MTE 221

Which action should the nurse take first when a patient develops epistaxis?

Apply squeezing pressure to the nostrils for 10 minutes.

Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?

Respiratory Acidosis

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Stop the infusion of blood

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8oF. The patient reports having no discomfort. Which action by the nurse is appropriate?

Check the patient's temperature again in 4 hours.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Basal cell carcinoma

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

Briefly ask specific questions about this episode of respiratory distress.

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction the patient.

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?

"I've been using my albuterol inhaler more frequently over the last 4 days."

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

"It is no longer possible for you to choke on or aspirate food."

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

Disconnect the infusion and infuse normal saline

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at the highest risk for deep-vein thrombosis?

Hip arthroplasty

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?

Kussmaul respirations

Measurement of arterial blood gas shows pH 7.19, PaCO2 18 mm Hg, HCO3 16 mmol/L, and PaO2 60 mm Hg. How would you interpret this?

Metabolic Acidosis

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

Notify the health care provider.

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies?

Plan to wait in the clinic for 20-30 minutes after the testing.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Recombinant

A 62 year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include

a hemoglobin (Hgb) of 8.6 g/dL

A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first?

Notify the health care provider.

After receiving change of shift report, which patient should the nurse assess first?

The patient receiving chemotherapy who has a temperature of 102 degrees Farenheit.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3

The nurse should plan to use a wet to dry dressing for which patient? A. A patient who has a wound with purulent drainage and dry brown areas.

A patient who has a wound with purulent drainage and dry brown areas.

A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next?

Administer a bronchodilator and recheck the peak flow.

A patient with rheumatoid arthritis has been taking corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?

Ask about feelings of fatigue or malaise.

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

The patient swims several days each week.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

The nurse notes that the patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?

Undermining

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

It is important for the nurse providing care for a patient with sickle cell crisis to

encourage the patient to ambulate as tolerated.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

"I need something for the pain in my eye. I can't stand it."

Which action will the nurse include in the plan of care for a patient who has thalassemia major?

Administer iron chelation therapy as needed.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Administer the prescribed hydromrphone (Dilaudid)

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Airway obstruction

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Candidiasis

Which action will the admitting nurse include in the plan of care for a patient with neutropenia?

Check temperature every 4 hours.

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling.

The nurse has obtained the health history, physical assessment data, and laboratory results shown below for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?History: Fatigue which has increased over the last month. Frequent constipation.Physical assessment: Conjunctiva pale, pink and moist. Multiple bruises. Clear lung sounds.Laboratory results: Hct 33%, WBC 1500/microliter, Platelets 70,000/microliter

Neutropenia.

A patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. Which response by the nurse is most appropriate?

Refer the patient to a qualified genetic counsellor

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak cough effort

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?

pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg