NUR 276 Final Possible Questions

A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A. Instruct the woman to call 911. B. Ask the partner if he can speak. C. Use the jaw-thrust maneuver. D. Perform chest compressions.

B. Ask the partner if he can speak.

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. How should the nurse document this finding? A. A systolic murmur B. A third heart sound (S3) C. An expected heart sound D. A fourth heart sound (S4)

A. A systolic murmur

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A. Abnormally prominent U wave

A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia B. Ataxia C. Photosensitivity D. Jaundice

A. Anorexia

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A. Asthma B. Glaucoma C. Depression D. Migraines

A. Asthma

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A. Carvedilol B. Fluticasone C. Captopril D. Isosorbide dinitrate

A. Carvedilol

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? A. Decreased blood pressure B. Increase of HDL cholesterol C. Prevention of bipolar manic episodes D. Improved sexual function.

A. Decreased blood pressure

A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medications should the nurse prepare to administer? A. Fab antibody fragments B. Flumanezil C. Acetylsteine D. Naloxone

A. Fab antibody fragments

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side B. Bubbling of the water in the water seal chamber with exhalation C. Crepitus in the area above and surrounding the insertion site D. Eyelets are not visible

A. Movement of the trachea toward the unaffected side

A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound B. Obtain impedance plethysmography C. Monitor Homan's sign D. Apply cold therapy to the affected leg

A. Obtain a venous duplex ultrasound

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The P wave falls before the QRS complex B. The T wave is in the inverted position C. The P-R interval measures 0.22 seconds D. The QRS duration is 0.20 seconds

A. The P wave falls before the QRS complex Rationale: The P wave falls before the QRS complex. T wave is upright, P-R interval is between 0.12-0.20 seconds. The QRS lasts between 0.04-0.10 seconds

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet.After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? A.Administer another nitroglycerin tablet. B. Initiate a peripheral IV. C. Call the Rapid Response Team. D. Obtain an ECG.

A.Administer another nitroglycerin tablet.

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication? A.Heart rate 46/min B. Oxygen saturation 95% C. Respiratory rate 18/min D. Blood pressure 160/94 mm Hg

A.Heart rate 46/min

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? A. "I flavor my meat with lemon juice." B. "I eat two eggs for breakfast each morning." C. "I cook my food with canola oil." D. "I take an omega-3 supplement daily."

B. "I eat two eggs for breakfast each morning."

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."

B. "I will take my bronchodilators after meals."

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? A. Insert an oral airway. B. Administer the abdominal thrust maneuver. C. Turn the client to the side. D. Perform a blind finger sweep

B. Administer the abdominal thrust maneuver.

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? A. Take aspirin if headaches develop. B. Eat foods that contain plenty of potassium. C. Expect some swelling in the hands and feet. D. Take the medication at bedtime

B. Eat foods that contain plenty of potassium.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis B. Flail chest C. Hemothorax D. Pneumothorax

B. Flail chest

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub

B. Increasing dyspnea

A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position? A. Lateral segment of the left lower lobe B. Lateral segment of the right lower lobe C. Posterior segment of the right middle lobe D. Posterior segment of the right lower lobe

B. Lateral segment of the right lower lobe

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

B. Massaging her legs

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance B. Suppress respiratory effort C. Induce sedation D. Decrease respiratory secretions

B. Suppress respiratory effort

A nurse is teaching a client who has a duodenal ulcer about his new prescription for cimetidine. The nurse should include which of the following instructions in the teaching? A."Take the medication with an antacid to minimize stomach upset." B."Your doctor might need to reduce your theophylline dose while taking this medication." C."Take the medication on an empty stomach for better absorption." D."You should plan to take this medication for at least 6 months."

B."Your doctor might need to reduce your theophylline dose while taking this medication."

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A.) Rhonchi on inspiration B.) Elevated temperature C.) Barrel-shaped chest D.) Diminished breath sound

B.) Elevated temperature

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? A. Positive Kernig's sign B. Positive Homan's sign C. Dull, aching calf pain D. Soft, pliable calf muscle

C. Dull, aching calf pain

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promotor thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer

C. Encourage the client to increase fluid intake

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine

C. Heparin

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

C. Hip arthroplasty

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature

C. Increased heart rate

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administrating this medication, which of the following actions should the nurse take? A. Offer the client a light snack. B. Measure the client's blood pressure C. Measure the client's apical pulse D. Weigh the client

C. Measure the client's apical pulse

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's blood pressure B. Auscultate heart tones C. Perform a 12-lead ECG D. Determine if pain radiated to the left arm

C. Perform a 12-lead ECG

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following adverse reactions to this medication? A. Ototoxicity B. Tachycardia C. Postural Hypotension D. Hypokalemia

C. Postural Hypotension

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll rinse my mouth after taking this medication." B. "I'll take this medication when I get an asthma attack." C."I'll take this medication once a day in the evening." D."I'll use a spacer device when I inhale this medication."

C."I'll take this medication once a day in the evening."

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? A. "I can walk a mile a day." B. "I've had a backache for several days." C. "I am urinating more frequently." D. "I feel nauseated and have no appetite."

D. "I feel nauseated and have no appetite."

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.

D. Administer oxygen via nasal cannula.

nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn via metered-dose inhaler B. Montelukast orally C. Budesonide via dry-powder inhaler D. Albuterol via jet nebulizer

D. Albuterol via jet nebulizer

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel

D. Barrel

A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which topic should the nurse include as a modifiable risk factor? A. Diagnosis of diabetes mellitus B. Family history of cardiac disease C. Increasing age D. Cigarette smoking

D. Cigarette smoking

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion

D. Confusion

A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? A. Blurred vision B. Palpitations C. Constipation D. Depression

D. Depression

8. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal Retractions

D. Intercostal Retractions

60.A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position

D. Place in a prone position

A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline(Theo 24). The nurse should tell the client that this medication might cause which of the following adverse effects? A. Drowsiness B. Constipation C. Oliguria D. Tachycardia

D. Tachycardia

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? (Select all that apply)

Forehead Bridge of nose Earlobe

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Frothy sputum

The nurse collecting date from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Shortness Of Breath while lying down

The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?

Uses garlic as a cholesterol lowering agents.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) a. Dyspnea b. Bradycardia c. Barrel chest d. Clubbing of the fingers e. Deep respirations

a. Dyspnea c. Barrel chest d. Clubbing of the fingers

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? a. "if my breathing begins to feel tight, I will use the cromolyn immediately." b. "I will be sure to take the albuterol before taking the cromolyn." c. "I will use both medications immediately after exercising." d. "I will administer the medications 10 minutes apart."

b. "I will be sure to take the albuterol before taking the cromolyn."

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instruction should the nurse provide the client's parent on administering the medication? a. Give the medication in the morning daily b. Administer the medication 2 hr before exercise c. Give the medication at the onset of wheezing d. administer the granules mixed with 20 oz of water.

b. Administer the medication 2 hr before exercise

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

B. Administer oxygen therapy.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity

B. Elevated central venous pressure (CVP).

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." B. "Use the incentive spirometer every 4 hr after the tube is removed." C. "Avoid speaking for long periods." D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed."

C. "Avoid speaking for long periods."

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."

C. "I will follow a daily diet high in calories and protein."

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A. "I am gaining weight." B. "I am constipated" C. "My vision seems yellow." D. "My tongue is red and beefy"

C. "My vision seems yellow."

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.

C. Preoxygenate the client with 100% oxygen for up to 3 min.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? A. Sedation B. Increased appetite C.White coating in the mouth D.Dry oral mucous membranes

C.White coating in the mouth

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Continue to monitor the client's respiratory status.

D. Continue to monitor the client's respiratory status.

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? A. Chest tube eyelets not visible B. Continuous bubbling in the suction control chamber C. Presence of tidal fluctuation in the water seal chamber D. Development of subcutaneous emphysema

D. Development of subcutaneous emphysema

A nurse is caring for a client who has a valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition> A. Anorexia B. Weight gain C. Breathlessness D. Distended abdomen

C. Breathlessness

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs. B. Request a dietitian consult. C. Suggest that the client rests before eating the meal. D. Request an order for an antiemetic.

A. Check the client's vital signs.

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

A. Chicken breast and corn on the cob

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every 12 hr

C. 0.9% normal saline IV at 50 mL/hr continuous

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. Increase the oxygen flow to 3 L/min. B. Assess the client's respiratory status. C. Call emergency services for the client. D. Have the client cough and expectorate secretions.

B. Assess the client's respiratory status.

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? A. Withholding the medication if the heart rate is above 100/min B. Instructing the client to eat foods that are low in potassium C. Measuring apical pulse rate for 30 seconds before administration D. Evaluating the client for nausea, vomiting, and anorexia

D. Evaluating the client for nausea, vomiting, and anorexia

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.

D. Instruct the client to use pursed-lip breathing.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions

D. Intercostal retractions

15.A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times. D. Empty the collection chamber prior to transport.

C. Keep the drainage system below the level of the client's chest at all times.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A. Auscultate lung fields B. Assess pulse and respirations. C. Assess characteristics of her sputum. D. Instruct to slowly exhale with pursed lips.

A. Auscultate lung fields

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A. Oral mucosa B. Conjunctivae C. Ear lobes D. Soles of the feet

A. Oral mucosa

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority? A. Provide the client with supplemental oxygen at 5 L/min via facemask. B. Place the client in high-Fowler's position with their legs in a dependent position. C. Give the client sublingual nitroglycerin. D. Administer morphine sulfate IV.

A. Provide the client with supplemental oxygen at 5 L/min via facemask.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub C. The third heart sounds (S3) D. A split second heart sound (S2)

A. The fourth heart sound (S4) Rationale: extra sound that is heard late in diastole just before S1. Occurs due to resistance to blood flow in an enlarged ventricle.

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? A. "Eat 3 large meals each day." B. "Limit water intake with meals." C. "Reduce protein intake." D. "Use a bronchodilator 1 hour before eating."

B. "Limit water intake with meals."

A nurse is caring for a client who reports a new onset of chest pressure severe epigastric distress. The physician prescribed monitoring of creatine kinase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a myocardial infarction (MI)? SATA A. 1 hr. B. 2 hr. C. 3 hr. D. 24 hr

B. 2 hr. C. 3 hr.

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client has a history of hypothyroidism. B. The client has a history of bronchial asthma. C. The client has a history of hypertension. D. The client has a history of migraine headaches.

B. The client has a history of bronchial asthma.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

C. Agitation

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant

C. Encourage the use of an incentive spirometer

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning

C. Performing the procedure independently

A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? A. Consume a high-protein diet. B. Administer the medication with food. C.Avoid caffeine while taking this medication. D.Increase fluids to 1L/per day.

C.Avoid caffeine while taking this medication.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction. B. Strip the client's chest tube. C. Clamp the client's chest tube. D. Reposition the client.

D. Reposition the client.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? a. Finger b. Earlobe c. Toe d. Skin fold

b. Earlobe

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? A. Administer a short-acting ß2 -agonist (SABA). B. Obtain a peak flow reading. C. Administer an inhaled glucocorticoid. D. Determine the cause of the acute exacerbation.

A. Administer a short-acting ß2 -agonist (SABA).

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what his blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse maker for the client? a. a room with air exhaust directly to the outdoor environment b. a room with another nonsurgical client c. a room in the ICU d. a room that is within view of the nurses' station

a. a room with air exhaust directly to the outdoor environment

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via nasal cannula. Which action should the nurse take? a. attach a humidifier bottle to the base of the flow meter b. Remove the nasal cannula while the client eats c. Secure the oxygen tubing to the bed sheet near the client's head. d. Apply petroleum jelly to the nares as needed to soothe mucous membranes

a. attach a humidifier bottle to the base of the flow meter

A nurse is caring for a patient who is experiencing dyspnea. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which intervention should the nurse complete first? a. Increase the oxygen flow b. Assist the client to Fowler's position c. Promote removal of pulmonary secreations d. Auscultate the client's lung fields

b. Assist the client to Fowler's position

A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care? a. Use aseptic technique b. Clean the inner cannula with mild soap and water c. Secure new tracheostomy ties before removing old ones. d. Apply suction when inserting the catheter

c. Secure new tracheostomy ties before removing old ones.