VN440 HW2

A pt with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. To decrease the amount of secretions retained, the nurse plans to: A. Administer continuous O2 B. Instruct the pt to gargle deep in the throat using warmed NS C. Place the pt in a high Fowler position D. Increase fluid intake to at least 2L/day.

Increase fluid intake to at least 2L/day. ***Rationale: Increase fluid intake helps to liquify respiratory secretions, which promotes expectoration.

A nurse reviews a medical record of a pt with ascites. What does the nurse identify that may be causing the ascites? A. Portal hypotension B. Kidney malfunction C. Decreased liver function D. Decreased production of K+

Decreased liver function ***Rationale: A deficit in albumin lowers the osmotic pressure in the intravascular space, leading to a fluid shift.

The nurse reviews a medical record & is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? A. Crohn's B. Cushing's C. End-stage renal D. Gastroesophageal reflux

End-stage renal ***Rationale: One of the kidney's functions is to eliminate K+ from the body. Diseases of the kidney can cause hyperkalemia.

A nurse caring for a post-op pt who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A. Postural drainage B. Cupping the chest C. Nasotracheal suctioning D. Frequent changes of position

Frequent changes of position ***Rationale: Frequent changes of position minimize pooling of respiratory secretions & maximize chest expansion, which aids in the removal of secretions & helps maintain the airway.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this pt? A. Monitor for signs of electrolyte imbalance B. Change the tube at least once every 48 hours C. Connect the NG tube to high continuous suction D. Assess placement by injecting 10mL of water into the tube

Monitor for signs of electrolyte imbalance ***Rationale: Gastric secretions, which are electrolyte rich, are lost through NG tube; imbalances that result can be life threatening.

A nurse is assigned to take care a group of pts. Which pt should the nurse see first? A. A 2-year-old male with diarrhea B. A 35-year-old male who is nauseated C. A 40-year-old female who has vomiting d/t food poisoning D. A 83-year-old female whose last BM was 3 days ago

2-year-old with diarrhea ***Rationale: The 2-year-old will be at higher risk for fluid & electrolyte imbalance d/t higher fluid content of the body & decreased ability to regulate fluid balance, which can be life threatening.

The nurse is monitoring a pt's HgB level. The nurse recalls that the amount of Hgb in the blood has what effect on oxygenation status? A. Expect with rare blood disorders, Hgb seldom affects oxygenation status. B. There are many other factors that impact oxygenation status more than HgB does C. A low HgB level causes reduced oxygen-carrying capacity. D. HgB reflects the body's clotting ability & may or may not impact oxygenation status

A low HgB level causes reduced oxygen-carrying capacity. ***Rationale: HgB carries oxygen to all tissues in the body.

The nurse is caring for a pt admitted with COPD. The nurse should monitor the results of which lab test to evaluate the client for hypoxia? A. RBC B. Sputum culture C. ABG D. Total hemoglobin

ABG ***Rationale: ABG is the only test that evaluates gas exchange in the lungs

A pt is admitted to the hospital with a dx of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? A. Sodium B. Calcium C. Potassium D. Phosphorus

Calcium ***Rationale: The muscle contraction-relaxation cycle requires an adequate serum calcium phosphorus ratio.

A nurse assesses the lungs of a client & auscultates soft, crackling, bubbling breath sounds that ae more obvious on inspiration. This assessment should be documented as: A. Vesicular B. Bronchial C. Crackles D. Rhonci

Crackles ***Rationale: Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli.

A pt who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? A. Crackles in the lungs B. Decreased HR C. Decreased BP D. Cyanosis

Crackles in the lungs ***Rationale: Crackles aka rales in the lungs are an early sign of pulmonary congestion & edema caused by fluid overload.

A pt with a hx of COPD is admitted with acute bronchopneumonia. The pt is in moderate respiratory distress. The nurse should place the pt in what position to enhance comfort? A. Side lying position with head elevated 45 degrees B. Sim's position with head elevated 90 degrees C. Semi-Fowler's position with legs elevated D. High-Fowler's position using the bedside table as an arm rest

High-Fowler's position using the bedside table as an arm rest ***Rationale: High-Fowler's elevates the clavicles & helps the lungs to expand, thus easing respirations.

A nurse is monitoring a pt who is receiving an IV infusion of NS. What is a serious complication of IV tx? A. Bleeding at the infusion site B. SOB with crackles C. Feeling of warmth throughout the body D. Infiltration at the catheter insertion site

SOB with crackles ***Rationale: Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority.

A nurse is caring for a pt for whom segmental postural drainage tx are prescribed. The nurse should avoid scheduling the tx at what time? A. At bedtime B. After a meal C. One hour before a meal D. One hour after awakening

After a meal ***Rationale: Productive coughing induced by postural drainage can cause N&V.

A pt's chest tube has accidentally dislodged. What is the nursing action of highest priority? A. Place the pt in left side-lying position B. Apply O2 via non-rebreather mask C. Apply a petroleum gauze dressing over the site D. Prepare to reinsert a new chest tube

Apply a petroleum gauze dressing over the site ***Rationale: A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax.

A nurse is evaluating the effectiveness of tx for a client with excessive fluid volume. What clinical finding indicates that tx has been successful? A. Clear breath sounds B. Positive pedal pulses C. Normal K+ level D. Increased urine specific gravity

Clear breath sounds ***Rationale: Excess fluid can move into the lungs, causing crackles.

A pt reports nausea, vomiting, & seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon review of the pt's prescribed med list, the nurse determines that what is the likely cause of the clinical findings? A. Digoxin (Lanoxin) B. Furosemide (Lasix) C. Propanolol (Inderal) D. Spironolactone (Aldactone)

Digoxin (Lanoxin) ***Rationale: These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia.

What clinical finding does a nurse anticipate when admitting a pt with an extracellular fluid volume excess? A. Rapid, thready pulse B. Distended jugular veins C. Elevated HCT level D. Increased serum sodium level

Distended jugular veins ***Rationale: Because of fluid overload in the intravascular space, the neck veins become visibly distended.

Pt admitted for dehydration & an IV infusion of NS at 125mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is A. D/C the IV site & contact PCP B. Elevate the head of the bed & obtain VS C. Contact PCP to obtain rx for sedative D. Assess for allergies & change the IV to an intermittent infusion device

Elevate the head of the bed & obtain VS ***Rationale: The pt's ability to speak indicates that the pt is still breathing. Elevate the head of the bed to facilitate breathing by decreasing pressure against the diaphragm.

A pt's IV infusion infiltrates. The nurse concludes that what is MOST likely the cause of the infiltration? A. Excessive height of the IV bag B. Failure to secure the catheter adequately C. Contamination during the catheter insertion D. Infusion of a chemically irritating medication

Failure to secure the catheter adequately ***Rationale: Infiltration is caused by catheter displacement, allowing fluid to leak into the tissues.

A pt is admitted to the hospital with the dx of cancer of the thyroid & a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this pt during the post-op period? A. Hypercalcemia may result from parathyroid damage. B. Hypotension & bradycardia may result from thyroid storm. C. Tetany may result from underdosage of thyroid hormone replacement D. Hoarseness & airway obstruction may result from laryngeal nerve damage.

Hoarseness & airway obstruction may result from laryngeal nerve damage. ***Rationale: Laryngeal nerve injury can cause laryngeal spasms, resulting in airway obstruction.

The pt receives a prescription for tap water enemas until clear. The nurse is aware that no more than 2 enemas should be given at one to prevent A. Hypercalcemia B. Hypocalcemia C. Hyperkalemia D. Hypokalemia

Hypokalemia ***Rationale: Repeated tap water enemas deplete cells & extracellular fluids of potassium & sodium, also resulting in water intoxication.

A pt admitted with a dx of intractable vomiting & can only tolerate sips of water. The initial blood work shows a Sodium level of 122 and Potassium 3.6. Based on the results and symptoms, what is the client experiencing? A. Hypernatremia B. Hyponatremia C. Hyperkalemia D. Hypokalemia

Hyponatremia ***Rationale: Vomiting & the use of diuretics deplete the body of sodium, which can lead to confusion, lethargy, seizures, & coma.

The nurse is caring for a pt who is receiving tx for Vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? A. Normal serum electrolyte levels B. Healthy skin integrity C. Resolution of peripheral edema D. Improved hGb & HCT levels

Improved hGb & HCT levels ***Rationale: Vitamin b12 is essential for appropriate maturation of RBC therefore relieving the deficiency is expected to improve the hGb and HCT

A pt reports vomiting and diarrhea x3 days. What clinical finding MOST accurately will indicate that the client has a fluid deficit? A. Presence of dry skin B. Loss of body weight C. Decrease in BP d. Altered general appearance

Loss of body weight ***Rationale: Dehydration is measured most accurately by serial assessments of body weight; 1L of fluid weighs 2.2lbs.

A pt with a dx of uncontrolled DM began recieving Lasix 2 days ago. The nurse reviews the morning lab results & discovers that the client's Potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? A. Hold the morning dose of the diuretic & have the lab repeat the test B. Continue to monitor the level to ensure that it stays within the normal limits. C. Notify the PCP of the result, which is critically low D. Anticipate a prescription for an increase in the dosage of the Lasix.

Notify the PCP of the result, which is critically low ***Rationale: Clients on diuretics require monitoring of serum electrolytes, especially potassium & sodium because they are excreted with water.

A nurse assesses a pt's serum electrolyte levels in the lab report. What electrolyte in intracellular fluid should the nurse consider MOST important? A. Sodium B. Calcium C. Chloride D. Potassium

Potassium ***Rationale: Potassium concentration is greater inside the cell & is a critical factor in the cell's ability to function.

A pregnant pt with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity? A. Oxygen B. Naloxone C. Calcium gluconate D. Suction equipment

Calcium gluconate ***Rationale: The antagonist of magnesium sulfate is calcium gluconate.

A nurse provides teaching for a pt who is scheduled for a cholecystectomy. In the initial post-op period, the nurse explains that the most important part of the treatment plan is A. Early ambulation B. Coughing & deep breathing C. Wearing anti-embolic elastic stockings D. Maintenance of NG tube

Coughing & deep breathing ***Rationale: The pt who has a cholecystectomy will have difficulty taking deep breaths & coughing because of the location of the surgical incision.

A pt with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: A. Relieve bronchia spasm B. Increase depth of respirations C. Loosen pulmonary secretions D. Expel carbon dioxide from the lungs

Loosen pulmonary secretions ***Rationale: Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means.

What is the PRIORITY nursing intervention for a client during the immediate postoperative period? A. Monitoring VS B. Observing for hemorrhage C. Maintaining a patent airway D. Recording I&O

Maintaining a patent airway ***Rationale: Maintaining a patent airway is ALWAYS the priority because airway obstruction may result in death.

A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli & improved oxygenation? A. The alveoli need oxygen to live. B. The alveoli have no direct effect on oxygenation. C. Collapsed alveoli increase oxygen demands. D. Oxygen is exchanged for carbon dioxide in the alveolar membrane

Oxygen is exchanged for carbon dioxide in the alveolar membrane ***Rationale: The exchange of O & CO occurs in the alveolar membrane. Therefore, if the alveoli collapse, this exchange cannot occur.

What are the clinical indicators that a nurse expects when an IV line has infiltrated? (Select all that apply) A. Heat B. Pallor C. Edema D. Decreased flow rate E. Increased BP

Pallor, edema, & decreased flow rate ***Rationale: The accumulation of fluid in the tissues between the surface of the skin & the blood vessels make the skin appear pale and can cause swelling. As the needle/catheter is dislodged from the vein, the drip rate of the IV slows or ceases.

A nurse is reviewing a plan of care for a pt who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? A. Oral psyllium (Metamucil) B. Oral Potassium supplement C. Parenteral half N.S D. Parenteral albumin (Albuminar)

Parenteral albumin (Albuminar) ***Rationale: Albumin is a hypertonic & will draw additional fluid from the tissues into the intravascular space.

The nurse's physical assessment of a client with heart failure reveals tachypnea & bilateral crackles. What is the priority nursing intervention? A. Initiate O2 tx B. Obtain a CXR immediately C. Place client in a high-Fowler position D. Assess the client for a pleural friction rub

Place client in a high-Fowler position ***Rationale: This position promotes lung expansion & gas exchange. It also decreases venous return & cardiac workload.

A pt with a hx of alcoholism & cirrhosis is admitted with severe dyspnea as a result of ascites. The nurse concludes that the ascites is MOST likely the result of increased A. Secretion of bile salts B. Pressure in the portal vein C. Interstitial osmotic pressure D. Production of serum albumin

Pressure in the portal vein ***Rationale: An enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure & resulting in ascites.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? A. Seizure activity is imminent B. Pulmonary edema has developed C. Bronchial constriction was precipitated by the stress of pregnancy D. Impaired diaphragmatic function was caused by the enlarged uterus.

Pulmonary edema as developed ***Rationale: Pulmonary edema is associated with severe preeclampsia. As vasospasm worsen, capillary endothelial damage results in capillary leakage into the alveoli.

A pt has a paracentesis, and the health care provider removes 1500mL of fluid. To monitor for serious post-procedure complication, the nurse should assess for: A. Dry mouth B. Tachycardia C. Hypertensive crisis D. Increased abdominal distention

Tachycardia ***Rationale: Fluid may shift from the intravascular space to the ABD as fluid is removed, leading to hypovolemia & compensatory tachycardia.

A pt's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? A. Call the lab to repeat test B. Take VS & notify the PCP C. Inform the cardiac arrest team to place them on alert D. Take an EKG & have lidocaine available.

Take VS & notify the PCP ***Rationale: Hyperkalemia causes cardiac dysrhythmias. The PCP should be informed because intervention may be necessary.

A nurse is caring for a pt with diarrhea. The nurse anticipates a decrease in which clinical indicator? A. Pulse rate B. Tissue turgor C. Specific gravity D. Body temperature

Tissue turgor ***Rationale: Skin elasticity will decrease because of a decrease in interstitial fluid.