Reed's 4th and final QUIZ

A client scheduled for a total laryngectomy and radial neck dissection for larynx cancer asks the nurse, " how will I talk after the surgery?" the best response by the nurse is 1, you will have a permanent opening into your neck and need rehabilitation for some voice restoration. 2, You may consider learning sign language for better communication. 3, you should start to write down things you want to communicate, so that it is easier for people around you.

1

QB A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction? 1, Hemolytic 2, Febrile 3, Circulatory overload 4, Sepsis

1 Hemolytic reaction occurs when the client's blood is incompatible with the donor's blood, chills, low back pain, hypotension and tachycardia are indication of a hemolytic transfusion reaction

The nurse found the client had an infiltration on their IV site, and their skin is cool to touch on the site. What should the nurse do after this? 1, Elevate the affected limb above heart level 2, apply Warm compress 3, Apply Cold compress 4, lower the affected limb below the heart level.

1, 2 If the site is WARM to touch, you use a cold compress, and never below the heart, it only slows down the fluid return.

a nurse is assessing a child which of the following are clinical manifestations of epiglottitis? SATA 1, hoarseness and difficulty speaking 2, difficulty swallowing 3, low-grade fever 4, drooling 5, dry barky cough 6, stridor lung sound

1, 2, 4, 6

QB A nurse is assessing a client who is unconscious, the client has a rhythmical breathing pattern of rapid deep respiration followed by rapid shallow respiration, alternating with periods of apnea, the nurse should document that the client is experiencing which of the following type of respiration? 1, Orthopnea 2, Cheyne-stokes 3, Paradoxical 4, kussmaul

2 Cheyne stoke respiration is a breathing pattern of deep to shallow and followed by apnea. it can be a result of a drug overdose or ICP and can precede death.

The nurse found the client stating pain at the Leg, and redness present. What grade should the nurse document this in Phlebitis scale? A, 1 B, 2 c, 3 d, 4

2 Pain at access site with erythema

The nurse found an asthma client exhibiting RR 25, o2 sat 88. What should the nurse do next? 1. raise bed to 40 degree 2, administer oxygen 4 ML via nasal canula 3, administer albuterol 4, call the provider first for a treatment order.

3 EZ right? why do I even bother.. :p

QB A nurse in an ED is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? 1, lethargy 2, spontaneous coughing 3, drooling 4, hoarseness.

3 Epiglottitis is a disorder caused by an inflammation of the epiglottis, which results in rapid swelling of the epiglottis, which can obstruct breathing; drooling is expected finding due to the toddler's inability to swallow saliva.

QBH A nurse is caring for a client who requires an IV insertion. When choosing the site, which of the following sites should the nurse select? 1, select a vein in the client's dominant arm 2 , choose the most proximal vein in the extremity 3, choose a vein that is soft on palpation 4, select a site distal to previous venipuncture attempts.

3 The nurse should select a vein that is soft and had a BOUNCY feeling when pressure is released upon palpation

QB The nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing, which of the following findings is the priority for the nurse to report to the provider? 1. Child temperature is 102 F 2, Child skin is Sallow 3, child is drooling 4, child's voice is hoarse.

3 When using the urgent versus nonurgent approach to the client's care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency left untreated the child can develop a complete respiratory obstruction.

The nurse found the client's leg with present redness with edema streak formation and palpable venous cord, but the dressing is dry, the client also complained burning sensation from the site. what should the nurse document in the Phlebitis scale? A, 1 B, 2 c, 3 d, 4

3 +3 pain at access site with erythema and edema streak formation and palpable venous cord

The nurse caring for a client is receiving IV fluid replacement, which of the following findings should the nurse identify as infiltration of the IV site? 1, redness at the IV catheter entry site 2, palpable cord along the vein used for the infusion 3, taut skin around the iv catheter site that is cool to the touch 4, bleeding at the IV insertion site.

3, taut skin around the IV site is cool to touch might have an infiltration IV site.

The nurse is administering a pack of RBC to a newly anemia-diagnosed client. After 30 mins of transfusion, the nurse found the client shivering, and complaining of lower back pain, upon close assessment client's HR at 140, BP was 87/55. What should the nurse do next? 1, call the provider 2, increase the transfusion rate 3, administer IV lactated ringer. 4, stop transfusion.

4 Pretty sure we all now this one.

QB A nurse observes tachycardia, dyspnea, a cough and distended neck veins in a client who is receiving a transfusion of packed RBC. which of the following interventions should the nurse use to prevent this manifestation with the client's next transfusion? 1, Warm the blood to room temp before administer 2, administer acetaminophen prior to the blood transfusion 3, give an antihistamine prior to the transfusion 4, Use a transfusion pump to regulate and maintain the transfusion at a slower rate.

4 These are manifestations of a hypervolemic reaction due to circulation overload, which occurs when blood transfusion is too rapid for the client's size or status. to prevent this issue with future transfusions, the nurse should use a transfusion pump to regulate the rate at a slower rate.

QB A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy, which of the following statements indicates that the client understands the impact of the surgery? 1, I am not going to be able to cough for a while after the surgery 2, After I recover from anesthesia, I will be able to eat regular food again 3, After the surgery, my voice will gradually return but might be weak 4, I understand that I will have a permanent tracheostomy after the surgery.

4 With a partial laryngectomy, the tracheostomy is temporary. However a total laryngectomy, the tracheostomy will be permanent.