322 Exam #2

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

A nurse is reviewing orders for a client having an acute asthma attack. Which medication should the nurse administer?

albuterol 2.5 mg per nebulizer

The nurse receives a change-of-shift report on the following four clients. Which client should the nurse assess first?

immobile client with a sudden onset of shortness of breath

The nurse is collecting data on a client with a urinary tract infection (UTI). Which statements should the nurse expect the client to make? Select all that apply.

"I need to urinate frequently." "It burns when I urinate." "I need to urinate urgently."

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which statement, if made by a group member, would indicate understanding of the teaching?

"I should notify the physician if urinary urgency, burning, frequency, or difficulty urinating occurs."

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day."

Sulfamethoxazole has been prescribed to treat a client's urinary tract infection. The initial dosage is 2 g orally. The nurse has 500-mg tablets available. How many tablets should the nurse give? Record your answer using a whole number.

4

A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which action by the nurse is most appropriate?

Assist the client to sit in a chair and lean slightly forward with hands on the knees.

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

Encourage the client's communication, allowing time to select or write words.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High protein diet

A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Impaired gas exchange related to airflow obstruction

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?

Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered

The graduate registered nurse (RN) is assigned the care of a client with acute renal failure and hypernatremia. Which actions can the graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Provide oral care.

The nurse is offering further education to a client about the management of COPD. Which outcomes would indicate the teaching has been effective? Select all that apply.

The client demonstrates pursed-lip breathing and coughing exercises. The client maintains smoking cessation. The client schedules follow-up physician appointments.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.

Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?

calcium gluconate

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

cardiac rhythm

A client with emphysema is at a greater risk for developing what acid-base imbalance?

chronic respiratory acidosis

A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds.

A client has undergone a left hemicolectomy for bowel cancer. Which combination of activities is most effective in preventing the occurrence of postoperative pneumonia in this client?

coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

depriving the client of sufficient oxygen supply.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

excess fluid volume

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

hypocalcemia

A client is admitted with fever and flank pain and is diagnosed with pyelonephritis. What is a priority nursing intervention in a client with this disorder?

monitoring laboratory values, especially WBCs

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

muscle weakness and a weak, irregular pulse

A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause

nervousness.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

normal saline solution as this is considered an isotonic solution

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply.

respiratory rate of 12 to 20 breaths per minute breath sounds present and equal in all lobes oxygen saturation on room air is 95%.

A client with bacterial pneumonia is to be started on IV antibiotics. The nurse should verify that which diagnostic test has been completed before administering the antibiotic?

sputum culture

A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client's blood glucose level in the emergency care unit was 576 mg/dl (31.97 mmol/L). The physician orders an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin. The nurse piggybacks the insulin infusion into the normal saline solution. The nurse questions whether piggybacking the levofloxacin into the same I.V. line is appropriate. Which health team member should the nurse collaborate with to check the compatibility of these solutions?

the pharmacist covering the floor

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by

wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.