3-respiratory
A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
117 mL/hr
A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
125 mL/hr
A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
15 mL
A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
4 mL
A nurse is preparing to administer dextrose 5% in water (D5W) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
8 gtt/min
A nurse is caring for a client who has a pneumothorax. Client reports an injury to their right ribs after falling 6 feet from a ladder. Client has a pain level of 8 on a scale of 0 to 10 over the right lower rib cage with ecchymosis. Client is dyspneic and respirations are shallow. Client states, "It's hard for me to breathe."
Obtain ABGs is anticipated. ABGs should be obtained to further assess the client's respiratory status. Prepare for insertion of a chest tube is anticipated. Chest tubes are inserted into a client who has a pneumothorax to re-expand the lung. Obtain intravenous access is anticipated. Intravenous access is anticipated to administer medications for chest tube insertion, as well as for emergency vascular access, if needed. Computed tomography (CT) of the chest is nonessential. The client's pneumothorax takes priority because it compromises gas exchange. A CT scan may be done after the client is stabilized following chest tube insertion. Pulmonary Function Tests (PFTs) are nonessential. PFTs are used for screening and measuring lung volumes and capacities. This test is not appropriate at this time; delaying the treatment of the pneumothorax could cause harm to the client. Thoracentesis is contraindicated. Thoracentesis is used to aspirate air or fluid from the pleural space but does not restore the expansion of the lung.
Nurses' Notes Client is admitted to the emergency department with periodic episodes of wheezing and shortness of breath. Client reports wheezing, chest tightness, and persistent dry cough that increases at night. Bilateral breath sounds with inspiratory and expiratory wheezing. Color pale, skin warm and dry.
The nurse should plan to administer a bronchodilator and measure the client's peak airflow because the client is most likely experiencing asthma. The nurse should monitor the client's pulmonary function tests and oxygen saturation to assess the client's progress and determine the need for supplemental oxygen.
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? a) Propranolol b) Theophylline c) Montelukast d) Prednisone
a) Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis
a) Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
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) When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.
A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? a) Tell the client to blow her nose gently before the instillation. b) Assist the client to a side-lying position. c) Hold the dropper 2 cm (1 in) above the naris. d) Instruct the client to stay in the same position for 2 min.
a) Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) a) Dyspnea b) Gastrointestinal bloating c) Jugular vein distention d) Confusion e) Hypotension
a, c, d
A nurse is caring for a client who has COPD. Select the 5 findings that require follow-up. a) Disorientation b) Barrel-shaped chest c) Yellow sputum d) Nebulizer use e) Ankle edema f) SaO2 92% g) Clubbing of fingers h) Lives alone
a, c, d, e, h
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? a) Hyperglycemia b) Adrenocortical insufficiency c) Severe dehydration d) Rebound pulmonary congestion
b) Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.
A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? a) Lactated Ringer's solution b) 0.9% sodium chloride c) Dextrose 5% in water d) Dextrose 5% in 0.45% sodium chloride
b) The nurse should prime the tubing with 0.9% sodium chloride, as this is the only IV solution that does not hemolyze RBCs. (*isotonic...like blood)(so no interaction w/ it)
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? a) Flushing b) Dyspnea c) Bradycardia d) Vomiting
b) Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine? a) "Administer the medication with food." b) "Chew on sugarless gum or suck on hard, sour candies." c) "Place a humidifier at your bedside every evening." d) "Discontinue the medication and notify your provider."
b) Clients who report dry mouth can get the most effective relief by sucking on hard candies (especially the sour varieties that stimulate salivation), chewing gum, or rinsing the mouth frequently. It is the local effect of these actions that provides comfort to the client.
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) The nurse should instruct the client that caffeine should be avoided while taking theophylline, as it can increase central nervous system stimulation.
A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription? a) Take the extended release tablets on an empty stomach. b) Add an antacid if the medication causes indigestion. c) Take the extended release tablets whole. d) Expect urinary output to decrease while on this medication.
c) The nurse should teach the client that extended release tablets should be taken whole and should not be broken, crushed, or chewed.
A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer? a) lisinopril b) digoxin c) furosemide d) potassium iodide
c) Furosemide results in loss of potassium from the nephron as part of its diuretic effect. This medication can be given when a client has an elevated potassium level and can lower the potassium level. For this client, the depletion of potassium is a beneficial effect. For a client who has a therapeutic potassium level, there would be a risk for hypokalemia due to the excretion of potassium.
A nurse is reviewing the medical record of a client who reports taking pseudoephedrine for sinus congestion as needed. The nurse should identify that pseudoephedrine is contraindicated for which of the following client conditions? a) eczema b) migraines c) hypertension d) diverticulitis
c) Clients who have hypertension or acute coronary syndrome should speak with their provider prior to taking decongestants, because of the potential for vasoconstriction, which would aggravate the chronic condition.
A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? a) Beclomethasone b) Salmeterol c) Formoterol d) Albuterol
d) Albuterol is an inhaled short-acting beta2 agonist (beta2-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.
A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? a) Reduces inflammation b) Suppresses the urge to cough c) Dries mucous membranes d) Stimulates secretions
d) Expectorants act by increasing secretions to improve a cough's productivity.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? a) Hypoglycemia b) Hypertension c) Polyuria d) Oral candidiasis
d) Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse her mouth with water.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? a) Initiating oxygen therapy b) Providing immediate rest for the client c) Positioning the client in high-Fowler's d) Administering a nebulized beta-adrenergic
d) The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation. (*theme: ABCs)(airway)
A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take? a) Check the unit of blood with an assistant personal (AP). b) Premedicate the client with an antiemetic. c) Plan to infuse the unit of blood over 6 hr. d) Remain with the client for the first 15 minutes of the transfusion.
d) The nurse should remain with the client for the first 15 to 30 minutes of the transfusion to monitor for a transfusion reaction, which occurs often during the first 50 mL of the transfusion.
A nurse is teaching an adolescent about medication therapy with oral acetylcysteine. Which of the following information should the nurse include in the teaching? a) "You should avoid eating eggs." b) "Your mouth will become dry." c) "It is necessary to monitor your serum electrolyte levels." d) "This medication has a very unusual odor."
d) This medication has an odor similar to rotten eggs due to the presence of disulfide linkages.
