PP2 Exam 1

SATA the nurse is assessing a pregnant 16-year-old client. which factors associated with adolescent pregnancy would the nurse consider when developing a plan on care for this client? a. higher rate of postpartum depression b. inappropriate dietary choices c. higher rate of anemia d. incomplete bone mass e. undeveloped secondary sex characteristics

a, b, c, d

SATA when preparing a child with asthma for discharge, which instructions would the nurse emphasize to the family? a. limit allergens in the home b. maintain a dry home environment c. avoid placing limits on the child's behavior expectations d. continue the medications even if the child is asymptomatic e. prevent exposure to infection by having the child tutored at home

a, d

which client in the pulmonary clinic will the nurse plan to teach about pulmonary functioning? a. client who has Chronic Obstructive Lung Disease (COPD) b. client who is being evaluated for lung histoplasmosis c. client who is recovering after pulmonary embolism d. client who has had positive tuberculosis skin testing

a. client who has Chronic Obstructive Lung Disease (COPD)

when caring for a client with chronic obstructive pulmonary disease (COPD) exacerbation and an oxygen saturation of 87%, which prescribed action by the health care provider would the nurse question? a. infuse 5% dextrose in 0.45 saline at 50mL/hour b. administer oxygen at no more than 3L/minute c. assist the client to sit up at the bedside for meals d. give ibuprofen 400mg every 6 hours PRN pain or fever

b. administer oxygen at no more than 3L/minute

which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? a. prevents bronchial spasm b. decreases air trapping in lung c. improves alveolar surface area d. strengthens diaphragmatic contraction

b. decreases air trapping in lung

which diagnostic test would be most useful in evaluating the effectiveness of treatment for asthma? a. chest x-ray b. pulmonary function tests c. serum eosinophil counts d. immunoglobulin E levels

b. pulmonary function tests

which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? a. respiratory acidosis b. respiratory alkalosis c. respiratory compensation d. respiratory decompensation

b. respiratory alkalosis

a 60-year-old client with gastric cancer has shiny tongue, paresthesias of the limbs, and ataxia. the laboratory results show cobalamin levels of 125 pg/mL. which medicaiton would the nurse expect to be prescribed for the client? a. oral hydroxyurea b. vitamin b 12 injections c. oral iron supplements d. erythropoietin injections

b. vitamin b 12 injections

the nurse performs a respiratory assessment and auscultates high-pitched, creaking, and accentuated breath sounds on expiration. which term describes the findings? a. rhonchi b. wheezes c. pleural friction rub d. bronchovesicular

b. wheezes

SATA which assessment findings would indicate a possible asthma exacerbation? a. fever b. stridor c. wheezing d. tachycardia e. hypotension

c, d

SATA diagnosed with COPD, a 50-year-old client's clinical data after treatment is: heart rate of 100 beats/min, BP of 138/82 mm Hg, RR of 32 breaths/min, tympanic temp. 98.2, and O2 sat of 80%. which vital sign obtained by the nurse indicates a positive outcome? a. radial pulse: 70 beats/min b. temperature: 98.6 c. respiratory rate: 14 breaths/min d. blood pressure: 110/70 mm Hg e. oxygen sat: 92%

c, d, e

the school nurse recommends suitable physical activity for a child with exercise-induced asthma. which statement by a parent indicates the need for additional teaching? a. ' i'll sign him up for swimming lessons' b. 'she'd really enjoy being on a bowling team' c. ' i'll encourage him to join a youth running club' d. ' i know she'd enjoy going to the gym and lifting weights'

c. ' i'll encourage him to join a youth running club'

when a client is seen in the ED with sudden onset severe dyspnea, coughing, and wheezes, which prescribed treatment would the nurse administer first? a. inhaled corticosteroid b. normal saline infusion c. albuterol via nebulizer d. intravenous methylprednisolone

c. albuterol via nebulizer

the nurse is caring for a client admitted with COPD. which laboratory test would the nurse monitor for hypoxia? a. red blood cell count b. sputum culture c. arterial blood gas d. hemoglobin

c. arterial blood gas

when a client is newly diagnosed with COPD, which action by the nurse has the highest priority? a. teach the client how to use the prescribed inhalers b. discuss the normal progression of the disease process c. ask whether the client is interested in quitting smoking d. explain the purpose of a pulmonary rehabilitation program

c. ask whether the client is interested in quitting smoking

which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery? a. implement postural drainage b. encourage pursed-lip breathing c. assist with incentive spirometry d. teach sustained exhalation

c. assist with incentive spirometry

which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds? a. thalassemia b. lead poisoning c. iron deficiency d. sickle shape of blood cells

c. iron deficiency

a child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. which intervention would be a priority for the nurse? a. having the child rest as much as possible b. checking the child's eosinophil count daily c. preventing exposure of the child to infection d. offering sips of water when administering the medication

c. preventing exposure of the child to infection

which laboratory result of a client with chronic bronchitis would be most important for the nurse to communicate to the health care provider? a. PaO 2 75 mm Hg b. PaCO 2 48 mm Hg c. hematocrit 52% d. leukocytes 16,000 mm 3

d. leukocytes 16,000 mm 3

which intervention would the nurse implement for a client admitted for an exacerbation of asthma? a. determine the client's emotional state b. give prescribed medications to promote bronchiolar dilation c. provide education about the effect of a family history d. encourage the client to use an incentive spirometer routinely

b. give prescribed medications to promote bronchiolar dilation

which finding in a client with asthma exacerbation requires the most rapid action by the nurse? a. report of chest tightness b. heart rate of 112 beats per minute c. expiratory wheezes in both lungs d. markedly decreased breath sounds

d. markedly decreased breath sounds

which client statement demonstrates an understanding of cyanocobalamin prescribed for pernicious anemia? a. "i should have a vitamin B12 injection every month" b." i'll take vitamin B12 supplements every morning with my breakfast" c. " i'll eat a diet high in green vegetables" d. " i will increase me intake of processed foods fortified with vitamin B12"

a. "i should have a vitamin B12 injection every month"

a client is admitted to the hospital with a diagnosis of COPD. which action would the nurse take to prevent client fatigue? a. provide small, frequent meals b. encourage pursed-lip breathing c. schedule nursing activities to allow rest d. encourage bed rest until energy level improves

c. schedule nursing activities to allow rest

which medication would cause the nurse to monitor a client closely for hemolytic anemia? a. tacrolimus b. methyldopa c. azathioprine d. procainamide

b. methyldopa

which finding would be of most concern when the nurse assesses a client with emphysema? a. barrel chest b. oral cyanosis c. pursed-lip expiration d. respirations 26 breaths per minute

b. oral cyanosis

SATA which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? a. mold b. cold air c. pet dander d. air pollution e. cigarette smoke

a, b, c, d, e

a client is admitted to the hospital with chronic asthma. which complication would the nurse monitor in this client? a. atelectasis b. pneumothorax c. pulmonary edema d. respiratory alkalosis

a. atelectasis

which laboratory test result would the nurse expect to be decreased in a client with iron-deficiency anemia? a. ferritin level b. platelet count c. white blood cell count d. total iron-binding capacity

a. ferritin level

which insect or arthropod is a common trigger for children with asthma? a. spider b. centipede c. carpenter ant d. household cockroach

d. household cockroach

the nurse is teaching pursed-lip breathing to a client with COPD. the client asks about the benefit of the exercises. which explanation would the nurse give? a. prevents complications that are associated with COPD b. relieves shortness of breath by increasing the breath rate c. increases the amount of air that the client can inhale with each breath d. keeps the airway open longer to decrease the work that goes into breathing

d. keeps the airway open longer to decrease the work that goes into breathing

which statement by the student nurse demonstrates correct understanding of anemia related to chronic disease? a. "red blood cells are normal in size and color; however, the number of cells produced is decreased" b." RBC indices are usually low, indicating a need for oral iron supplementation" c. "administration of vitamins B 12 and folate will help treat this type of long-term anemia" d. "this is the mildest form of anemia and is easily corrected through administration of blood products"

a. "red blood cells are normal in size and color; however, the number of cells produced is decreased"

the nurse teaches a client with chronic obstructive pulmonary disease (COPD) and cor pulmonale about nutrition. which instruction would the nurse include? a. eat small meals six times a day to limit oxygen needs b. drink large amounts of fluid to help liquefy secretions c. lie down after eating to conserve energy needed for digestion d. increase the intake of protien to decrease intravascular hydrostatic pressure

a. eat small meals six times a day to limit oxygen needs

the nurse is caring for a school-aged child with cystic fibrosis. which pathophysiologic factor has the greatest effect on the child's health status? a. extremely thick mucus causing obstructive airway b. acute inflammation of the lung parenchyma c. endocrine glands secreting increased levels of hormones d. increased irritability of the airways resulting in obstruction

a. extremely thick mucus causing obstructive airway

which laboratory finding of a pregnant client would alert the nurse to the need for further assessment? a. hemoglobin 10 g/dL b. urine specific gravity of 1.020 c. glucose level of 1+ in the urine d. white blood cell count of 9000/mm

a. hemoglobin 10 g/dL

a client with COPD reports chest congestion, especially upon awakening in the morning. to address the concern, the nurse would make which suggestion? a. use a clean and disinfected humidifier in the bedroom b. sleep with two or more pillows c. cough regularly even if the cough does not produce sputum d. cough and deep-breathe each night before going to sleep

a. use a clean and disinfected humidifier in the bedroom

which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? a. is able to obtain pulse oximeter readings b. demonstrates use of a metered-dose inhaler c. knows the health care providers office hours d. can identify triggers that may cause wheezing

b. demonstrates use of a metered-dose inhaler

which instruction would the nurse give to the pregnant client with anemia? a. take an iron and calcium supplement together daily b. drink orange juice with an iron supplement c. include fresh fruit at every meal d. include 4 servings of calcium-rich foods daily

b. drink orange juice with an iron supplement

a client is hospitalized for an exacerbation of emphysema. the client is experiencing a fever, chills, and difficulty breathing on exertion. which is an important nursing action? a. check for capillary refill b. encouraging increased fluid intake c. suctioning secretions from the airway d. administering a high concentration of oxygen

b. encouraging increased fluid intake

which laboratory value will the nurse review when caring for a client with a megaloblastic anemia? a. serum iron b. folate level c. transferrin level d. platelet count

b. folate level

the nurse is providing hygiene care to an immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). which nursing intervention is priority when the client becomes short of breath during the care? a. obtain a pulse oximeter to determine the client's oxygen saturation level b. put the client in a high fowler position c. darken the lights and provide a rest period of at least 15 min d. continue the hygiene activities while reassuring the client

b. put the client in a high fowler position

a client with COPD is breathing rapidly and using accessory muscles of respiration. the nurse auscultates the lungs and hears crackles and wheezes. which action would the nurse take? a. encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula b. place the client in a side-lying position and perform chest physiotherapy using clapping and vibration c. raise the head of the bed to a high-fowler position and administer 2 L/min oxygen per nasal cannula d. assist the client is assuming a position of comfort and perform postural drainage

c. raise the head of the bed to a high-fowler position and administer 2 L/min oxygen per nasal cannula

which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? a. metabolic alkalosis caused by excessive production of acid metabolites b. respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide c. respiratory acidosis caused by impaired respirations and increased formation of carbonic acid d. metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation

c. respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

a client with an acute emphysema episode is dyspneic and anxious. to decrease the dyspnea, which action would the nurse take? a. increase the client's oxygen intake b. have the client breathe into a paper bag c. teach the client to do pursed-lip breathing d. check the client's vital signs

c. teach the client to do pursed-lip breathing

when the nurse is evaluating the client with an acute asthma attack who has just received a nebulizer bronchodilator treatment, which finding requires the most rapid nursing action? a. labored breathing and absent breath sounds b. continued high-pitched expiratory wheezes c. use of pursed-lip breathing during expiration d. hyper resonance to percussion of posterior chest

a. labored breathing and absent breath sounds

a child with status asthmaticus is admitted to the pediatric intensive care unit. which would the nurse include in the plan of care as the child starts to recover from the episode? a. maintain the high-fowler position b. restrict fluids to two thirds of the usual intake c. keep droplet precautions in place for 24 hrs d. administer the prescribed prophylactic antibiotic

a. maintain the high-fowler position

when assessing the breath sounds of a client with COPD, the nurse hears the moist rumbling sounds that improve after the client coughs. which term would the nurse use to document the lung sounds? a. rhonchi b. wheezes c. fine crackles d. vesicular sounds

a. rhonchi