client with a spinal cord injury. which assessment findings alert the nurse that the client is developing autonomic hyperreflexia?

hypertension and bradycardia

the nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. the nurse understand that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?

hypotension

the nurse provides teaching to the parents of an adolescent client. the client diagnosis is generalized anxiety disorder. which statements by the nurse are included in the teaching?

if the anxiety is unresolved the sense of fear can affect the activities of daily living if your child's moderate anxiety is left untreated it can progress to an anxiety disorder your child's brain chemistry may be contributing cause of their anxiety evidence shows that a genetic association is present with anxiety disorder

a client is admitted with a head injury. the nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. what does the nurse identify as the most likely cause?

inadequate antidiuretic hormone secretion

initially after a stroke, a client's pupils are equal and reactive to light. later, the nurse assesses that right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. what complication should the nurse consider that the client is developing.

increasing intracranial pressure

the nurse is providing care for a 2 month old infant scheduled for a pyloromyotomy. which of pre operative actions can the nurse expect to perform

keep NPO as order before surgery begin iv fluids at maintenance rate

the nurse is assigned to care for a client after a left pneumonectomy. which position is contraindicated for this client

lateral position

a client with with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. the nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hr?

lorazepam (ativan)

the nurse is determining the need for suctioning in a client with an endotracheal tube attached to mechanical ventilator. which observation by the nurse is inconsistent with the need for suctioning?

low peak inspiratory pressure on the ventilator

what action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

monitor the client for signs of brain injury

the nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardiac. which action should the nurse take?

monitor vital signs and discontinue attempts at suctioning until the client is stabilized

after an automobile collision a client who sustained multiple is oriented to person and place but is confused to time. the client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. which nursing action takes priority?

monitoring the client for increasing intracranial pressure

the nurse is reviewing the arterial blood gas results of an assigned client. which arterial blood gases indicate metabolic alkalosis

pH of 7.48, Pco2 of 40 mm Hg. HCO3- of 36 mEq/L

a client sustains a crushing injury of the spinal above the level of origin of the phrenic nerve. as a result of this injury, the nurse expects what client response?

respiratory paralysis and cessation of diaphragmatic contractions

the nurse is suctioning a client through a tracheal tube. during the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. which should be the nurse action.

stop the procedure and oxygenate the client

the nurse is suctioning an adult client through through tracheostomy tube. during the procedure the nurse notes that the client oxygen saturation by pulse oximetry is 89% which action should the nurse implementa/

stop the suctioning procedure.

the nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. the nurse interprets that which sign experienced by the client should be reported immediately to the RN.

stridor

a client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. the nurse determines that which method for communication may be the easiest for the client?

use a picture or word board

the low pressure alarm sounds on the ventilator. the nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. which initial action should the nurse take?

ventilate the client manually

the nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? SATA

vomiting irritability decreased level of consciousness