Health and Illness exam 2

The nurse is asked, "Which patient should receive oxygen via a nonrebreather mask?" Which statement by the nurse is accurate?

"A patient with a CO2 level of 55 mmHg."

The nurse is teaching a patient who is suspected of having allergic asthma about upcoming testing. Which patient statement indicates that the teaching was effective?

"A scratch test will tell me how severe my allergy is."

The nurse is teaching an older adult patient who fell and sustained a femur fracture how to prevent future falls at home. Which statement should be included in the teaching?

"Avoid using throw rugs, especially on smooth, slick surfaces."

The nurse is teaching a patient's spouse about what to expect after surgery. Which statement by the spouse regarding ambulation after surgery requires reteaching by the nurse?

"Bedrest is recommended for the first day after surgery to allow the body to heal."

A patient with cystic fibrosis (CF) asks the nurse why they need to maintain a high-calorie, high-fat diet. Which response by the nurse explains the need for 50% more calories?

"CF affects digestion and nutrient absoption, so you need extra calories."

The respiratory therapist is conducting a training class for new nurses regarding chest physiotherapy. Which statement by a nurse regarding chest physiotherapy is accurate?

"Chest physiotherapy helps clear the lungs of secretions."

The nurse is assessing a patient with a cough. Which question about the cough, if answered in the affirmative, is most concerning to the nurse?

"Do you cough up blood and how often?"

The nurse is performing a focused assessment on a patient suspected of having viral pneumonia. Which question should the nurse ask the patient to determine the potential cause of pneumonia?

"Has anyone in your household been sick?"

A 50-year-old patient has osteoarthritis of the hip related to long-term steroid use. The patient tells the nurse the healthcare provider has stated that they are too young for a hip replacement. Which response by the nurse is best?

"Hip replacements may only last 10 years, and the revision surgery is harder than the original replacement."

The nurse is teaching a woman with cystic fibrosis (CF) about possible complications during pregnancy. Which response by the patient indicates an understanding of the teaching?

"I am at higher risk for gestational diabetes because of my CF."

The nurse is admitting a pregnant patient following an acute asthma attack. Which patient statement indicates the need for teaching regarding asthma and medication use?

"I have not been taking my asthma medication because I am pregnant."

The nurse is providing discharge teaching for a patient admitted for a back injury. The nurse instructs the patient on proper body mechanics for lifting. Which patient statement indicates that further teaching is needed?

"I should bend my back when I pick up an object."

During a family-centered patient-teaching session with a patient with cystic fibrosis (CF), the nurse teaches interventions to prevent infection. Which patient statement indicates understanding of the teaching?

"I should cough into a clean tissue and throw it away immediately."

The nurse teaches a patient with altered mobility about the importance of exercise. Which patient statement indicates that further teaching is necessary?

"I should not exercise when I am on bedrest."

The nurse is discussing plans to care for a patient experiencing dyspnea. Which statement reflects the priority independent intervention?

"I should place the patient in high Fowler position."

The nurse is teaching a parent about caring for their child who has a new diagnosis of cystic fibrosis. Which statement by the parent indicates understanding of the type of diet recommended?

"I should provide a high-calorie diet with high-fat food."

A 5-year-old patient who was diagnosed with asthma is being discharged after a brief hospitalization. The nurse is completing the discharge teaching with the parents. Which parent statement requires further teaching?

"I will always step outside of the house to smoke."

The nurse is teaching a patient about cast care at home. Which instruction should the nurse include in the teaching?

"If severe itching occurs, use a blow dryer on a cool setting."

A nurse is working with a 16 year old client who is attempting to lose weight. The client admits having difficulty following the weight loss diet prescribed by the healthcare provider. Which suggestion by the nurse might assist the client in being compliant with the prescribed diet in a way that is sensitive to the client's age?

"It can be difficult to avoid unhealthy foods if that's what your friends are eating when you are with them. Try to choose healthier options when you can.

The unlicensed assistive personnel asks the nurse to explain why a patient with pneumonia is placed in the high-Fowler position. Which response by the nurse is accurate?

"It is an intervention used to aid in airway clearance."

A patient asks, "Why do I need to have my position changed every 2 hours?" Which response should the nurse provide?

"Low oxygen in the tissues increases the risk of skin breakdown."

The nurse is providing discharge teaching for a patient with pneumonia. Which information should the nurse include to promote effective gas exchange?

"Maintain adequate fluid intake."

The nurse is teaching fracture prevention to a community group consisting of parents of school-aged children. Which parent statement indicates the need for additional teaching?

"My child is overweight, but that has nothing to do with the risk for fracture."

A patient with a fracture is preoperative for an internal fixation procedure. The nurse is teaching the patient about the risks of continuing to smoke before the surgery. Which statement should the nurse include?

"Nicotine has been shown to decrease circulation to the bone, leading to delayed healing."

The nurse is teaching a patient with a cast about symptoms to monitor after discharge. Which statement by the patient reflects an understanding of complications associated with a cast?

"Numbness and tingling should be reported immediately."

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse pads the patient's joints. Which explanation for this action should the nurse provide to the patient?

"Padding your joints should increase your comfort."

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement?

"Patients must be moved correctly in bed to prevent skin shearing."

A patient with asthma asks the nurse why they have an asthma attack every time they play with their dog. Which response from the nurse is appropriate?

"Pets can be an allergen, which can trigger an asthma attack."

The nurse is providing discharge teaching for a patient with an alteration of mobility. The family asks the nurse, "What is the best thing we can do to keep our father free from injury?" Which response by the nurse is appropriate?

"Pick up all the throw rugs you have so your father doesn't fall."

A 60-year-old female patient asks the nurse what they can do to prevent hip fractures. Which information should the nurse provide the patient?

"Postmenopausal women like you who are not taking hormone replacement therapy should consume 1500 mg of calcium per day."

An elderly patient is talking with the nurse about osteoporosis and hip fractures. The patient would like to know the best approach to strengthen their bones. What is the nurse's best response?

"Talk with your physician about a calcium supplement."

The nurse is assessing a 19-year-old man with cystic fibrosis (CF) who states that they are finding their condition is less controlled with the current combination of pharmacologic and nonpharmacologic therapies. How shoul the nurse respond?

"Tell me more about how your condition is less controlled."

The nurse is teaching a patient with a fractured femur about the differences between opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which statement by the patient demonstrates an understanding of the teaching?

"The NSAID will help with both pain and inflammation."

A patient with a fracture received pain medication after the application of a right leg cast. Which patient statement indicates a complication and requires immediate notification to the healthcare provider?

"The pain is worse than it was before the pain medication."

The family of a patient with cystic fibrosis (CF) is learning how to perform chest percussion therapy (CPT) to promote airway clearance. Which instruction should the nurse include regarding positioning?

"The patient should sit or lie with their head down while CPT is being performed."

A patient's healthcare provider has directed the patient to obtain peak flowmeter readings throughout the day over the next several weeks to establish baseline flow readings. The patient asks why it is necessary to take readings so often. How should the nurse respond?

"The readings will be used to evaluate the severity of future airway obstruction."

A patient with a femur fracture is placed in traction. The patient asks the nurse, "Why do I need traction?" Which response by the nurse is accurate?

"The traction will pull and realign your bone in the correct position."

The nurse is preparing to administer an anticoagulant to an older adult patient admitted with a hip fracture. The family asks why the patient needs the injection. Which response by the nurse is accurate?

"This is to prevent the patient from developing a blood clot, as hip fractures increase the patient's risk."

An 80-year-old patient recovering from total hip surgery asks, "Why do I need occupational therapy? I've been retired for 20 years." Which response by the nurse is appropriate?

"This therapy helps with activities of daily living."

The nurse completes the collection of a sputum sample for a Gram stain analysis. The patient asks, "Why did you have to have a sample of my sputum?" Which answer by the nurse provides the patient with accurate information?

"This will allow for a quick identification of the cause of infection."

The nurse is explaining the risk factors for cystic fibrosis (CF) to a couple planning to have a family. The husband informs the nurse of having a relative who has cystic fibrosis (CF) and asks "Does that mean my child will have CF?" Which response from the nurse is accurate?

"To have cystic fibrosis, a child must inherit one copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation from each parent."

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents best indicates effective teaching?

"We will replace the carpet in our child's bedroom with tile."

A patient who takes an inhaled corticosteroid reports dizziness and heart palpitations and has a heart rate of 110 beats/min and a blood pressure of 88/44 mmHg. Which question should the nurse ask first?

"When did you last take your inhaled corticosteroid?"

The nurse is caring for a child recently diagnosed with cystic fibrosis (CF). The mother is trying to cope with the diagnosis and asks the nurse, "What caused this?" Which response by the nurse is accurate?

"You didn't do anything wrong. CF is caused by an inherited gene mutation that causes a problem with the balance of salt and water in the mucous cells."

A postmenopausal client asks the nurse what she can do to prevent fracturing her hips, as her mother and grandmother both experienced this health problem. What response by the nurse is the most appropriate?

"You should consider a smoking cessation program."

A patient presents with severe soft tissue damage to the left leg and an open tibial fracture. The surgeon has assessed the need for surgery to fix the leg using external fixation. The patient asks the nurse what that means. Which is the nurse's best response?

"You will have metal rods attached to your leg on the outside until the bone heals."

Parents of a 13-year-old child who sustained a hip fracture from a bicycle accident ask the nurse how long the child will be in a cast. Which response by the nurse is accurate?

"Your child will be in a cast about 4-6 weeks."

The family of a patient with limited mobility asks, "Why is our father not moving now? He moved well before." Which response from the nurse addresses the most likely cause of the patient's limited mobility?

"Your father's limited mobility is likely due to pain."

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak and has impaired mobility from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response?

"Your immobility in the hospital has caused a condition known as deconditioning."

The nurse receives a referral for a patient for occupational therapy. The patient's family asks, "Why does our mother need this referral?" Which response by the nurse is appropriate?

"Your mother needs assistance in completing daily tasks so she can be more independent."

The nurse is performing a nutritional assessment of a client who weighs 185 lb and is 5​ feet, 3 inches tall. This​ client's body mass​ index, rounded to the nearest​ hundredth, is

32.77

The nurse is assigned to care for four patients. Which patient should the nurse consider to be at highest risk for a hip fracture?

65-year-old female patient with osteoporosis

Mobility for the patient changes throughout the lifespan. What best describes this process?

:Growth and development

The nurse is assessing a group of patients. Which patient should the nurse consider to be at the greatest risk for an alteration in oxygenation?

A 67- year old patient

The nurse discusses scoliosis with a group of parents of school-age children. The nurse includes degrees of curvature of the spine in the discussion. Which curvature of the spine should the nurse include as being severe?

A curve 40 degrees or greater

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client?

A gift card

A patient with respiratory distress is showing signs of decreasing cardiac output and hypoxemia. Which action should the nurse take first?

Administer oxygen via face mask.

A patient who underwent surgical repair of a hip fracture is scheduled for the first physical therapy session in 1 hour. Which intervention should the nurse perform first?

Administer pain medication

A patient is experiencing decreased tissue perfusion, hypovolemia, and hypoxemia. Which action by the nurse is most important?

Administering fluids

The nurse is screening a patient at a high risk for contracting Legionnaires disease. Which factor should the nurse identify as one that places the patient at risk for the disease?

Age of the patient

The nurse is presenting issues related to alterations in mobility with a group of community members. Which major risk factor should the nurse include?

Aging

A patient presents with manifestations of wheezing and difficulty breathing after picking wildflowers in the yard. Which is the most likely cause of the asthmatic symptoms?

Allergic hypersensitivity reaction to the flowers

An 8-year-old child is admitted to the hospital for asthma. Which diagnostic test should the nurse expect to be ordered for this patient?

Allergy skin testing

The structure of the respiratory system that serves as the site of gas exchange is the:

Alveoli

Which manifestation is a hallmark that the nurse should recognize finding in a patient suspected of cystic fibrosis?

An increased amount of chloride in the sweat

The nurse is caring for a patient diagnosed with lobar pneumonia. The patient is experiencing dyspnea and asks the nurse, "Why is it so difficult for me to breathe?" The nurse should understand that which statement describes the pathophysiology causing the dyspnea?

An inflammatory response results in fluid leakage into the interstitial spaces.

The nurse is assessing the hip incision of a patient who underwent an arthroplasty 3 days ago and notices purulent drainage. After a culture and sensitivity of the drainage has been obtained, which class of medication should the nurse expect the healthcare provider to prescribe?

Antibiotic

A patient with asthma is taking an inhaler that blocks parasympathetic input to bronchial smooth muscles. Which class of medication is this patient taking for asthma control?

Anticholinergic

The nurse is caring for a patient with Alzheimer disease who has difficulty chewing and swallowing food. For which lung disease is the patient at risk?

Aspiration pneumonia

The nurse is caring for a patient who wears a brace on their right ankle. Which action should the nurse take first?

Assess the right foot for impaired sensation.

An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse's first priority?

Assessing the client's pain management

The nurse is assessing an older adult patient at home who has suctioning equipment at the bedside. The patient has a history of aspiration pneumonia. Which action is the priority?

Assessing the gag reflex

The nurse is caring for a patient who is two days' postoperative from surgery to repair a fractured femur. The patient says, "I am tired of lying in this bed; I am so uncomfortable." Which is the appropriate intervention by the nurse at this time?

Assisting the patient in moving to the chair to elevate the extremity

The nurse is completing a focused physical examination of a patient with asthma. Which assessments should be included for this exam?

Auscultation of the lungs and assessment of level of consciousness

Which advice should the nurse include when teaching parents of a child with asthma about triggers?

Avoiding secondhand smoke

The nurse is caring for a patient with suspected bronchopneumonia. The patient states, "I do not understand how I could have gotten this sick." The nurse's response is based on the knowledge that which factor may have caused this condition?

Bacteria found in water-cooled air-conditioning systems

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse?

Blocked large airway passages

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client?

Blood pH 7.32

A patient who is concerned about a deformity resulting from an oblique fracture of the femur states, "I can't believe that one leg is shorter than the other now. I look so strange!" Physical assessment by the nurse reveals normal findings, except for the shortened leg. The nurse understands that the patient is at greatest risk for which problem?

Body Image, Disturbed

The parent of a child recently diagnosed with cystic fibrosis (CF) states that they are overwhelmed with caring for the child and that they do not know what to do next. Which suggestion should the nurse provide to incorporate elements of family-oriented care for this child?

Bring the family together for a teaching session.

A patient has increased shortness of breath and mucous plugs in the lungs. Which test should the nurse expect to be performed?

Bronchoscopy

The nurse is preparing a presentation to colleagues on cystic fibrosis (CF) and plans to include the role of the cystic fibrosis transmembrane conductance regulator (CFTR) protein in the body. Which information should the nurse include?

CFTR is responsible for regulating the movement of chloride across cellular membranes.

A patient with a history of lung cancer presents with right hip pain after sustaining a fall. X-rays are inconclusive, but the patient is in excruciating pain. Which diagnostic test should the nurse expect the healthcare provider to prescribe?

CT scan

During a health​ assessment, a client​ states, "I only eat carbohydrates and​ low-fat foods. I​ don't understand why I am still gaining​ weight!" Which principles of nutrition should guide the​ nurse's response? Select all that apply

Carbohydrates should be high in fiber and low in sugar. Eating too many carbohydrates leads to excess​ glucose, which is converted to fat. Excess carbohydrates can lead to obesity.

The nurse is caring for an infant with a suspected fracture of the femur. Which condition puts an infant at risk for fracture of a long bone?

Cesarean birth

A patient has a chronic cough but does not show symptoms of wheezing or dyspnea. The nurse suspects that the patient has asthma. Which other symptom displayed by the patient contributed to the nurse's suspicion of asthma?

Chest tightness

A young pregnant patient who is visiting the clinic with her spouse informs the nurse that they both carry the gene for cystic fibrosis (CF). Which diagnostic test should the nurse expect the healthcare provider to order to determine the health of the fetus?

Chorionic villus sampling (CVS)

During a home​ visit, the nurse is assessing an older adult client. Which assessment findings support the nursing diagnosis Imbalanced​ Nutrition: Less than Body​ Requirements? Select all that apply.

Client reports a problem with dentures slipping while chewing. Client complains of occasional dry mouth and problems with feelings of nausea. ​Client's Social Security payments have gone down over the last year. Client is prescribed 15 medications.

During a home visit, the nurse is assessing an older adult client. Which assessment findings support the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements? Select 4 that apply.

Client reports a problem with dentures slipping while chewing. Client complains of occasional dry mouth and problems with feelings of nausea. Client is prescribed 15 medications. Client's monthly income has been reduced over the last year.

Which of the following statements best characterizes vitamin​ use?

Clients should be careful not to exceed recommended allowances for daily vitamin intake.

The nurse is providing discharge instructions for a patient with pneumonia. Which information is essential for the nurse to include?

Completing the prescribed medication regimen

The nurse is reviewing a patient's chest x-ray results, which are inconclusive for a diagnosis of pneumonia. For which additional diagnostic testing should the nurse prepare the patient to confirm diagnosis?

Computerized tomography (CT) scan

A client with osteoarthritis tells the nurse about having difficulty walking to the bathroom first thing in the morning. Which nursing action would assist the client?

Consult with a physical therapist for an assistive walking device such as a walker or cane

A patient with respiratory difficulties lost weight over the last few months. Which action should the nurse take?

Consult with dietary services to provide small, frequent meals.

The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. Which of the following action items might the nurse include that would help vegans and vegetarians increase their iron​ intake? Select all that apply.

Consume lentils. Increase intake of vitamin C. Consume Swiss chard. Consume tofu.

The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. Which of the following action items might the nurse include that would help vegans and vegetarians increase their iron intake? Select 4 that apply.

Consume tofu. Consume lentils Take a iron supplement Consume swiss chard

The nurse assigned to the newborn nursery is conducting physical assessments on the newborn babies. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?

Continue to monitor the newborn per facility policy.

The nurse is assessing an elderly patient suspected of having asthma. Which is one of the most common symptoms of asthma in this age group?

Cough

The nurse is assessing a patient with cystic fibrosis (CF). The nurse observes that the patient coughed into their sleeve and then wiped the mouth with the back of the hand. Which patient teaching should help to prevent the spread of infection?

Coughing into a tissue, disposing of it immediately, then using an alcohol-based gel

The nurse is conducting a health history on a patient diagnosed with a spinal cord injury. Which data is most appropriate for the nurse to collect?

Current medications

A couple visits the clinic to discuss family planning and inform the nurse of having a distant cousin with cystic fibrosis. Which diagnostic test should the nurse expect the healthcare provider to order?

Cystic fibrosis transmembrane conductance regulator (CFTR)

The nurse is caring for a patient with asthma. Which manifestation noted during patient assessment should the nurse associate with the classification of moderate persistent asthma?

Daily symptoms and exacerbations that can last for days

The nurse is preparing teaching material on the many unique concerns that manifest during the adulthood of a patient with cystic fibrosis (CF). Which condition should the nurse include to be a result of the long-term effect on the body?

Damage to the lungs, pancreas, and liver may lead to organ replacement.

Which laboratory test result should indicate to the nurse that the patient requires vitamin D supplements?

Decreased phosphorus

The nurse is preparing to assess a patient diagnosed with viral pneumonia. Which complication should the nurse anticipate?

Dehydration

A 7-year-old child is admitted with a fractured skull. The admitting nurse suspects abuse. Which question should the nurse consider to help determine if this is an abusive injury?

Does the story match the injury

Which instruction should the nurse provide the patient with pneumonia to promote the maintenance of adequate nutrition?

Eat small, frequent meals to maintain adequate nutritional intake."

The nurse is teaching the mother of a child who has recently been diagnosed with asthma. The nurse should explain that which type of asthma attack is triggered by the loss of heat or moisture from the bronchial surface?

Exercise induced

The nurse is assessing a patient who was admitted to the emergency department for a pelvic fracture. After receiving care from the nurse for a couple of hours, the patient reports shortness of breath. Which complication should the nurse suspect?

Fat embolism

While conducting a gait and posture assessment, the nurse becomes concerned and suspects that the patient has a herniated lumbar disc. Which assessment finding caused the nurse's suspicion?

Flattened lumbar curve

The nurse is providing a teaching session about common conditions that impact older adult patients, including hip fractures. Which information about hip fractures should the nurse include?

Frequently result from falls

Which condition should the nurse recognize as being more common in a pregnant woman with cystic fibrosis?

Gestational diabetes

The nurse is auscultating tracheal sounds of a patient. Which sound should the nurse recognize as a normal finding?

Harsh, high-pitched sound

A community nurse is conducting a wellness check for an older adult patient. Which finding indicates the patient is at increased risk for hip fractures?

Has a sedentary lifestyle

The nurse is caring for an older adult with a decreased gag reflex. Which nursing intervention is a priority?

Have suction equipment available.

The nurse is caring for a patient with a nonbleeding, closed femur fracture. The healthcare provider wants to evaluate for blood pooling around the fracture and into the surrounding tissue. Which test should the nurse anticipate to be ordered for the patient?

Hematocrit

Which cause of an alteration in oxygenation should the nurse consider to be a nonmodifiable risk factor?

Hemoglobin disorder

Which dietary intervention should the nurse discuss with a patient diagnosed with cystic fibrosis (CF)?

High-calorie, high-fat diet

The nurse is assessing a patient with emphysema. Which symptom of emphysema is not obvious from inspection and direct observation by the nurse?

Hyperresonance sounds from the lungs

A patient presents with a broken right radius and ulna after falling. The nurse is assessing the 5 Ps and asks the patient to wiggle the fingers on the right arm. The patient asks, "Why are you asking me to do this?" Which response by the nurse is appropriate?

I am checking for paralysis."

An older adult patient who sustained a fall at the home is transported to the emergency department for evaluation. The patient informs the nurse, "I was able call for help." Which patient statement indicates a need for further teaching?

I attempted to stand up and walk to the phone."

The nurse is teaching a patient about the importance of nutrition and the role it plays in bone healing. Which statement by the patient indicates an understanding of appropriate breakfast choices to aid bone healing?

I will eat cheese and eggs."

The public health nurse is providing community education aimed at promoting nutritional habits that decrease an individual's modifiable risk factors for heart disease. Which topic should the nurse NOT include in this teaching session?

Importance of eliminating all fats

The nurse is caring for a patient who fell and sustained a hip fracture. Which clinical manifestation should the nurse expect to find during the assessment?

Inability to move or stand

During an assessment, the client states that his bowel movements cause discomfort because the feces is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the client with improving the quality of his bowel movement? (Select 2 that apply.)

Increase water intake Increase fiber intake

The healthcare provider orders a sweat test for a patient suspected to have cystic fibrosis (CF). Which finding should the nurse expect?

Increased chloride

The nurse assesses a patient diagnosed with an alteration in mobility. Which assessment finding should the nurse determine as not related to immobility?

Increased gastrointestinal motility

The nurse is assessing a teenage boy with cystic fibrosis. The parent of the patient states that the boy has been feeling down and tired all the time, playing video games most of the day. Which recommendation should the nurse provide to improve overall health and endurance of this patient?

Increased physical activity

A new staff nurse is developing a plan of care for a patient with asthma. Which nursing intervention in the plan of care indicates the need for the preceptor nurse to intervene?

Increasing external stimuli

The nurse is teaching a patient with cystic fibrosis (CF) about clearing mucus from the lungs. Which instruction should the nurse provide?

Inhale, then actively exhale, expelling mucus.

The nurse is assessing a patient with cystic fibrosis (CF). Which assessment activity is the priority?

Inspect the patient for retractions and nasal flaring.

The nurse is conducting a gait and posture assessment for a young female client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment?

Inspecting the client's spine for curvature

A patient with asthma is prescribed an anticholinergic agent. Which rationale describes using this type of medication?

It blocks parasympathetic input to bronchial smooth muscles

An older adult patient is diagnosed with an intracapsular hip fracture. Which statement by the nurse explains this type of injury?

It is found in the head or neck of the femur within the capsule of the hip joint."

The nurse is instructing the unlicensed assistive personnel (UAP) about the use an abduction splint for a patient who underwent an arthroplasty after sustaining a hip fracture. Which information should the nurse include?

Keep the extremities always slightly apart."

The nurse is teaching an older adult woman with cystic fibrosis (CF) how to prevent urinary incontinence due to weak pelvic muscles. Which exercise should the nurse include?

Kegel

The nurse is assessing a patient who underwent a surgical repair of a hip fracture. Which finding warrants immediate notification of the healthcare provider?

Lack of lower extremity sensation or movement

A hospitalized patient is recovering from an acute asthma attack. Which nursing intervention is most appropriate during the recovery period?

Limiting the number of visitors

The nurse is completing a nutritional assessment on a client who has the medical diagnosis of hypertension (high blood pressure). What type of diet would be a good choice to recommend for this client?

Low sodium (salt)

The nurse is caring for a patient who is diagnosed with pneumonia. The x-ray results reveal consolidation in the lower lobe of the left lung. Which position should the nurse place the patient in to help mobilize secretions after providing chest physiotherapy?

Lying on the right side with the bed in the Trendelenburg position of 18 in

A patient is suspected of having a spinal cord injury. The nurse tells the patient, "Your healthcare provider has ordered a diagnostic test that measures how your nerves respond to stimulation." The nurse is referring to which test?

Magnetic evoked potentials

The nurse is providing discharge teaching to an asthmatic patient. Which lifestyle alterations should the nurse suggest to improve asthma management?

Maintaining a healthy weight

A patient with asthma is having difficulty breathing while lying supine. The patient can talk in phrases without experiencing shortness of breath and has a moderately elevated respiratory rate. Which level of an asthma attack did the patient have based on these assessment findings?

Mild

A patient with asthma reports, "I have symptoms daily that sometimes persist into the night." Which classification of asthma is this patient experiencing?

Moderate persistent

Bariatric surgery is an option for which category of​ clients?

Morbidly obese

The nurse is assessing a 5-year-old boy with cystic fibrosis. The patient's parent is confused about the medication and asks, "Which one of these medications breaks up his secretions?" Which response by the nurse is accurate?

Mucolytic

Which structural difference should the nurse expect when assessing a preschooler compared to an adult patient?

Narrow nasopharynx

Which admission assessment is most appropriate for the nurse to perform for a patient with altered mobility?

Observe as the patient walks across the room.

What is a primary prevention tool used for colon cancer screening?

Occult blood testing

A patient with impaired mobility needs assistance with completing activities of daily living (ADLs). The nurse should request a referral for which collaborative rehabilitation service?

Occupational therapy

A client sustained multiple fractures in a motor vehicle accident. The nurse determines that the client is at the highest risk for osteomyelitis (bone infection) due to which type of fracture?

Open, compound

Which breathing difficulty should the nurse understand is associated with body position?

Orthopnea

Where should the nurse feel the strongest vibration when performing tactile fremitus on a patient?

Over the trachea

The nurse is assessing a client who has recently had several blood tests done. Which laboratory results would the nurse identify as indicators of​ malnutrition? Select all that apply.

PAB 12​ mg/dL Cholesterol 120​ mg/dL PAB 100​ mg/L

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse assigns a goal to promote comfort for the patient. Which action is most important for the nurse to include in the plan of care?

Pad joints

The nurse admits a patient who sustained a hip fracture. Which medication should the nurse anticipate will be prescribed?

Pain medication to reduce comfort

The nurse is discussing fall prevention methods with an older adult patient. Which intervention should the nurse include?

Participating in daily weight-bearing exercises

The nurse at the rehabilitation center is developing a plan of care for a patient who underwent a right hip replacement secondary to a hip fracture. Which outcome is most appropriate for discharge to home?

Patient ambulates independently with an assistive device.

The nurse is teaching a young woman recently diagnosed with cystic fibrosis and their parent about chest physical therapy (CPT) and postural drainage. Which instruction should the nurse include?

Percuss or vibrate only over the upper ribs and never over the sternum, breastbone, stomach, or lower ribs and back.

A patient presents with chest congestion and a cough. Which skill should the nurse expect to use to specifically assess for chest congestion?

Percussion and auscultation

The nurse is teaching a patient who is newly diagnosed with asthma about possible asthma triggers. Which triggers should the nurse instruct the patient to avoid?

Pets, smoke, stuffed animals

The nurse is teaching an 8-year-old patient with asthma how to use an inhaler with a spacer. Which information should the nurse include?

Place the mouthpiece of the spacer in your mouth and form a tight seal with the lips.

A patient who has been receiving intravenous fluids to increase perfusion now has crackles in the lungs. Which action should the nurse perform first?

Place the patient in high Fowler position

Which independent nursing intervention is a priority for a patient who is experiencing dyspnea?

Place the patient in high Fowler position.

A 15 year old client who fell from a balance beam in physical education is diagnosed with an ankle sprain. Which action by the nurse is the most appropriate?

Placing an ice pack on the ankle

The nurse is caring for a patient experiencing an asthma attack. Which nursing intervention is most appropriate to address the patient's shortness of breath?

Placing the patient in a high Fowler position

A patient underwent surgical repair of a hip fracture this morning. The nurse provides an incentive spirometer to improve gas exchange. Which complication of hip fractures is the nurse attempting to prevent?

Pneumonia

The nurse is caring for a patient diagnosed with Legionnaires disease. The patient is experiencing hypoxia. Which is the nurse's priority action?

Positioning the patient to promote airway clearance

The nurse is assessing a 24-year old woman with cystic fibrosis (CF) who would like to start a family. The patient and the spouse want to discuss what to expect with the pregnancy and birth of their child. Which topic related to a mother with CF should the nurse include?

Possible decreased fertility

The nurse is preparing a patient who sustained a hip fracture for a hemiarthroplasty. Which risk should the nurse provide teaching for before surgery?

Postoperative infection

The parent of a child newly diagnosed with cystic fibrosis (CF) asks, "What is the best way to help my child eliminate mucus?" Which recommendation by the nurse is appropriate?

Practicing huffing

Which independent nursing intervention would not be appropriate for a client who is experiencing an alteration in oxygenation?

Prescribing bronchodilators

The nurse is planning a teaching seminar for a group of young adult clients who are at risk for obesity. Which statement by the nurse best addresses their needs?

Proper diet and exercise programs improve the ability to think and the positivity of self-perception.

The nurse is teaching RICE therapy to a patient with a fractured arm. Which intervention should be implemented for this patient?

Propping the patient's arm up on a pillow

The nurse is evaluating the oxygenation status of a patient during an asthma attack. Which diagnostic tool would be the most useful for gathering this information?

Pulse oximeter

Which type of passive exercise should the nurse implement to maintain joint mobility in an immobile patient?

Range of motion

Vaccinations can help promote healthy oxygenation by:

Reducing the transmission of preventable diseases.

The nurse is reviewing laboratory results for the patient experiencing hypoxia secondary to a diagnosis of pneumonia. Which result reflects impaired gas exchange?

SaO2 90%

The public health nurse is providing community education aimed at promoting nutritional habits that decrease an​ individual's modifiable risk factors for heart disease. Which topics should the nurse include in this teaching​ session? Select all that apply.

Selecting lean protein sources Benefits of consuming fruits and vegetables Preparing balanced meals Strategies for maintaining recommended daily caloric intake

The nurse presents genetic factors that might affect mobility to a community group. Which genetic factor listed by a community member should lead the nurse to provide further teaching?

Sickle cell disease

The nurse is preparing a patient to ambulate for the first time after a prolonged period of bedrest. The patient reports dizziness when first standing. Which action should the nurse take first?

Sit the patient on the edge of the bed until the dizziness passes.

During assessment of a patient with an alteration in mobility, the nurse notices that the patient has become confused and is having hallucinations. Which medication should the nurse suspect is causing the patient's symptoms?

Skeletal muscle relaxants

The nurse is reviewing the medication record of a patient admitted with an alteration in mobility. Which class of medications should lead the nurse to carefully observe the patient for central nervous system (CNS) effects?

Skeletal muscle relaxants

The process of digestion is important for the purpose of nourishment. In which body organ does most of our digestion take place?

Small intestine

The nurse is caring for a patient with a history of respiratory issues. Which lifestyle factor is the priority to address?

Smoking history

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate?

Space periods of activity with periods of rest

A patient is being evaluated for the source of a productive cough and shortness of breath. Which diagnostic test should the nurse expect to be ordered first?

Sputum specimen

The nurse is assessing a 24-year old man with cystic fibrosis (CF) who is accompanied by his spouse. The couple states that they have been trying to have a family for a long time. Which complication of CF should the nurse expect the healthcare provider to discuss first with the patient?

Sterility

The nurse receives an prescription for penicillin as part of the treatment for a patient with pneumonia. Which type of pneumonia should the nurse suspect based on the prescribed medication?

Streptococcus pneumoniae

The home care nurse visiting a patient reports that the patient is experiencing a headache, fever, malaise, and a nonproductive cough. The patient states, "This all started yesterday." Which characteristic about the onset of symptoms should the nurse identify as consistent with a diagnosis of viral pneumonia?

Sudden onset

A patient with diffuse emphysema asks about options for improving lung health. Which statement by the nurse is correct?

Surgical options can be considered to improve lung health with diffuse emphysema.

Prior to an assessment, the nurse is reviewing the chart of a child suspected to have pneumonia. Which manifestation should the nurse anticipate?

Tachypnea

The nurse is preparing a patient for immediate surgery for the repair of a hip fracture. Which intervention should the nurse include in the preoperative plan of care?

Teach importance of early ambulation.

The nurse is preparing to implement a nonpharmacologic intervention for a patient with pneumonia who is experiencing difficulty coughing up secretions. Which intervention should the nurse implement first?

Teach the patient incentive spirometry

A patient with alterations in the respiratory system tells the nurse, "I need to stop and rest often." Which intervention should the nurse suggest?

Teach the patient to space activities with rest periods.

The nurse is preparing educational materials for a client with hypertension. Which of the following elements should the nurse include when preparing this​ material? Select all that apply.

Teaching the client how to read nutritional labels Showing the client how to follow the DASH eating plan Helping the client to recognize foods that are low in sodium Explaining the effects of sodium on blood pressure

The home care nurse is assessing an older adult client diagnosed with mild cognitive impairment and is living alone. Which information is of concern?

The client had an unintended weight loss of 10 pounds during the last two weeks.

The nurse is assessing the nutritional status of an older client. Which finding is most likely to suggest​ xerostomia?

The client has a chronically dry mouth despite adequate intake of fluids.

A patient recovering from a hip replacement for a hip fracture develops pneumonia. The nurse creates an aggressive plan of care to promote mobility and treat the pneumonia. Which rationale supports the nurse's action?

The mortality rate increases to 43% in older adult patients with hip fractures who develop pneumonia.

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?

The newly licensed nurse is observed continuing to ask the client questions regarding personal medical history while the client demonstrates difficulty breathing and signs of respiratory impairment.

The nurse is reviewing patient charts before the start of the shift. Which patient is at most risk for aspiration pneumonia?

The older adult patient who had an exploratory abdominal surgery 4 hours ago

While assessing a patient for posture and gait, the nurse identifies a concave cervical spine, a convex thoracic spine, and a flattened lumbar spine. Which reason should concern the nurse in the light of these findings?

The patient may have a herniated lumbar disc.

The nurse is caring for a patient who is recovering from surgery for a fractured hip. How soon after surgery should the nurse assist the patient to ambulate?

The patient should ambulate as soon as possible after surgery.

The nurse is teaching a patient who was recently diagnosed with asthma about allergy testing results that indicate the patient is allergic to dust mites. Which expected outcome is appropriate for this patient following the teaching?

The patient uses furniture covers and a mattress pad to cover the bed to prevent exposure.

The nurse is planning care for a patient who is admitted with a compound fracture of the tibia. Which is an appropriate goal for this patient?

The patient will not demonstrate signs or symptoms of a wound infection.

The nurse is planning care for a patient who is diagnosed with asthma. Which expected outcome is appropriate for this patient?

The patient will verbalize triggers for asthma attacks.

The nurse is reviewing the risk factors for pneumonia in pregnancy. Which patient has the greatest risk of acquiring pneumonia during pregnancy?

The patient with a history of smoking

The nurse is caring for a patient in the clinic with the goal of developing no neurologic complications after a humerus fracture is casted. Which assessment finding indicates that the patient is healing appropriately?

The patient's fingers on the affected extremity are warm and pink.

The nurse is caring for a patient with pneumonia who is experiencing fatigue. Which finding indicates that the patient has met the goal of obtaining adequate rest?

The patient's sleep is uninterrupted.

A patient with impaired mobility has been prescribed axillary crutches. The nurse teaches the patient crutch walking. Which part of the body should the nurse instruct the patient to use for bearing weight when using the crutches?

The wrists

A patient scheduled for a joint aspiration study asks the nurse what this test will show? Which response by the nurse is accurate?

This test is done to determine if you possibly have a fracture."

The nurse is caring for a patient with a pleural effusion. Which test should the nurse expect to be ordered?

Thoracentesis

The nurse is teaching an adolescent with cystic fibrosis (CF) about the purpose of weight-bearing exercise. Which purpose should the nurse provide for this activity?

To decrease the risk of osteoporosis, osteopenia, and broken bones

Which is the purpose of pulmonary function tests when diagnosing asthma?

To evaluate the degree of airway obstruction

The nurse is teaching a young patient with cystic fibrosis (CF) about the importance of maintaining a high-calorie, high-fat diet. Which recommendation should the nurse provide in terms of total daily calorie intake?

Total calories should be 50% more than that of a person without CF.

The nurse is admitting a patient with a fractured humerus to the orthopedic unit. Which therapy for fractures applies a straightening or pulling force to return to or maintain the fractured bones in its normal anatomic position?

Traction

The nurse is caring for a patient with a pneumothorax. Which factor should the nurse suspect caused this alteration?

Trauma

The nurse is developing a plan of care for a patient who had a surgical repair of a hip fracture. The nurse assigns the following nursing diagnoses: Mobility: Physical, Impaired and Risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include?

Turn and reposition every 2 hours.

The nurse is developing a plan of care for an immobile patient and is concerned about skin integrity. Which intervention is appropriate for the nurse to include?

Turn the patient every 2 hours

The nurse is performing an assessment for a patient with a history of asthma. Which finding indicates that the asthma is worsening and requires the nurse to take immediate action?

Use of accessory muscles in breathing

A child with a suspected arm fracture is brought to the emergency department. As the healthcare provider removes the splint applied by emergency medical services (EMS), the patient's mother exclaims, "Why are you taking that off? Doesn't my child need that splint?" Which response by the nurse is correct?

We have to remove it to see what other treatment your child might need."

The nurse is performing a nursing assessment on a patient who is diagnosed with pneumonia. Which question is important for the nurse to ask first?

What is your full name

A hairdresser whose father recently died of emphysema reports a cough lasting several months. Which factor should the nurse consider as contributing to the patient's condition?

Workplace exposure chemicals

A 70-year-old patient presents at the emergency department with trauma to the right hip from a fall. Which diagnostic test should the nurse anticipate being ordered by the healthcare provider?

X-ray

Following a motor vehicle accident, a patient reports severe arm pain. The healthcare provider suspects a simple radial fracture. Which test should the nurse initially anticipate to diagnose a fracture?

X-ray

The nurse is providing dietary teaching to a patient with pneumonia. The patient asks, "Why do I need extra calories if I am not hungry or doing any activity?" Which explanation should the nurse provide to the patient?

Your body needs the extra calories when you are ill."

The nurse is caring for a pregnant patient diagnosed with cauda equina syndrome. Which procedure should the nurse expect to prepare the patient to undergo?

surgery

The nurse is caring for an older adult patient who requires an assistive device for ambulation. Which device should the nurse recommend for the patient?

walker