N140 Exam 2 - PrepU

Bring the viral load to a virtually undetectable level

A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy? Bring the viral load to a virtually undetectable level Reverse the HIV+ status to a negative status. Treat mycobacterium avium complex. Eliminate the risk of AIDS.

Liver

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Large intestine Stomach Kidneys

At bedtime

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Immediately before a meal When secretions have mobilized At bedtime When bronchospasms occur

Comminuted

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? Comminuted Compound Depressed Impacted

Pulmonary system

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Cardiovascular system Pulmonary system Pain Nutrition

Hyperkalemia.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypocalcemia. Hyperkalemia. Hypernatremia. Hypoglycemia.

biopsy.

Kaposi sarcoma (KS) is diagnosed through computed tomography. skin scraping. visual assessment. biopsy.

3 to 5 minutes

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

Preexisting conditions

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Family history Weight Age Preexisting conditions

"I will feel warm and may have chest pain"

is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching? "I will feel light-headed when the contrast medium is introduced." "I will feel a dull pain when the catheter is introduced." "I will feel waves of nausea throughout the procedure." "I will feel warm and may have chest pain"

70 - 100

what is a normal range for MAP?

Tachycardia

When a client is in the compensatory stage of shock, which symptom occurs? Tachycardia Bradycardia Urine output of 45 cc/hour Respiratory acidosis

Hypoxemia

When a client is receiving 100% oxygen, what is the key sign of onset of acute respiratory distress syndrome? Stridor Hypoxemia Tachypnea Chest pain

Compound

A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? Greenstick Compound Spiral Oblique

Increasing heart rate

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? Elevated blood pressure Increasing heart rate Heart rate of 70 beats/minute Pale, warm, dry skin

Immerse the child's legs in cool water.

A child tips a pot of boiling water onto his bare legs. The mother should: Cover the child's legs with ice cubes secured with a towel. Avoid touching the burned skin and take the child to the nearest emergency department. Liberally apply butter or shortening to the burned areas. Immerse the child's legs in cool water.

Immunosuppressive agents

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? Chest physiotherapy Immunosuppressive agents Anticoagulation Antibiotic therapy

Full-thickness

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Deep partial-thickness Superficial partial-thickness Superficial Full-thickness

Between 24 and 48 hours

A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last? About 72 hours At least 1 week Between 24 and 48 hours Less than 24 hours

Water-seal chamber

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Suction control chamber Air-leak chamber Collection chamber Water-seal chamber

The client has experienced extensive full-thickness burns.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client has experienced partial-thickness burns. The client has experienced extensive full-thickness burns. The client is in hypovolemic shock. The paramedic administered high doses of opioids during transport.

continue to take antibiotics for the entire 10 days.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: maintain fluid intake of 40 oz (1,200 ml) per day. turn and reposition himself every 2 hours. continue to take antibiotics for the entire 10 days. follow up with the physician in 2 weeks.

70%

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 60% 70% 40% 50%

obtain a urine specimen for culture administer pantoprazole IV daily monitor urine output every hour

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. maintain the IV site inserted on admission administer pantoprazole IV daily monitor urine output every hour institute vital signs every 4 hours obtain a urine specimen for culture

production of an immune response

What does a positive Mantoux test indicate? production of an immune response development of full-blown tuberculosis an active case of tuberculosis active immunity to tuberculosis

Clubbing of the fingers

What finding by the nurse may indicate that the client has chronic hypoxia? Peripheral edema Clubbing of the fingers Crackles Cyanosis

The tongue

What is a common source of airway obstruction in an unconscious client? A foreign object Edema Saliva or mucus The tongue

Nonrebreather mask

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? Nonrebreather mask Simple mask Nasal cannula Face tent

Sexual abstinence Latex male condoms Polyurethane female condoms Dental dams

A client asks a nurse, "What can I use to decrease my risk of exposure to HIV?" What will the nurse include as effective in reducing the risk of HIV exposure? Select all that apply. Latex male condoms Lambskin condoms Polyurethane female condoms Dental dams Sexual abstinence

blood pressure.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. heart rate. temperature.

N-acetylcysteine

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? Flumazenil Diazepam N-acetylcysteine Naloxone

sprain

A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced? strain All options are correct. sprain contusion

compensatory respiratory alkalosis

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 >45 mm Hg compensatory respiratory alkalosis heart rate <100 bpm metabolic acidosis

Have the patient lie down and place the arm below the level of the heart.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? Apply a tourniquet to the arm above the bite. Make an incision and suck the venom out. Apply ice to the area. Have the patient lie down and place the arm below the level of the heart.

Fat embolism syndrome

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Fat embolism syndrome Complex regional pain syndrome Compartment syndrome Delayed union

Emergency response personnel performed this intervention outside the hospital.

The nurse is caring for a client in the intensive care unit and while reviewing the client's history, the nurse notes the client had a King laryngeal tube inserted to begin ventilation. The nurse recognizes this intervention was required for which reason? The client's airway is oversized requiring a specialized endotracheal tube. Emergency response personnel performed this intervention outside the hospital. Laryngeal edema prevented placement of an endotracheal tube. The client was hemorrhaging into the neck.

Pneumonia

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States? Atelectasis Pneumonia Tracheobronchitis Pulmonary embolus

Longer survival

The nurse teaches the client that reducing the viral load will have what effect? Longer immunity Shorter survival Longer survival Shorter time to AIDS diagnosis

Tension pneumothorax

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Tension pneumothorax Cardiac tamponade Pulmonary contusion Flail chest

A diet rich in protein

What dietary recommendations should a nurse provide a client with a lung abscess? A carbohydrate-dense diet A diet low in calories A diet with limited fat A diet rich in protein

tetracycline

Which antimicrobials is not commonly used to treat burns? silver nitrate (AgNO3) 0.5% solution mafenide (Sulfamylon) silver sulfadiazine (Silvadene) tetracycline

CD4+ counts

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? CD4+ counts ELISA Western blotting assay HIV RNA

Fracture

Which term refers to a break in the continuity of a bone? Dislocation Fracture Subluxation Malunion

Vitamin B6

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin D Vitamin B6 Vitamin C Vitamin E

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Assess and document any bruises and lacerations. Ensure that the police are present when the examination is performed. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Have the patient shower or wash the perineal area before the examination. Record a history of the event, using the patient's own words.

occurs through an area of diseased bone.

A fracture is considered pathologic when it results in a fragment of bone being pulled away by a ligament or tendon and its attachment. involves damage to the skin or mucous membranes. presents as one side of the bone being broken and the other side being bent. occurs through an area of diseased bone.

Follow the same sexual precautions as someone who has been diagnosed with AIDS.

A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection? Limit interactions with people who are already HIV infected. Follow the same sexual precautions as someone who has been diagnosed with AIDS. Limit interactions with people who are not HIV infected. Quit their job and get admitted to a hospital or a cancer treatment center.

Delirium

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? Delirium Bradycardia Diaphoresis Temperature of 101 degrees F (38 degrees C)

Caregiver cleans the client's anal area without wearing gloves

A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching? Caregiver disposes of syringe and needle in a metal coffee can with lid. Caregiver washes hands before and after providing care to the client. Caregiver cleans the client's anal area without wearing gloves Caregiver uses a dilute bleach solution to clean up a urine spill.

Jugular venous distention

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Positive increase in the fluid balance ratio Decreased pulse rate to 110 beats/minute Jugular venous distention Vesicular breath sounds

"Are the burns associated with chemicals used in the plant?"

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?" "How many victims are anticipated for transport?" "Are the victims suffering from thermal burns?"

Tension pneumothorax

A mediastinal shift occurs in which type of chest disorder? Cardiac tamponade Traumatic pneumothorax Tension pneumothorax Simple pneumothorax

Auscultate the lung for adventitious sounds.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? Auscultate the lung for adventitious sounds. Have the patient inform the nurse of the need to be suctioned. Have the patient cough. Assess the CO2 level to determine if the patient requires suctioning.

Use of accessory muscles

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Controlled breathing Use of accessory muscles Pursed-lip breathing Diaphragmatic breathing

pH 7.28, PaO2 50 mm Hg

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.36, PaCO2 32 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.35, PaCO2 48 mm Hg pH 7.28, PaO2 50 mm Hg

ventilation exceeds perfusionDe

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?

AIDS

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? DAF AIDS CVID SCID

Related to circumferential eschar

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to femoral artery occlusion Related to fat emboli Related to circumferential eschar Related to infection

Dyspnea and wheezing

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Sore throat and abdominal pain Hemoptysis and dysuria Nonproductive cough and normal temperature Dyspnea and wheezing

Deep purple cutaneous lesions

A nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment? Severe joint pain Venous stasis and phlebitis formation Lymphedema of the lower extremities Deep purple cutaneous lesions

uncoordinated muscle movements

A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has vascular lesions caused by dilated blood vessels. an inability to understand the spoken word. uncoordinated muscle movements. difficulty swallowing.

15-mm induration

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? A blister 15-mm induration 5-mm induration Reddened area

Replace lost fluids and electrolytes.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Monitor cardiac status. Replace lost fluids and electrolytes. Prevent renal shutdown.

Endotracheal suctioning

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Use of a cooling blanket Encouragement of coughing Incentive spirometry Endotracheal suctioning

Cough or change in chronic cough

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Pain on inspiration Cough or change in chronic cough Obvious trauma Shortness of breath

Using strict hand hygiene

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Using strict hand hygiene Turning the client every 4 hours to prevent fatigue Providing oral hygiene daily Keeping the head of the bed at 15 degrees or less

keeping his airway patent

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: encouraging him to perform activities of daily living (ADLs). helping him communicate. preventing him from developing an infection. keeping his airway patent

Prevent internal rotation of the affected leg.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? Use measures other than turning to prevent pressure ulcers. Keep the hip flexed by placing pillows under the client's knee. Prevent internal rotation of the affected leg. Keep the affected leg in a position of adduction.

Ineffective airway clearance.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Risk for falls. Impaired tissue integrity. Ineffective breathing pattern. Ineffective airway clearance.

Place the end of the chest tube in a container of sterile saline.

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? Clamp the chest tube immediately. Apply an occlusive dressing and notify the physician. Secure the chest tube with tape. Place the end of the chest tube in a container of sterile saline.

Impaired gas exchange

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Anxiety Impaired gas exchange Ineffective tissue perfusion (cardiopulmonary) Decreased cardiac output

A client with a nasogastric tube

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client who is receiving acetaminophen (Tylenol) for pain A client who ambulates in the hallway every 4 hours A client with a nasogastric tube A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

Decreased elasticity of the alveolar sacs Increased residual volume Increased diameter of alveolar ducts Increased thickness of alveolar sacs

A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply. Increased diameter of alveolar ducts Decreased dead space Decreased pulmonary compliance Increased residual volume Decreased elasticity of the alveolar sacs Increased thickness of alveolar sacs

Jaw-thrust

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Abdominal thrust Jaw-thrust Seldinger Neck tilt-head lift

Impaired gas exchange

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? Impaired spontaneous ventilation Decreased cardiac output Impaired gas exchange Ineffective airway clearance

Repositioning the patient's head

A nurse is establishing a patient's airway. Which action would the nurse perform first? Inserting an artificial airway Using the jaw-thrust maneuver Repositioning the patient's head Giving abdominal thrusts

organ damage

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? unsteady gait weight loss liver dysfunction organ damage

Urine

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission? Blood Breast milk Semen Urine

A mask will be placed over the nose and mouth during the test. The client will be expected to lie under the camera. The imaging time will amount to 20 to 40 minutes.

A nurse is instructing a client who is scheduled for a perfusion lung scan. What teaching should the nurse include in the information about the procedure? Select all that apply. An injection will be placed into the lung during the procedure. A mask will be placed over the nose and mouth during the test. The imaging time will amount to 20 to 40 minutes. The client will be expected to be NPO for 12 hours prior to the procedure. The client will be expected to lie under the camera.

Chronic diarrhea

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of? Oral candida Nausea and vomiting Anorexia Chronic diarrhea

Attachment

A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step? Attachment Cleavage Uncoating Budding

Most cases are typically diagnosed in infancy.

A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation? Overall, these conditions more commonly affect females. The conditions appear to predominate in males after adolescence. Primary immunodeficiencies are more common than secondary immunodeficiencies Most cases are typically diagnosed in infancy.

Ear lobe and then to the xiphoid process

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? Chin and then to the xiphoid process Chin and then to the umbilicus Ear lobe and then to the xiphoid process Ear lobe and then to the umbilicus

Flank pain Shaking chills Tightness in the chest

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. Shaking chills Tightness in the chest Flank pain Fatigue Hunger

Protecting himself or herself

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Gaining control of the situation Securing the area Providing care to the injured Protecting himself or herself

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client exhibits restlessness and confusion. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client exhibits bronchial breath sounds over the affected area. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.

immobilization

A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? surgical repair external rotation enhancing complications immobilization

is breathing air in and out of the lungs.

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: is breathing air in and out of the lungs. provides a blood supply to the lungs. helps people who cannot breathe on their own. is when the body changes oxygen into CO2.

Oxygen toxicity

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Hypoxia Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis

27%

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 45% 27% 36% 18%

skin breakdown wound infection pneumonia

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. wound infection skin breakdown diarrhea pneumonia

"Keep your right leg elevated above heart level."

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? "Cover the cast with a blanket until the cast dries." "A foul smell from the cast is normal." "Keep your right leg elevated above heart level." "Use a knitting needle to scratch itches inside the cast."

Risk for injury

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? Ineffective cerebral tissue perfusion Risk for injury Complicated grieving Bathing or hygiene self-care deficit

pulmonary edema.

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of hypothermia. head injury. pulmonary edema. hyponatremia.

Adventitious breath sounds

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits Troponin levels less than 0.35 ng/mL Adventitious breath sounds Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute A change in apical pulse rate from 102 to 88 beats/min

6 weeks

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? 18 weeks 12 weeks 24 weeks 6 weeks

Every 30 minutes

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? Every 15 minutes Every 30 minutes Every 60 minutes Every 120 minutes

I'll make sure to keep my ankle elevated as much as possible."

A client is being discharged from the Emergency Department after being diagnosed with a sprained ankle. Which client statement indicates the client understands the discharge teaching? "I'll get the prescription filled for the narcotic pain reliever." "I need to stay off my ankle for at least the next 3 to 4 weeks." "I'll make sure to keep my ankle elevated as much as possible." "I'll start with ice for the first couple of hours and then apply heat."

Troubleshoot to identify the malfunction

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? Troubleshoot to identify the malfunction. Reposition the endotracheal tube. Manually ventilate the client. Notify the respiratory therapist.

contusion

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose? subluxation contusion sprain strain

One side of the bone is broken and the other side is bent.

A client is brought to the emergency department after injuring the right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? The fracture line extends through the entire bone substance. The fracture results from an underlying bone disorder. Bone fragments are separated at the fracture line. One side of the bone is broken and the other side is bent.

Paradoxical chest movement

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? Clubbing of fingers and toes Chest pain on inspiration Respiratory acidosis Paradoxical chest movement

Continuous positive airway pressure (CPAP)

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Bi-level positive airway pressure (BiPAP) Continuous positive airway pressure (CPAP) Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night

A continuous infusion of total parenteral nutrition

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A continuous infusion of total parenteral nutrition A full liquid diet Isotonic enteral nutrition every 6 hours An infusion of crystalloids at an increased rate of flow

ondansetron

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? loperamide meperidine ondansetron magnesium hydroxide

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Increased paCO² levels Loss in consciousness Decreases in liver enzymes Ecchymoses and petechiae Reports of chest pain

Continues assessing the client's respiratory status frequently

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning Changes the setting on the ventilator to increase breaths to 14 per minute Consults with the physician about removing the client from the ventilator

alcohol

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: seafood. alcohol. exposure to sunlight. applying skin moisturizers.

"Be sure to take this drug about 1/2 hour before or 2 hours after you eat."

A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? "It doesn't matter if you take this drug with or without food." "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." "You should take the drug with an antacid." "When you take this drug, eat a high-fat meal immediately afterwards."

Take prescribed albuterol (Ventolin) before performing postural drainage.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Perform drainage 1 hour after meals. Hold each position for 5 minutes. Lay in bed with the head on a pillow. Take prescribed albuterol (Ventolin) before performing postural drainage.

Partial pressure of arterial oxygen (PaO2)

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) Bicarbonate (HCO3-) pH

The right foot is cooler than the left foot.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: Vesicular breath sounds are audible in the lung periphery. The balloon deflates prior to systole. The right foot is cooler than the left foot. Bilateral pedal pulses are 1+.

"An allograft is a temporary wound covering obtained from cadaver skin."

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? "An allograft is an expensive sheet of skin obtained from a culture." "An allograft is a temporary wound covering obtained from cadaver skin." "An allograft is a temporary wound covering obtained from pig skin." "An allograft is a permanent wound covering taken from a donor site in your body. "

Be alert for signs and symptoms of infection and report them immediately to the physician.

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? Be alert for signs and symptoms of infection and report them immediately to the physician. This medication is commonly used for many inflammatory reactions and is relatively safe. If the client experiences nausea, omit the dose. The client should be alert for joint aches.

Bank autologous blood.

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client? Sign a refusal of blood transfusion form so the client will not receive the transfusion. Bank autologous blood. Ask people to donate blood. Using volume expanders in case blood is needed.

"Apply ice packs for the first 24 to 48 hours, then apply heat packs."

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? "Apply ice packs for the first 12 to 18 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." "Apply heat packs for the first 24 to 48 hours."

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. Delayed capillary refill Decreasing blood pressure Cool, moist skin Increasing urine volume Increasing heart rate

Encourage the client to cough forcefully.

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? Insert a nasopharyngeal airway. Prepare the client for a bronchoscopy. Encourage the client to cough forcefully. Insert an oropharyngeal airway.

Irrigate the wounds with water.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Irrigate the wounds with water. Do nothing until the chemical agent is identified. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. Wash the wounds with soap and water and apply a barrier cream.

Assess blood urea nitrogen and creatinine.

A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's bestaction? Administer fluids 100 mL/hour IV. Encourage the client to drink more fluids. Assess blood urea nitrogen and creatinine. Assess liver function tests.

The early appearance of the burn injury may change.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? The wound is susceptible to infections. The early appearance of the burn injury may change. The client's condition is likely to deteriorate after 72 hours. It helps determine the percentage of the total body surface area (TBSA) that is burned.

Sprain

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? Dislocation Strain Subluxation Sprain

Intoxication

A client suffering from carbon monoxide poisoning would exhibit which manifestation? Severe hypertension Cherry red skin coloring Intoxication Hyperactivity

Kinking of the ventilator tubing

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A disconnected ventilator circuit Kinking of the ventilator tubing An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm

Enzyme-linked immunosorbent assay (ELISA)

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? Complete blood count (CBC) Schick Enzyme-linked immunosorbent assay (ELISA) Western Blot

X-ray

A client sustains an injury to the left ankle when he fell down three steps. There was immediate swelling and pain from the injury, and the client was taken to the local emergency department. What initial test does the nurse anticipate the physician will order to rule out a fracture? Arthrography Computerized tomography (CT scan) X-ray Arthroscopy

Teach the client about medication side effects.

A client taking fosamprenavir reports "getting fat." What is the nurse's best action? Teach the client about medication side effects. Assess the client's diet. Arrange for a psychological counseling. Have the client increase exercise.

Keeping a pillow between the client's legs at all times

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Maintaining the client in semi-Fowler's position Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours

Avoid fibrous foods, lactose, fat, and caffeine.

A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise? Increase intake of iron and zinc. Consume large, high-fat meals. Avoid fibrous foods, lactose, fat, and caffeine. Reduce food intake.

inflammatory

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? neuroendocrine hypertension intravascular fluid excess inflammatory

dislocation

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose? sprain strain fracture dislocation

joint manipulation and immobilization

A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform? heat and immobilization joint manipulation and immobilization analgesia and immobilization ice and immobilization

Avascular necrosis

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? Avascular necrosis Pulmonary embolism Hypovolemic shock Infection

Risk for Impaired Gas Exchange

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Alteration in Tissue Perfusion Acute Pain Risk for Impaired Gas Exchange Risk for Infection

Disturbed body image related to loss of fat in the face and arms

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority? Risk for impaired liver function related to drug therapy effects Deficient knowledge related to the effects of the disease Risk for infection related to the immune system dysfunction Disturbed body image related to loss of fat in the face and arms

trimethoprim-sulfamethoxazole

A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection? amphotericin B trimethoprim-sulfamethoxazole fluconazole nystatin

Control the shivering.

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? Maintain the client in a supine position with legs elevated 12 inches. Keep the client dry and covered. Control the shivering. Place the client on a warming blanket.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Monitor and record hourly intake and output. Request order for patient-controlled analgesia pump

To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. To decrease the work of breathing To provide visual feedback to encourage the client to inhale slowly and deeply To reduce stress on the myocardium To clear respiratory secretions To provide adequate transport of oxygen in the blood

Initiate oxygen therapy.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Initiate oxygen therapy. Administer analgesics as ordered. Perform nasopharyngeal suctioning. Administer a heparin bolus and begin an infusion at 500 units/hour.

Maintain bed rest with the head of the bed at 20 degrees.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Maintain bed rest with the head of the bed at 20 degrees. Sit the client upright in a padded chair for meals. Maintain NPO (nothing by mouth) status for surgical repair. Withhold opioid pain medication to prevent ileus.

premedicating the client with an analgesic prior to application.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include premedicating the client with an analgesic prior to application. protecting the bed linens and client's clothing from contact to prevent staining. monitoring the client's Na+ and K+ serum levels and replace as prescribed. monitoring the client for the development of respiratory acidosis.

Fasciotomy

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for? Amputation Fasciotomy Joint replacement Bone graft

neurogenic shock

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? anaphylactic shock septic shock hypovolemic shock neurogenic shock

"Describe the pain and rate it on the pain scale."

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? "Describe the pain and rate it on the pain scale." "Pain medication usually does not help this type of pain." "Your left toes have been amputated." "The pain is really from the nerves in the upper leg."

84 mm Hg

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 84 mm Hg 45 mm Hg 58 mm Hg 120 mm Hg

Ensure that a large tourniquet is in the room.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? Document the receiving report from the transferring nurse. Review the physician's orders for type and frequency of pain medication. Delegate the gathering of enough pillows for proper positioning and comfort. Ensure that a large tourniquet is in the room.

BUN: 28 mg/dL

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? K+: 5.0 mEq/L Ca: 9 mg/dL BUN: 28 mg/dL Na+: 145 mEq/L

Provide feedback on the client's strengths and available resources.

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate? Provide wound care without discussing the amputation. Provide feedback on the client's strengths and available resources. Request a referral to occupational therapy. Encourage the client to perform range-of-motion (ROM) exercises to the right leg.

HIV encephalopathy

A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? Cytomegalovirus (CMV) HIV encephalopathy Distal sensory polyneuropathy (DSP) Candidiasis

Pneumocystis jiroveci

A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect? Pneumocystis jiroveci Mycobacterium avium complex Legionella Cytomegalovirus

Listen and show interest as the client expresses feelings.

A client with acquired immunodeficiency syndrome is admitted with Pneumocystis cariniipneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do? Continue with the bath and tell the client not to worry. Listen and show interest as the client expresses feelings. State that his friends' behavior shows they aren't true friends. Ask the physician to obtain a psychiatric consultation.

Elevating the stump for the first 24 hours

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Removing the pressure dressing after the first 8 hours Applying heat to the stump as the client desires Elevating the stump for the first 24 hours Maintaining the client on complete bed rest

IV gamma globulin administration

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen? Thymus grafting Factor VIII administration IV gamma globulin administration Platelet administration

Rhonchi

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document? Venous hum Rales Bronchovesicular Rhonchi

Use of accessory muscles to breathe Purulent sputum with frequent coughing

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply. Purulent sputum with frequent coughing Hypoventilation breathing pattern Use of accessory muscles to breathe Respiratory rate of 10 breaths per minute Tympany percussed bilaterally over the lung bases

Manual resuscitation bag

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Oxygen analyzer Water-seal chest drainage set-up Tracheostomy cleaning kit Manual resuscitation bag

A lung volume reduction

A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? A lung volume reduction Lobectomy A wedge resection A sleeve resection

Administering a cough suppressant as needed

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety? Administering a cough suppressant as needed Applying oxygen via nasal cannula Assisting the client to a prone position Obtaining arterial blood gas values immediately after the procedure

Pneumocystis pneumonia

A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client? Community-acquired pneumonia Tuberculosis Pneumocystis pneumonia Mycobacterium avium complex (MAC)

Pathologic fracture

A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall? Pathologic fracture Transverse fracture Impacted fracture Compound fracture

Suction the client's artificial airway.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Ventilate the client with a handheld mechanical ventilator. Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage.

Barrel chest

A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population? Barrel chest Pigeon chest Kyphoscoliosis Funnel chest

Calcium channel blockers

A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client? Angiotensin receptor blockers Angiotensin converting enzyme inhibitor Beta blockers Calcium channel blockers

Western blot test for confirmation of diagnosis.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: polymerase chain reaction test for confirmation of diagnosis. p24 antigen test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis. Western blot test for confirmation of diagnosis.

Pinpoint pupils

A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? Hyperventilation Hypertension Pinpoint pupils Flushed face

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. Allow the family to express their emotions freely. Provide a private place for the family to be together. Ask the family if they would like to view the body. Talk with the family about the client having "passed on." Provide sedation to family members as needed.

Supporting the client's emotional status

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Supporting the client's emotional status Performing the pelvic examination Collecting semen Obtaining consent for examination

The client's urinary output is 0.5 mL/kg/hour.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's heart rate is rapid. The client's urinary output is 0.5 mL/kg/hour. The client's breathing is unlabored and skin is clammy. The client is conscious.

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement? "The only treatment option is thymus gland transplantation." "Hematopoietic stem cell transplantation cannot be performed until the age of 5 years." "We can ask our family members to donate blood for stem cell harvesting." "We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."

"Before you do the exercise, I'll give you pain medication if you need it."

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "Breathe in and out quickly." "Don't use the incentive spirometer more than 5 times every hour." "You need to start using the incentive spirometer 2 days after surgery." "Before you do the exercise, I'll give you pain medication if you need it."

"I won't donate blood because I don't want to get AIDS."

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? "A man should wear a latex condom during intimate sexual contact." "I won't donate blood because I don't want to get AIDS." "I.V. drug users can get HIV from sharing needles." "I've heard about people who got AIDS from blood transfusions."

Runs of ventricular tachycardia

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Runs of ventricular tachycardia Oxygen saturation of 93% Blood pressure remains stable

On the cheeks below the eyes

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Between the eyes and behind the nose Above the eyebrows Behind the ethmoid sinuses On the cheeks below the eyes

A myocardial infarction.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: Arrhythmias. Valvular damage. A myocardial infarction. Cardiomyopathies.

95%

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? 75% 40% 95% 80%

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient who is bleeding from the chest Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Patient with a lumbar spine injury Patient with extensive facial trauma

Absent distal pulses

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about? Excessive capillary refill Raised temperature in the affected limb Flushed feeling in the client Absent distal pulses

Absent distal pulses

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about? Flushed feeling in the client Absent distal pulses Excessive capillary refill Raised temperature in the affected limb

Ensure a patent airway and that the patient is receiving 100% oxygen.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Draw labs for a chemistry panel. Send the patient to the hyperbaric chamber. Send the patient for a chest x-ray. Ensure a patent airway and that the patient is receiving 100% oxygen.

Streptococcus pneumoniae

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Mycobacterium tuberculosis Streptococcus pneumoniae Pseudomonas aeruginosa Staphylococcus aureus

pleurisy

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Lung infarction Pleurisy Bacterial pneumonia Bronchogenic carcinoma

Pleurisy

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Pleurisy Lung infarction Bronchogenic carcinoma Bacterial pneumonia

Kussmaul respirations

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Biot's respirations Cheyne-Stokes Kussmaul respirations Apnea

Superficial

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Full-thickness Deep partial-thickness Superficial partial-thickness Superficial

Hypovolemic shock

A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern for this patient? Infection Pain resulting from muscle spasm Hypovolemic shock Knee and hip dislocation

Dyspnea

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Dyspnea Ascites Hypertension Syncope

Diving in an ocean

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Running a race in hot humid weather Swimming in a lake Diving in an ocean Working in a chemical plant

10,500 mg

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg? 9100 mg 6300 mg 7700 mg 10,500 mg

Intubation and mechanical ventilation

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Administration of oxygen via venture mask Thoracotomy with chest tube insertion Intubation and mechanical ventilation Pericardiocentesis

As soon as tolerated, after a reasonable period of immobilization

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin? In about 4 to 5 weeks, after new bone is well established In 2 to 3 months, after normal activities are resumed In 2 to 3 weeks, when callus ossification prevents easy movements of bony fragments As soon as tolerated, after a reasonable period of immobilization

Epinephrine

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Epinephrine Proventil Prednisone Benadryl

Stage III

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage III Stage II Stage IV Stage I

Induced vomiting

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Administration of activated charcoal Dilution with water or milk Induced vomiting Gastric lavage

Administer an analgesic as ordered.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Elevate the legs. Administer an analgesic as ordered. Massage the extremities. Apply a heat lamp.

Inspecting the roof of the nasopharynx.

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: Inspecting the posterior region of the epiglottis. Inspecting the roof of the nasopharynx. Examining the base of the oropharynx. Palpating the throat above the cricoid cartilage.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? Remove his burned pants so that the air can help cool the wound. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

MRI can view soft tissues and can help stage cancers.

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? MRI can view soft tissues and can help stage cancers. Lung blood flow can be viewed after a radiopaque agent is injected. Narrow-beam x-ray can scan successive lung layers. Tumor densities can be seen with radiolucent images.

Developing a list of people with whom the client has had contact

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? Developing a list of people with whom the client has had contact Reviewing the risk factors for TB Client teaching about the cause of TB Client teaching about the importance of TB testing

2,400 mL

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 2,400 mL 1,200 mL 3,600 mL 4,800 mL

Urgent

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? Urgent Delayed Immediate Emergent

Blood-tinged sputum

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? Blood-tinged sputum Productive cough Bradypnea Respiratory alkalosis

immersion of the client in a cold-water bath.

An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include immersion of the client in a cold-water bath. IV hydration with normal saline solution. endotracheal intubation with mechanical ventilation. administration of sodium supplements.

Subluxation

An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as? Compartment syndrome Volkmann's contracture Sprain Subluxation

36%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 18% 27% 36% 9%

Delavirdine Efavirenz

As part of HAART therapy, a client is prescribed a non-nucleoside reverse transcriptase inhibitor (NNRTI). What would be an example of a drug from this class? Select all that apply. Efavirenz Amprenavir Stavudine Abacavir Delavirdine

a patent airway established.

As the first priority of care, a patient with a burn injury will initially need: pain medication administered. an indwelling catheter inserted. a patent airway established. fluids replaced.

Decompensation (Progressive)

At what point in shock does metabolic acidosis occur? Early Decompensation (Progressive) Irreversible Late

Emphysema

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds? Pulmonary edema Atelectasis Emphysema Bronchitis

deviation from the midline.

During assessment of the respiratory system, the nurse inspects and palpates the trachea in order to assess: trachea? evidence of muscle weakness. evidence of exudate. deviation from the midline. color of the mucous membranes.

Brain

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Kidneys Lungs Liver Brain

"A snug fit is needed to minimize scarring and overgrowth of skin."

During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? "The garment can be removed for an hour each day." "A snug fit is needed to minimize scarring and overgrowth of skin." "Perhaps the garment should be resized." "The garment acts as a skin layer and prevents infection."

Pelvic fractures

Elderly clients who fall are most at risk for which injuries? Pelvic fractures Cervical spine fractures Wrist fractures Humerus fractures

Head injury

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Myocardial infarction Multiple sclerosis Diabetes Head injury

spleen.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the large intestine. spleen. liver. gallbladder.

Measuring and documenting the drainage in the collection chamber

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Keeping the collection chamber at chest level Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber

Auscultating the lungs for bilateral breath sounds

For a client with an endotracheal (ET) tube, which nursing action is the most important? Providing frequent oral hygiene Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours

Auscultating the lungs for bilateral breath sounds

For a client with an endotracheal (ET) tube, which nursing action is the most important? Providing frequent oral hygiene Monitoring serial blood gas values every 4 hours Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours

Diaphragm contracts and elongates the chest cavity.

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. Intercostals muscles relax to allow for expansion. Diaphragm contracts and elongates the chest cavity. Lungs are pulled up and pushed back against the thoracic cage. Anteroposterior rib diameter decreases.

Compartment syndrome

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? Fat embolism syndrome Disseminated intravascular coagulation Carpal tunnel syndrome Compartment syndrome

Applying knee splints

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Performing shoulder range-of-motion exercises Hyperextending the client's palms

Impacted

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture? Comminuted Compression Greenstick Impacted

Chemical irritation

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? Direct lung damage Drug ingestion Chemical irritation Aspiration

Elevate the legs higher than the heart.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? Place a cool compress on head. Elevate the legs higher than the heart. Shake the client to arouse. Cover the client with a blanket.

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote the strengthening of the client's diaphragm Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote more efficient and controlled ventilation and to decrease the work of breathing Promote the client's ability to take in oxygen

Pulmonary edema

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Congestive heart failure Pulmonary edema Pneumonia Panic attack

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Suction the patient since the patient may be obstructed by secretions. Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. Call respiratory therapy and wait until they arrive to determine what is happening.

Assist with chest physiotherapy every 2 to 4 hours.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care? Limit fluid intake to 1 1/2 to 2 liters per day. Assist with chest physiotherapy every 2 to 4 hours. Encourage client to ambulate frequently in the halls. Maintain the client in a supine or side-lying position.

Request that the pastor be present to support the family at the client bedside

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action? Request that the pastor be present to support the family at the client bedside Hand off care of the other client to another nurse Delegate the blood transfusion to the licensed practical/vocational nurse Explain to the family it is a busy time on the unit but someone will be with them soon

"Are you hearing anything that is disturbing you?"

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? "Does it feel like there is a tight band around your head?" "Are you finding the light is too harsh or bothering your eyes?" "Are you experiencing any burning or numbness?" "Are you hearing anything that is disturbing you?"

Increase the force of myocardial contraction

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? Increase the force of myocardial contraction Slow the heart rate Depress the central nervous system Dilate the bronchial tree

Measure the circumference of the arm.

The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Administer diphenhydramine (Benadryl). Assess peripheral pulses. Administer cimetidine (Tagamet). Measure the circumference of the arm.

PaO2

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? PCO2 pH HCO3 PaO2

Rapid onset of severe dyspnea

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Cyanosis Bilateral wheezing Inspiratory crackles

Elevated B-type natriuretic peptide (BNP) levels

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? Elevated B-type natriuretic peptide (BNP) levels Elevated white blood count Elevated myoglobin levels Elevated troponin levels

Crackles at lung bases

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Absent breath sounds Egophony Bronchial breath sounds Crackles at lung bases

Crackles at lung bases

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Crackles at lung bases Absent breath sounds Egophony Bronchial breath sounds

Symmetry of the client's chest expansion

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Cool air humidified through the tube A scheduled time for deflation of the tracheal cuff Symmetry of the client's chest expansion Tracheal cuff pressure set at 30 mm Hg

Crackles in the lung bases

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Low-pitched rhonchi during expiration Sibilant wheezes Crackles in the lung bases Pleural friction rub

Malnutrition

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is Hypocalcemia Neutropenia Malnutrition Chronic diarrhea

They can be heard during inspiration and expiration.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? They can be heard during inspiration and expiration. They are heard in clients with decreased secretions. They result from air passing through widened air passages. They occur when the pleural surfaces are inflamed.

A rapid, bounding pulse

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A weak and thready pulse A slow and imperceptible pulse A rapid, bounding pulse A slow but steady pulse

Adrenergic drugs

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Administer analgesic medications as ordered.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Have the client complete active range-of-motion exercises. Rupture any hemorrhagic blebs that are noted.

Mean arterial pressure of 70 mm Hg

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Central venous pressure of 6 mm Hg Mean arterial pressure of 70 mm Hg Urine output of 0.2 mL/kg/hr ScvO2 of 60%

Side effects of drug therapy

The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications? The use of condoms The action of each antiretroviral drug Side effects of drug therapy What vaccinations to have

Call security personnel to assist

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? Apply physical restraints Call security personnel to assist Move out of the client's view Administer antipsychotic medication

The client requires total parenteral nutrition

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? The client requires infusion of intravenous antibiotics The client will require intravenous access for three days The client requires infusion of a dextrose 5% water (D5W) The client requires total parenteral nutrition

Sitting on the edge of the bed

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? Prone Sitting on the edge of the bed Lateral recumbent Supine

Claw-like deformity of the right hand without ability to extend fingers

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding? Extension of the fingers of the right hand Nodules on the knuckles of the third and fourth finger Claw-like deformity of the right hand without ability to extend fingers Dislocation of the fingers

Foot

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? Hand Foot Forearm Upper arm

Assess the client for a cough reflex.

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? Offer the client ice chips. Instruct the client that bed rest must be maintained for 2 hours. Ensure the client remains moderately sedated to decrease anxiety. Assess the client for a cough reflex.

"The client is in shock because the blood volume has decreased in the system."

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct? "The client is in shock because the blood volume has decreased in the system." "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because your loved one is not responding and brain dead." "The client is in shock because all peripheral blood vessels have massively dilated."

Cyanosis

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? Restlessness Confusion Dyspnea Cyanosis

Stabbing pain during respiratory movement

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Dyspnea and coughing Fever and chills Dullness or flatness on percussion over areas of collected fluid Stabbing pain during respiratory movement

Heightened anxiety phase

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Acute disorganization phase Heightened anxiety phase Denial phase Reorganization phase

"I can take my child to the beach, as long as we play in the sand rather than swim in the water."

The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed? "I will apply lotion following every bath to prevent dry skin." "I will avoid letting my child drink any juice that has been sitting out for more than an hour." "I can take my child to the beach, as long as we play in the sand rather than swim in the water." "I will let my neighbor have my pet iguana."

Diagnostic and laboratory testing

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Establishing a patent airway Diagnostic and laboratory testing Assessment of peripheral pulses Undressing the client

It prolongs exhalation.

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? It prolongs exhalation. It increases the respiratory rate to improve oxygenation. It will prevent the alveoli from overexpanding. It will assist with widening the airway.

To avoid resistance to the drugs

The nurse is gathering data from laboratory studies for a client who has HIV. The client's CD4+ cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse? The client has another infection present that is causing a decrease in the CD4+ cell count. The client has advanced HIV infection. The client has converted from HIV infection to AIDS. The client's CD4+ cell count has decreased due to the pneumocystis pneumonia.

Iodine allergy

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? Inflammation Dysrhythmias Bleeding Iodine allergy

Hypovolemic

The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury? Neurogenic Cardiogenic Septic Hypovolemic

Disseminated intravascular coagulation (DIC)

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Septicemia Stevens-Johnson syndrome from the administration of antibiotics Disseminated intravascular coagulation (DIC)

The difference between the systolic and diastolic pressure

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? The difference between the arterial and venous blood pressure The difference between an upper extremity and lower extremity blood pressure The difference between the systolic and diastolic pressure The difference between an apical and radial pulse

A urinary output of 30 mL/hr

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr

A urinary output of 30 mL/hr

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 100 mL/hr A urinary output of 80 mL/hr A urinary output of 30 mL/hr A urinary output of 10 mL/hr

Frequent and thorough handwashing

The nurse is preparing a teaching plan for a client with an immunodeficiency. What aspect would the nurse emphasize as most important? Adherence to prophylactic medication administration Identifying the signs and symptoms of infection Frequent and thorough handwashing Incorporation of treatment regimens into daily patterns

30 g

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male client. How many grams will the nurse administer? 30 g 15 g 60 g 90 g

3422

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula Puts on clean gloves; removes and discards the soiled dressing in a biohazard container

Shortness of breath

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? Headache Shortness of breath Weight loss Fever

WBC: 42,000/mm3

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? WBC: 42,000/mm3 Hemoglobin: 14.2 g/dL ESR: 19 mm/hour Potassium: 4.8 mEq/L

Occupational and environmental influences Previous history of smoking Previous history of lung disease in the patient or family

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.) Occupational and environmental influences Previous history of smoking Financial ability to pay the bill Social support Previous history of lung disease in the patient or family

semen breast milk blood vaginal secretions

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. urine vaginal secretions blood semen breast milk

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence.

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

"I will be sure to eat lots of fresh fruits and vegetables every day."

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will wash my hands whenever I get home from work." "I will be sure to eat lots of fresh fruits and vegetables every day." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will make sure to have my own toothbrush and tube of toothpaste at home."

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."

The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond? "Your child may die without proper medication and treatment." "Selective immunoglobulin A deficiency is the term used to describe the early stages of AIDS." "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract." "If left untreated, selective immunoglobulin A deficiency can cause uncontrolled muscle movements with progressive neurologic deterioration."

60 mm Hg

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 90 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg

"Your immune system was most likely affected by an underlying disease process."

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency. "Your condition will predispose you to frequent and recurring infections." "You will now be more likely to develop cancer in the future." "Your diagnosis was inherited." "Your immune system was most likely affected by an underlying disease process."

Compartment syndrome.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? Infection. Compartment syndrome. Phlebitis. Chronic venous insufficiency.

Administer medication, as ordered, for the reported discomfort.

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate? Do nothing because it isn't possible to have pain in a missing limb. Contact the health care provider. Administer medication, as ordered, for the reported discomfort. Initiate a consult with a psychologist.

No tenderness during palpation

Upon palpation of the sinus area, what would the nurse identify as a normal finding? No tenderness during palpation Light not going through the sinus cavity Tenderness during palpation Pain sensation behind the eyes

Roll the client in a blanket

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy

Aspiration pneumonia

Which is a potential complication of a low pressure in the endotracheal tube cuff? Tracheal ischemia Aspiration pneumonia Pressure necrosis Tracheal bleeding

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

Which is a true statement regarding air pressure variances? The thoracic cavity becomes smaller during inspiration. Air flows from a region of lower pressure to a region of higher pressure during inspiration. Air is drawn through the trachea and bronchi into the alveoli during inspiration. The diaphragm relaxes during inspiration.

Venturi mask

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Nasal cannula Partial-rebreathing mask T-piece Venturi mask

To keep fire and smoke from airway

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To keep fire and smoke from airway To prevent collapse and further injuries To extinguish flames more quickly To promote blood flow to the brain and vital organs

Cytomegalovirus

Which microorganism is known to cause retinitis in people with HIV/AIDS? Cryptococcus neoformans Cytomegalovirus Pneumocystis carinii Mycobacterium avium

Removing all external sources of pressure, such as clothing and jewelry

Which nursing intervention is essential in caring for a client with compartment syndrome? Starting an I.V. line in the affected extremity in anticipation of venogram studies Wrapping the affected extremity with a compression dressing to help decrease the swelling Keeping the affected extremity below the level of the heart Removing all external sources of pressure, such as clothing and jewelry

Absent distal pulses

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? Absent distal pulses Urge to cough Difficulty in breathing Hematoma

Emphysema

Which of the following disease processes cause increased compliance? Pulmonary fibrosis Acute respiratory distress syndrome Pulmonary edema Emphysema

Disseminated intravascular coagulation (DIC)

Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? Fat embolism syndrome (FES) Avascular necrosis (AVN) Disseminated intravascular coagulation (DIC) Complex regional pain syndrome (CRPS)

It compromises wound healing and immunocompetence.

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It maximizes the risk of impaired ventilation. It maximizes the risk of sodium retention and hypotension. It compromises dexterity and mobility.

Kaposi's sarcoma

Which of the following is the most common HIV-related malignancy? Kaposi's sarcoma B-cell lymphoma Cervical carcinoma Pancreatic carcinoma

Hypotension Tachycardia Anxiety

Which of the following is to be expected soon after a major burn? Select all that apply. Tachycardia Hypotension Anxiety Hypertension Bradycardia

"My brother got sick like me after eating the same food."

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning? "I've been feeling sick to my stomach for about 3 or 4 days now." "I have a pain in my left side, down low near my groin." "The food I ate seemed to look and taste like it should." "My brother got sick like me after eating the same food."

Silver nitrate solution

Which of the following topical burn preparations act as wick for sodium and potassium? Acticoat Silver nitrate solution Silver sulfadiazine (Silvadene) Mafenide acetate (Sulfamylon)

Difficulty lying on affected side

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Minimal pain with movement Increased ability to stretch arm over the head Difficulty lying on affected side Pain worse in the morning

liquids

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS? Gluten Liquids Sucrose Iron and zinc

Nonrebreathing mask

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Heightened anxiety phase

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? Acute disorganization phase Denial phase Heightened anxiety phase Reorganization phase

Modified Trendelenburg

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? Modified Trendelenburg Semi-Fowler's Supine Prone

Liver

Which solid organ is most frequently injured in a penetrating trauma? Lung Pancreas Brain Liver

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "Because I had a previous reaction to the test, this time I need to get a chest X-ray." "I will avoid contact with my family until I am done with the test." "If the test area turns red that means I have tuberculosis." "I will come back in 1 week to have the test read."

Crush injuries

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery? Penetrating abdominal injuries Intra-abdominal injuries Blunt trauma Crush injuries

Nonunion

Which term refers to the failure of fragments of a fractured bone to heal together? Dislocation Subluxation Malunion Nonunion

Full-thickness

Which type of burn injury requires skin grafting? Full-thickness Superficial partial-thickness Superficial Deep partial-thickness

Incomplete

Which type of fracture involves a break through only part of the cross-section of the bone? Oblique Open Incomplete Comminuted

Compound

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone? Compound Complete Simple Incomplete

hyperbaric

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure? Low-flow systems Transtracheal High-flow systems hyperbaric

Anaphylactic

Which type of shock occurs from an antigen-antibody response? Septic Anaphylactic Cardiogenic Neurogenic

Volume cycled

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative pressure Volume cycled Time cycled Pressure cycled

Dead Space

Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus? Silent unit Normal perfusion-to-ventilation ratio Low ventilation-perfusion ratio Dead space

Intermittent mandatory ventilation (IMV)

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Intermittent mandatory ventilation (IMV) Pressure support Assist control Synchronized intermittent mandatory ventilation (SIMV)

A nurse washes her hands before beginning client care.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? A highly virulent organism is present. Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. A nurse washes her hands before beginning client care. Host defenses are impaired.

The tissues give a crackling sensation when palpated.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? The tissues give a crackling sensation when palpated. Skin around tube is pink. Absence of bloody drainage in the anterior/upper tube Bloody drainage is observed in the collection chamber.

See if there are leaks in the system.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if a kink has developed in the tubing. See if the wall suction unit has malfunctioned. See if there are leaks in the system. See if the chest tube is clogged.

Encourage increased fluid intake.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Encourage increased fluid intake. Offer nutritious snacks 2 times a day. Place client on bed rest. Give antibiotics as ordered.

Circulatory (distributive)

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Hypovolemic Circulatory (distributive) Obstructive Carcinogenic

Progressive loss of lung function associated with chronic disease

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? Progressive loss of lung function associated with chronic disease Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function with history of normal lung function

Substernal pain Dyspnea Fatigue

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. Bradycardia Dyspnea Mood swings Substernal pain Fatigue

encourage coughing and deep breathing.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: encourage coughing and deep breathing. report fluctuations in the water-seal chamber. milk the chest tube every 2 hours. clamp the chest tube once every shift.

The sternum protrudes and the ribs are sloped backward.

An client is described as having pectus carinatum. What would be the physical manifestation of this condition? The sternum is depressed from the second intercostal space. The thoracic and lumbar spine have a lateral S-shaped curvature. The sternum protrudes and the ribs are sloped backward. The chest is rounded, ribs are horizontal, and sternum is pulled forward.

pneumonectomy.

In general, chest drainage tubes are not used for a patient undergoing lobectomy. wedge resection. segmentectomy. pneumonectomy.

The only complete cartilaginous ring in the larynx

In relation to the structure of the larynx, which describes the cricoid cartilage? The largest of the cartilage structures Used with the thyroid cartilage in vocal cord movement The only complete cartilaginous ring in the larynx The valve flap of cartilage that covers the opening to the larynx during swallowing

Chest tube drainage, 190 mL/hr

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Moderate amounts of colorless sputum Heart rate, 112 bpm Pain of 5 on a 1-to-10 scale Chest tube drainage, 190 mL/hr

"Ventilation is the movement of air in and out of the respiratory tract."

The nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement? "Ventilation is the process of getting oxygen to the cells." "Ventilation is the movement of air in and out of the respiratory tract." "Ventilation is the exchange of gases in the lung." "Ventilation is the process of gas exchange."

stretched or pulled beyond its capacity

A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"? injury resulting from a blow or blunt trauma subluxation of a joint stretched or pulled beyond its capacity injuries to ligaments surrounding a joint

Apply a dressing over the wound and tape it on three sides.

A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Prepare a chest tube insertion tray. Prepare to start an I.V. line. Apply a dressing over the wound and tape it on three sides.

escharotomy

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? allograft silvadene application escharotomy debridement

Urgent

Which category of triage encompasses clients with serious health problems that are not immediately life threatening? Emergent Nonurgent Psychological support Urgent

Aortic insufficiency

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Hypertension Aortic insufficiency Diabetes mellitus Unstable angina pectoris

"Brightly colored clothes help to ward off bees."

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "If a bee comes near me, I should stay still." "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "I need to avoid using perfumes and scented soaps when I'm going outside."

Dull

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? Tympanic Resonant Dull Hyperresonant

Intubate the client and control breathing with mechanical ventilation

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery Increase oxygen administration

The health care provider can have a polymerase chain reaction test run.

A client diagnosed with human immunodeficiency virus (HIV) asks how the health care provider determines what his or her viral load is. What is the nurse's best response? The health care provider can have a sedimentary rate run. The health care provider can have a basic metabolic panel run. The health care provider can have an ELISA test run. The health care provider can have a polymerase chain reaction test run.

Oxygen at 2 L/min by nasal cannula

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Morphine 2 mg intravenously Dopamine (Intropin) intravenous solution Oxygen at 2 L/min by nasal cannula NS at 60 mL/hr via an intravenous line

Oxygen at 2 L/min by nasal cannula

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution Oxygen at 2 L/min by nasal cannula Morphine 2 mg intravenously

Modified Trendelenburg

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? Semi-Fowler's Modified Trendelenburg Trendelenburg Supine

full thickness (third degree)

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? superficial (first degree) full thickness (third degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree

Lungs are clear on auscultation.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? Respiratory rate is 12 to 18 breaths per minute. Client can perform incentive spirometry. Client reports no chest pain. Lungs are clear on auscultation.

60; 50

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 60; 50 60; 40 75; 40 75; 50

Significant

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: Not significant Negative Significant Nonreactive

Fat embolism

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? Compartment syndrome Infection Fat embolism Volkmann's ischemic contracture

6 to 12 months

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 1 to 3 weeks 2 to 4 months 3 to 5 days 6 to 12 months

Headache

Which condition is an early manifestation of HIV encephalopathy? Vacant stare Hallucinations Headache Hyperreflexia

CVID

Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction? CVID Hyperimmunoglobulinemia E syndrome Wiskott-Aldrich syndrome Ataxia-telangiectasia

Ribonucleic acid (RNA)

Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material? Glycoprotein envelope Deoxyribonucleic acid (DNA) Viral core Ribonucleic acid (RNA)

Absence of breath sounds in the right thorax

On auscultation, which finding suggests a right pneumothorax? Bilateral pleural friction rub Bilateral inspiratory and expiratory crackles Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax

History of diabetes

Which factor inhibits fracture healing? Increased vitamin D and calcium in the diet Age of 35 years Immobilization of the fracture History of diabetes

Famotidine (Pepcid) Nizatidine Lansoprazole

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. Nizatidine Famotidine (Pepcid) Lansoprazole Furosemide Desmopressin

Acute respiratory distress syndrome

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Tracheobronchitis Bronchitis Lung cancer

Septic

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Neurogenic Anaphylactic Cardiogenic Septic

Respiratory distress

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Masses in pleural space Respiratory distress Loss of consciousness Watery sputum

Skin grafting will be necessary.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? The wound will take up to 3 weeks to heal. Pain management will be a challenge. Ligaments, tendons, muscles, and bone are not involved. Skin grafting will be necessary.

The nursing assistant is pouring a glass of water to wet the client's mouth.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? The nursing assistant is pouring a glass of water to wet the client's mouth. The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is assisting the client to the side of the bed to use a urinal. The nursing assistant is asking a question requiring a verbal response.

Younger than 20

The majority of patient with primary immunodeficiency are in which age group? 20 to 40 Younger than 20 51 to 60 41 to 50

decreased catabolism

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote increased glucose demands. decreased catabolism. increased skeletal muscle breakdown. increased metabolic rate.

Asthma

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? Pneumothorax Adult respiratory distress syndrome Asthma Acute respiratory obstruction

Circulatory hypoxia

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Histotoxic hypoxia Hypoxemic hypoxia Anemic hypoxia Circulatory hypoxia

pleural friction rub.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as sibilant wheezes. pleural friction rub. crackles. sonorous wheezes.

Do not flex the hip more than 90 degrees.

The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? Do not flex the hip more than 30 degrees. Do not flex the hip more than 90 degrees. Do not flex the hip more than 60 degrees. Do not flex the hip more than 120 degrees.

Narrowed pulse pressure

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? Increase in diastolic pressure Decrease in respiratory rate Increase in systolic blood pressure Narrowed pulse pressure

Hypovolemic

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? Hypovolemic Anaphylactic Neurogenic Cardiogenic

Diagnosis of peripheral vascular disease

The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? Reduced lighting in the room Increased temperature of the room Diagnosis of peripheral vascular disease Placement of the probe on an earlobe

Run a normal saline line to keep the vein open

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Run a normal saline line to keep the vein open Start a dextrose 5% water infusion Obtain a blood culture from the IV insertion site Remove the peripheral IV line

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

Encourage breathing exercises

Which intervention does a nurse implement for clients with empyema? Institute droplet precautions Encourage breathing exercises Do not allow visitors with respiratory infections Place suspected clients together

Contact the primary care provider and prepare for an escharotomy.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Elevate the leg on pillows and reassess the leg in 1 hour. Contact the primary care provider and prepare for an escharotomy. Document the findings and instruct the client to report numbness of the extremity. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Assess pulse and blood pressure

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Assess pulse and blood pressure. Administer prescribed pain medication. Lay the client's head to a flat position. Notify the physician.

Apply firm pressure over the involved area or artery.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Elevate the injured part. Immobilize the area to control blood loss. Apply firm pressure over the involved area or artery.

5% albumin

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? 6% dextran 6% hetastarch Blood products 5% albumin

Take deep breaths and cough forcefully.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? Tickle the back of the throat to produce the gag reflex. Take deep breaths and cough forcefully. Drink 8 oz of water to thin the secretions for expectoration. Use the secretions present in the oral cavity.

Fibrotic changes in lungs

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? Hemorrhage Lung contusion Fibrotic changes in lungs Damage to surrounding tissues

Production of antidiuretic hormone and corticosteroid hormones

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body? Release of catecholamines Secretion of epinephrine and norepinephrine Activation of renin-angiotensin-aldosterone system Production of antidiuretic hormone and corticosteroid hormones

tidal volume.

The term for the volume of air inhaled and exhaled with each breath is expiratory reserve volume. tidal volume. vital capacity. residual volume.

viral set point.

The term used to define the amount of virus in the body after the initial immune response subsides is primary infection stage. viral clearance rate. viral set point. window period.

avascular necrosis

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? shock avascular necrosis fat embolism pulmonary embolism

Auscultation

What assessment method would the nurse use to determine the areas of the lungs that need draining? Auscultation Inspection Arterial blood gas (ABG) levels Chest X-ray

Ventilation is the movement of air in and out of the respiratory tract.

What is the difference between respiration and ventilation? Ventilation is the movement of air in and out of the respiratory tract. Ventilation is the process of getting oxygen to the cells. Ventilation is the exchange of gases in the lung. Ventilation is the process of gas exchange.

increase cardiac output

What is the major clinical use of dobutamine? increase cardiac output. treat hypertension. treat hypotension. prevent sinus bradycardia.

Producing sound

What is the primary function of the larynx? Facilitating coughing Producing sound Preventing infection Protecting the lower airway from foreign objects

463 and humidify inspired air

What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Moisten and filter expired air Move mucus to the back of the throat Cool and dry expired air 463 and humidify inspired air

Draining secretions, air, and blood from the thoracic cavity is necessary.

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Compare the client's palm with the size of the burn wound

What quick assessment technique should the nurse use to assess the percentage of burn injury? Compare the client's palm with the size of the burn wound Observe the client's level of consciousness Observe the color of the client's wound Check the client's vital signs

Bone marrow transplantation

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? Removal of the thymus gland Radiation therapy Antibiotics Bone marrow transplantation

Hoarseness of the voice

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Urine output of 70 ml the first hour Hoarseness of the voice Moderate to severe pain Complaints of intense thirst

Cherry red skin color

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? Headache Palpitations Confusion Cherry red skin color

Orthopnea

When assessing a client, which adaptation indicates the presence of respiratory distress? Orthopnea Productive cough Sore throat Respiratory rate of 14 breaths per minute

Hypercapnia, hypoventilation, and hypoxemia

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypotension, hyperoxemia, and hypercapnia Hypercapnia, hypoventilation, and hypoxemia

HIV-1 is more prevalent than HIV-2 subtypes

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? the fact that it is a mutated virus originally thought to be bovine in nature cure rate means of transmission HIV-1 is more prevalent than HIV-2 subtypes

Positioning the hands in the midline slightly above the umbilicus

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Placing the thumb side of one hand at the xiphoid process Positioning the hands in the midline slightly above the umbilicus Having the conscious client lie down Using a sequence of four thrusts, each progressing in intensity

1

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? 4 1 2 3

Administer bronchodilator as ordered.

Which action should the nurse take first in caring for a client during an acute asthma attack? Obtain arterial blood gases. Administer bronchodilator as ordered. Send for STAT chest x-ray. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

Respiratory or urinary system infections

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy? Rheumatoid arthritis Depression, memory impairment, and coma Cardiac dysrhythmias and heart failure Respiratory or urinary system infections

Vascular lesions

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis? Vascular lesions Thrush Thrombocytopenia Eczema

Column B

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? Column A Column B Column C Column D

Enzyme immunoassay (EIA)

Which blood test confirms the presence of antibodies to HIV? Enzyme immunoassay (EIA) p24 antigen Erythrocyte sedimentation rate (ESR) Reverse transcriptase

Abstain from food for at least 6 hours before the procedure.

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? Abstain from food for at least 6 hours before the procedure. Avoid atropines as they dry the secretions. Practice holding the breath for short periods. Avoid sedatives or narcotics as they depress the vagus nerve.