Adaptive Processes Exam 3 - Practice Questions

A pulse oximetry monitor indicates that the patient has a drop in SpO2 from 95% to 85%. What is the first action the nurse should take?

Assess patient for signs of cyanosis and check position of probe

Radiographic studies

CT and mammography to indicate tumor

T/F: Palliative care and Hospice Care are the same thing.

False

T/F: Central nervous system brain tumors are easy to treat with a good prognosis.

False CNS brain tumors are difficult to treat with a poor prognosis.

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

Sweat chloride test

T/F: Brain tumors are the most common type of solid tumors in children

True

T/F: Cancer Incidences have decreased since the 1990s.

True

T/F: Leukemic cells invading the periosteum can lead to severe pain and possible fractures in the child.

True

T/F: Smoking cessation is the most important intervention in COPD.

True

T/F: Infants, whose fontanelles are open, may not show early signs of increased intracranial pressure.

True Open fontanelles will accommodate increased intracranial pressure and infants may not show typical symptoms of increased ICP. They may present with irritability, failure to thrive, loss of developmental milestones, and loss of motor skills

A 2-year old has just been diagnosed with CF. The parents ask the nurse what early respiratory symptoms they should initially expect to see in their child. Which is the nurse's best response? a. "You can expect your child to develop a productive cough." b. "You can expect your child to develop bronchiectasis." c. "You can expect your child to develop a barrel-shaped chest." d. "You can expect your child to be cyanotic"

a. "You can expect your child to develop a productive cough." A productive cough is common in patients with CF. A barrel-shaped chest is long-term respiratory problems that occurs as a result of recurrent hyperinflation of alveoli. Bronchiectasis develops in advanced stages of CF. Cyanosis is not an expected early finding.

The parents of a 4-month-old with CF asks the nurse what time to begin the child's first CPT each day. Which is the nurse's best response? a. "You should do the first CPT 30 minutes before feeding the child breakfast." b. "You should do the first CPT 30 minutes after feeding the child breakfast." c. "You should do CPT after deep-suctioning the child each morning." d. "You should do the first CPT only when the child has congestion or coughing."

a. "You should do the first CPT 30 minutes before feeding the child breakfast." CPT on an infant should be completed prior to a feeding to prevent emesis and aspiration.

Which of the following definitions best describes cystic fibrosis? a. A multi-symptom disorder affecting the exocrine or mucus producing glands b. A chromosomal abnormality inherited as an autosomal-dominant trait c. An inflammation of the pulmonary parenchyma d. A chronic lung disease related to high concentrations of oxygen and ventilation.

a. A multi-symptom disorder affecting the exocrine or mucus producing glands CF affects many organ as well as the exocrine or mucus producing glands. It is an autosomal recessive abnormality.

The home health nurse visits a patient with metastatic breast cancer receiving palliative care. The patient is experiencing pain at a level 9/10. In prioritizing activities for the visit, what should the nurse complete first? a. Administer prn pain medication b. Check pressure points for skin breakdown. c. Auscultate for breath sounds. d. Ask family about patients fluid intake

a. Administer prn pain medication The nurse should administer pain medication then continue with visit assessments. The nurse should investigate cause of pain to further alleviate symptoms.

The nurse is caring for a client that has a chest tube. The client becomes acutely SOB and has very decreased lung sound in the chest tube side lung. What would the nurse do first? a. Assess chest tube connection and check for kinks in drainage system. b. Place client in low Fowler's c. Place client on 100% nonrebreather mask. d. Clamp chest tube and call the HCP.

a. Assess chest tube connection and check for kinks in drainage system.

The client with COPD has been prescribed O2 therapy per nasal. What interventions will the nurse anticipate. a. Assess skin under cannula and ears b. Monitor O2 saturation frequently c. If flow rate greater than 2 liters add humidity d. Titrate O2 for >90 % O2 saturation e. When ambulating the cannula may be removed

a. Assess skin under cannula and ears b. Monitor O2 saturation frequently c. If flow rate greater than 2 liters add humidity d. Titrate O2 for >90 % O2 saturation

The nurse is caring for a client with the ABGs below: pH: 7.29, PCO2: 55, HCO3: 26, PaO2: 75, Saturation 93% Which action should the nurse take first? a. Assess the client's Respiratory Rate b. Assess the client's urine output c. Document the finding as normal d. Call a code and begin CPR

a. Assess the client's Respiratory Rate This is respiratory acidosis the client may be hypoventilating

A nurse is assessing a child with leukemia. Which of the following are early manifestations of leukemia? a. Bruising b. Fever c. Hematuria d. Ulcerations in mouth e. Fatigue f. Petechiae

a. Bruising b. Fever e. Fatigue f. Petechiae Clinical Manifestations would include signs of neutropenia, anemia, and thrombocytopenia such as fever, petechiae, bruising, fatigue

Which intervention is appropriate for care of the child with cystic fibrosis? a. Complete chest physiotherapy two to four times per day. b. Decrease exercise and limit physical activity. c. Give cough suppressants and antihistamines. d. Administer bronchodilator or nebulizer treatments after chest physiotherapy.

a. Complete chest physiotherapy two to four times per day. Chest physiotherapy is recommended two to four times per day to help loosen secretions and move secretions to facilitate expectoration. Exercise and physical activity is recommended to stimulate mucus secretion and to establish a good habitual breathing pattern. Cough suppressants and antihistamines are contraindicated. The goal is for the child to be able to cough and expectorate mucus secretions. Bronchodilator or nebulizer treatments are given before chest physiotherapy to help open the bronchi for easier expectoration.

A child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates worsening of the condition? a. Decreased wheezing b. Pulse rate of 90 beats per minute c. Respirations of 18 breaths per minute d. Warm, dry skin

a. Decreased wheezing

The nurse is examining a child with bronchiolitis. Which symptom should the nurse interpret as a sign of​ dehydration? (Select all that​ apply.) a. Delayed capillary refill b. Dry, sticky mucous membranes c. Intercostal muscle retractions d. Weak peripheral pulses e. Decreased urine output

a. Delayed capillary refill b. Dry, sticky mucous membranes d. Weak peripheral pulses e. Decreased urine output Intercostal retractions are a sign of respiratory distress, not dehydration. Weak peripheral pulses, decreased urine output, dry, sticky mucous membranes, and delayed cap refil are all signs of dehydration.

The nurse is caring for a client with a FEV1 of <30% predicted. What Gold Classification would they be? a. GOLD 4 b. GOLD 2 c. GOLD 3 d. GOLD 1

a. GOLD 4

The nurse is caring for a client who has just had an arterial blood gas. What is the priority action? a. Holding the site until bleeding stopped b. Analyzing metabolic disturbances c. Providing ice pack for vasoconstriction d. Assessing pain at the site

a. Holding the site until bleeding stopped

A child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of which of the following? a. Most children with asthma can participate in sports if the asthma is controlled b. Physical activities are inappropriate for children with asthma c. Vigorous physical exercise frequently precipitates an asthmatic episode d. Children with asthma must be excluded from team sports

a. Most children with asthma can participate in sports if the asthma is controlled If asthma is well controlled, sports are recommended for children to help increase physical activity and decrease complications. They should always have their Albuterol inhaler with them while exercising.

Which assessments would the nurse complete during a neurological assessment? Select ALL that apply. a. Muscle strength b. Level of Consciousness c. Pupil size and reaction d. Bowel sounds

a. Muscle strength b. Level of Consciousness c. Pupil size and reaction Although bowel sounds are included in a physical assessment, they are not part of a neurological assessment. All other assessments listed are included.

Which client would be most likely to have respiratory acidosis? A client with: a. Neurologic disorder with respiratory muscle weakness b. Response to pain, anxiety c. Renal failure d. Prolonged vomiting

a. Neurologic disorder with respiratory muscle weakness

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement? a. Palliative care interventions hasten death b. Palliative care provides symptom management c. Palliative care promotes optimal functioning d. Palliative care provides pain management

a. Palliative care interventions hasten death Palliative care focus on pain and symptom management. Interventions are not intended to quicken death, but to alleviate the symptom to improve quality of life and optimal function.

The nurse is caring for a client with the following ABGs: pH- 7.26 CO2- 30 HCO3- 18 a. Partially Compensated metabolic acidosis b. Partially Compensated metabolic alkalosis c. Fully Compensated metabolic alkalosis d. Fully Compensated metabolic acidosis

a. Partially Compensated metabolic acidosis *Reminder that if it is partially compensated, all three will be abnormal

The nurse is caring for a client with the following ABGs: pH- 7.31 CO2- 50 HCO3- 26 a. Respiratory Acidosis b. Metabolic Acidosis c. Respiratory Alkalosis d. Metabolic Alkalosis

a. Respiratory Acidosis

The nurse is caring for a client with COPD who is receiving an albuterol per nebulizer. The nurse understands the client is experiencing a side effect of this medication by noting which assessment? a. The client is jittery with tachycardia. b. The client has urinary incontinence. c. The clients glucose level is low. d. The client is difficult to arouse.

a. The client is jittery with tachycardia.

The nurse is receiving report from night shift. What client would the nurse see first? a. The client with new bilateral crackles. b. The client who has a barrel shaped chest c. The client with a frequent productive cough. d. The client with clubbing on both fingers.

a. The client with new bilateral crackles.

The nurse is caring for a client in DKA with a metabolic acidosis. The client has Kussmaul breathing at 38 breaths a minute. The nurse is aware that: a. the increase is a respiratory compensation for the metabolic acidosis b. the client has anxiety and needs to stay calm c. a 100 percent non rebreather will be needed d. this is unrelated to the acidosis

a. the increase is a respiratory compensation for the metabolic acidosis The compensatory response for metabolic Acidosis would be to blow of CO2. The client will do this by increasing the depth and rate of respiration.

The nurse is caring for a client on a non-selective beta blocker for tachycardia. What assessment would be most concerning to the nurse? a. wheezes in lungs bilaterally b. productive sputum c. increased urine output d. heart Rate is 62 BPM/L

a. wheezes in lungs bilaterally A non selective beta blocker may cause bronchospasm. And wheezes would be a concerning finding.

Pneumothorax

air in the pleural space

The nurse is assessing a 72 year old client with end stage chronic obstructive pulmonary disease (COPD) for admission into a palliative care program. The client shared concerns about the effects of ending treatment and the possibility of increasing symptoms. What is the best response by the nurse? a. "You will be educated on pain reducing methods" b. "We will manage your symptoms to increase your quality of life." c. "Are you worried you will feel short of breath?' d. "Are you having second thoughts regarding stopping treatment?"

b. "We will manage your symptoms to increase your quality of life."

The nurse is caring for a client with a chest tube with a pleruevac system. The night nurse reported the chest tube drainage at 6 am to be at level 300. It is now 10 am and the nurse asseses the level now. Document the findings a. 175 ml of serosanguineous fluid and pleur evac emptied b. 175 ml of serosanguineous fluid over 4 hours c. over 100 mls of serosanguineous and HCP notified d. 475 ml of serosanguineous fluid over 4 hours

b. 175 ml of serosanguineous fluid over 4 hours

The nurse is caring for a client who has admitted for asthma. The client has O2 sats of 91 % exhibits audible wheezes and is using accessory muscles. Which class of medication would the nurse anticipate administering? a. A beta blocker b. A beta2 agonist c. An antibiotic d. An antiviral

b. A beta2 agonist This patient needs a Beta 2 agonist (e.g., Albuterol) for bronchodilation

The nurse is caring for clients on an oncology unit and is checking the am lab results. Which client would the nurse see first? a. A client with nausea and vomiting with potassium level of 3.0 mEq/l. b. A nosebleed client with a platelet count of 32,000/mm3. c. A client who has a WBC count of 3,000 cells/mcL after chemotherapy. d. A client with fatigue and a hemoglobin of 8 g/dL

b. A nosebleed client with a platelet count of 32,000/mm3. The thrombocytopenic client would be the most concerning

The most accurate evaluation of a clients acid base status is a. Litmus testing of urine b. Arterial Blood gasses c. CO2 monitoring of exhaled air d. Basic met panel with base excess

b. Arterial Blood gasses

The client on a post op medical floor has CO2 sensor for monitoring while on a PCA pump. The alarm is going off indicating a high CO2 reading. The nurse will a. Increase the O2 to 2LNC b. Assess the client's Respiratory Rate c. Call the physician for an Arterial Blood Gas d. Instruct the family members to arouse the client.

b. Assess the client's Respiratory Rate The Nurse is concerned about hypoventilation caused by the narcotic in the PCA. It is important to assess the RR first

A nurse is caring for a cihld with thrombocytopenia. Which of the following actions should the nurse take? a. Obtain rectal temperatures b. Avoid peripheral venipunctures c. Limit visitors d. Administer routine immunizations e. Monitor for signs of bleeding

b. Avoid peripheral venipunctures e. Monitor for signs of bleeding. With a patient with low platelets, nurses should monitor for signs of bleeding, avoid unnecessary venipunctures or injections, and avoid rectal temperatures and medications.

What is the gold standard for a definitive diagnosis of children with leukemia? a. MRI b. Bone Marrow Biopsy c. PET Scan d. Lumbar Puncture

b. Bone Marrow Biopsy Bone marrow biopsy is the definitive test for leukemia. LP is done to determine CNS involvement.

Metastasis refers to? a. A cancer producing substance b. Cancer cells that have spread to another location c. A tumor that consists of an overgrowth of non-cancerous cells d. The second stage in the development of cancer .

b. Cancer cells that have spread to another location

If the client receiving chemotherapy is at high risk for infection, which measure is the most important to take to minimize the occurrence? a. Client should wear a mask in own hospital room b. Encouraging daily personal hygiene, oral care and perineal care c. Flushing all lumens of central line access device every eight hours d. Limit foods to commercially canned products only

b. Encouraging daily personal hygiene, oral care and perineal care the client's own flora is the most common source of microbial colonization and infection. Handwashing and hygiene is the single most important measure to minimize risk.

A client is admitted to the hospital with complaints of sudden onset of severe and excessive vomiting. Which lab value in an arterial blood gas would you expect to see? a. PaCO2 42 b. HCO3 30 c. pH 7.32 d. SaO2 90

b. HCO3 30 The client will be in metabolic alkalosis. So bicarb will be high.

The nurse is caring for client who is getting a bedside chest tube placed for a pneumothorax. What prescription would the nurse question? a. Have 1% lidocaine for injection into the insertion b. Have large dose of hydromorphone IV ready to administer c. Prepare the pleur evac to connect the chest to after insertion d. Attach client to continuous oximetry and monitor closely

b. Have large dose of hydromorphone IV ready to administer

When a patient has neutropenia, they are at risk for which complication? a. Severe pain b. Infection c. Metastasis d. Bleeding

b. Infection

The client is an anorexic client with starvation , What imbalance would be most likely seen with this symptom? a. Metabolic Alkalosis b. Metabolic Acidosis c. Respiratory Acidosis d. Respiratory Alkalosis

b. Metabolic Acidosis

The treatment of a nervous system tumor in children consists of all of the following except: a. Chemotherapy b. Myelography c. Surgery d. Radiation

b. Myelography Treatment may involve surgery, radiation, chemotherapy, or a combination of these

The nurse is concerned with the client's oxygenation status. What lab would indicate there is a problem? The client is on no O2 at this time. a. O2 Saturation of 94% b. PO2 of 62 c. End tidal Co 35 d. Hemoglobin is 9

b. PO2 of 62

The nurse provides preoperative instruction for a client scheduled for a left lobectomy for cancer of the lung. Which information should the nurse include about the client's postoperative care? a. A chest tube is not needed for this operation b. Proper pain management for deep breaths c. Client will be positioned on operative site d. Oxygen will be used to maintain ventilation

b. Proper pain management for deep breaths

The nurse is caring for a client with chest tube. They are assessing for tidaling with respiration. Where would the nurse look for this? a. The white ball is not moving. b. The white ball in the water seal chamber will go up and down. c. The orange bellows will be in the window. d. There will be a small bubble in the water seal chamber with respiration

b. The white ball in the water seal chamber will go up and down.

The nurse is teaching the parents of a​ 9-month-old client with respiratory syncytial virus​ (RSV) about ways to help the child recover quickly from the disorder. Which information should the nurse​ include? (Select all that​ apply.) a. Help the infant blow the nose to clear the airway b. Use a bulb syringe to clear the nose before giving a bottle c. Encourage infant to play with others to elevate spirit d. Permit the infant to rest and nap throughout the day e. Provide frequent small meals throughout the day

b. Use a bulb syringe to clear the nose before giving a bottle d. Permit the infant to rest and nap throughout the day e. Provide frequent small meals throughout the day A 9 month old would have difficulty blowing their nose even with assistance and would be a non reliable way to clear airway. The infant should not play with other children until virus is non contagious.

Clinical manifestation of COPD are a. weight gain b. barrel chest c. prolonged inspiratory phase d. less dyspnea laying flat

b. barrel chest

Anemia may be a side effect of chemotherapy treatment. Children with profound anemia should a. receive blood transfusions of packed cells until their hemoglobin reaches 12. b. be allowed to regulate their physical activity with adult supervision c. be placed on strict bed rest with no physical activity until their hemoglobin level reaches 10. d. be restricted in their physical activity.

b. be allowed to regulate their physical activity with adult supervision Children can regulate their own activity level with adult supervision to balance activity and rest.

An elderly client is receiving palliative care for heart failure. The primary purposes of palliative care are to (Select all that apply): a. administer narcotics cautiously to avoid addiction b. educate family members on how to assess their loved ones pain c. assess coping ability with disease d. provide life saving treatment e. improve quality of life

b. educate family members on how to assess their loved ones pain c. assess coping ability with disease e. improve quality of life Palliative care focuses on quality of life and not life saving treatments. Nurses should assess coping strategies and educating family on how to determine pain levels. Addiction to pain medication is not a concern at end of life.

The nurse is caring for a client with colon cancer who is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells? a. reproductive organs b. liver c. white blood cells d. stomach

b. liver

The nurse is caring for a client with a chest tube. The order is for the chest tube to be set at -20 cm suction. The nurse checks the pleur evac and notes this finding. The nurse understands the client is: a. on suction as ordered due to the orange bellows not visible b. not on suction and the nurse should check connection to wall suction c. maintained on water seal so the nurse does not worry d. on 20 cm as prescribed

b. not on suction and the nurse should check connection to wall suction

Hemothorax

blood in the pleural space

A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These nurses should recognize these findings are associated with which of the following diagnoses?

bronchiolitis

The nurse is caring for a client who has been diagnosed with stage I cancer of the colon. When assessing the need for psychological support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" Open ended questions will provide the nurse with the most knowledge of the clients emotional state.

Which client is most at risk for cancer? a. A client who exercises three times every week and does not consume alcoholic beverages b. A client who obtains regular cancer screenings and consumes a high-fiber diet c. A client with a body mass index of 35 kg/m2 and smoked cigarettes for 20 years d. A client who limits fat consumption and has regular mammography and Pap screenings

c. A client with a body mass index of 35 kg/m2 and smoked cigarettes for 20 years

Pain control is often a concern of dying children and their parents. Which strategy should the nurse use to help them deal with this concern? a. Use heavy sedation to help the child cope with this phase. b. Assure the parents that the pain will be relieved. c. Adopt a medication schedule that will prevent the pain from escalating. d. Only give intravenous pain medication when a child is near death.

c. Adopt a medication schedule that will prevent the pain from escalating.

During a home​ visit, the nurse assesses a​ 2-year-old child. Which factor should the nurse identify as putting the child at risk for contracting respiratory syncytial virus​ (RSV)? (Select all that​ apply.) a. Toddler wears clean but rumpled pants. b. Both parents had RSV as infants. c. Both parents smoke cigarettes. d. The absence of soap at the sink. e. Infant shares sippy cup with sibling in daycare.

c. Both parents smoke cigarettes. d. The absence of soap at the sink. e. Infant shares sippy cup with sibling in daycare. Exposure to cigarette smoke, sharing items especially with children in daycare, and lack of handwashing all increase risk for RSV

The nurse is defining COPD to a client what definition best describes the disease. a. COPD is the presence of abnormal enlargement to the alveoli b. COPD is defined by the pulmonary vascular changes c. COPD is an airflow limitation disease d. COPD is the presence of chronic bronchitis

c. COPD is an airflow limitation disease

COPD can cause pulmonary hypertension. What complication may arise from this? a. Acute Respiratory Distress Syndrome (ARDS) b. Bronchiectasis c. Cor Pulmonale d. Respiratory consolidation

c. Cor Pulmonale

Which statement is best describes the Tumor, Node, Metastasis (TNM) classification system? a. Determines the type of cells and degree of cellular differentiation. b. Determines the five year survival rate for the cancer. c. Determines the anatomical extent of the disease involvement according to three parameters. d. Determines the anatomical site of the tumor and the tissue of origin.

c. Determines the anatomical extent of the disease involvement according to three parameters.

Which statement best describes a neuroblastoma? a. It is the most common benign tumor in children. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. Diagnosis is usually made after metastasis occurs. d. The majority of tumors begin in the brain.

c. Diagnosis is usually made after metastasis occurs. Neuroblastomas are often referred to as "silent" tumors because diagnosis is usually made after metastasis occurs. It begins in the abdomen along the adrenal gland and retroperitoneal sympathetic chain. It is the most common malignant tumor in children.

A nurse is caring for a child who has oral mucositis. Which of the following actions should the nurse take? a. Apply viscous lidocaine b. Swab the mucosa with lemon glycerin swabs c. Encourage gargling with a warm saline mouth rinse d. Offer soft foods e. use soft disposable toothbrush for oral care

c. Encourage gargling with a warm saline mouth rinse d. Offer soft foods e. use soft disposable toothbrush for oral care offering soft foods decreases amount of chewing needed and possible irritation. A soft toothbrush or swab should be used for oral care to avoid pain and trauma. A warm saline wash is effective in soothing and cleansing oral cavity. Viscous lidocaine should be avoided due to depression of gag reflex and risk for aspiration. Lemon glycerin swabs can cause tooth decay and erosion of tissue.

The nurse is caring for a lung cancer client in the induction stage of chemotherapy. The client experiences tumor lysis syndrome. Which of the following metabolic disturbances can occur because of tumor lysis syndrome? a. Hypoglycemia b. Hypokalemia c. Hyperuricemia d. Hypercalcemia

c. Hyperuricemia Uric acid is increased with tumor lysis syndrome. Moreover, you would see hyperglycemia, hyperkalemia, and hypocalcemia.

Which client would be most likely to have respiratory acidosis? a. Renal failure b. Hyperventilation c. Hypoventilation d. Diabetic acidosis.

c. Hypoventilation

The nurse is with a client using an albuterol MDI. The client takes two puffs in rapid succession. Which intervention is the priority? a. Call the pharmacy and order spacer for this client b. Notify the HCP that the client needs to resume nebulizer treatments c. Instruct the client about proper techniques for using and MDI inhaler d. Instruct client to rinse the mouth after use

c. Instruct the client about proper techniques for using and MDI inhaler The client is misusing the inhaler. They should take 1 puff per minute even when using a spacer.

The client has had prolonged vomiting from a virus, What imbalance would be most likely seen with this symptom? a. Respiratory Acidosis b. Metabolic Acidosis c. Metabolic Alkalosis d. Respiratory Alkalosis

c. Metabolic Alkalosis

Your client received chemotherapy last week and admits to the ED with a nose bleed. What lab would the nurse anticipate drawing on this client? a. Total neutrophil count b. BUN and creatinine c. Platelet count d. PT and INR

c. Platelet count

When caring for the client with chronic obstructive pulmonary disease (COPD). When the nurse identifies a nursing diagnosis of impaired gas exchange, what finding will be most useful in evaluating the effectiveness of treatment? a. Absence of wheezes, rhonchi, or crackles b. Even, unlabored respirations c. Pulse oximetry reading of 92% d. Respiratory rate of 18 breaths/minute

c. Pulse oximetry reading of 92% A goal of impaired gas exchange is to have adequate perfusion to the capillary beds. A pulse ox of 92% would indicate this.

The client is hyperventilating due to anxiety, What imbalance would be most likely seen with this symptom? a. Metabolic Acidosis b. Metabolic Alkalosis c. Respiratory Alkalosis d. Respiratory Acidosis

c. Respiratory Alkalosis

The nurse is caring for a client receiving chemotherapy in a peripheral IV. The nurse identifies this agent to be a vesicant drug. The most important action for the nurse to implement would be to: a. Infuse the medication over twenty four hours b. Inform the client about central lines c. Stop the infusion if swelling noted at site d. Assess the platelet count.

c. Stop the infusion if swelling noted at site

Which statement best describes the purpose of pursed lip breathing? a. To prevent complication associated with COPD b. To prolong inhalation so more air enters the alveoli c. To prevent airway bronchial collapse d. To use position changes to drain secretions

c. To prevent airway bronchial collapse

The nurse is caring for a client receiving inhaled corticosteroids. What should the nurse include in teaching a. The expected outcome is bronchodilation b. Administer the inhaler with meals c. You should rinse you mouth after inhalation d. Tachycardia is expected.

c. You should rinse you mouth after inhalation

The nurse is providing education for a client who is discharging after a mastectomy and will be caring for a Jackson Pratt drain. Which statement by the client indicates a need for further education? a. "I should not take a bath while the drain is in." b. "I should report any drainage change especially if it changes to bloody." c. "I should keep the JP drain securely to my clothes so it doesn't pull." d. "I can remove it myself when the drainage stops."

d. "I can remove it myself when the drainage stops." The client should not take baths with JP in but may cleanse area with mild soap. The HCP will need to remove this in an office.

The nurse is caring for a child with leukemia who is receiving chemotherapy. The child is on neutropenic precautions. Friends of the child come to the desk and ask for a vase for flowers they have picked from their garden. Which of the following is the nurse's best response? a. "As soon as I can wash a vase, I will put the flowers in it and bring it to the room." b. "Get rid of the flowers immediately. You could harm the child." c. "I will get you a special vase that we use on this unit." d. "The flowers from your garden are beautiful but should not be placed in the room at this time."

d. "The flowers from your garden are beautiful but should not be placed in the room at this time." Fresh flowers, are prohibited in neutropenic clients, as are fresh fruit/veggies, and live plants. These are neutropenic precautions.

There are several children in the ER waiting area who all have asthma. The nurse has only one room left in the ER. Based on the following information, which child should be seen first? a. A 16 year old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 94%. b. A 9 year old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. c. A 5 year old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 92%. d. A 12 month old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 92%.

d. A 12 month old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 92%. The child with a mild cry and diminished breath sounds is showing signs of impending respiratory failure and silent chest

A 10 year old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates worsening of the condition? a. Pulse rate of 90 beats per minute b. Respirations of 18 breaths per minute c. Warm, dry skin d. Diminished wheezing

d. Diminished wheezing This is SILENT CHEST!

Which of the following statements is appropriate for the nurse to address to the parents of a child with CF who are planning to have a second child? a. There is a 50% change the child will be normal. b. There is a 25% chance the child will only be a carrier. c. There is a 50% chance the child will be affected. d. Genetic counseling is recommended.

d. Genetic counseling is recommended. CF affects many organ as well as the exocrine or mucus producing glands. It is an autosomal recessive abnormality, therefore, none of the other statements are true.

The nurse understands the need for further teaching when the client states a. Shortness of breath and cough are common symptoms b. I should exercise moderately at least three times a week c. I should get my influenza and pneumococcal vaccine d. I should lay down if I become short of breath

d. I should lay down if I become short of breath

The nurse is caring for a client receiving chemotherapy. Which assessment finding would indicate the client has developed stomatitis? a. Rust-colored sputum b. White, patches on the tongue c. Pale coloring on mucosal lining d. Red, open sores on the oral mucosa

d. Red, open sores on the oral mucosa

A diagnostic test to determine severity of COPD would be a. CBC with differential b. sputum culture c. Alpha-1 antitrypsin deficiency screening d. Spirometry/FEV1-FVC

d. Spirometry/FEV1-FVC

The definitive diagnosis of a nervous system tumor in children is a. MRI b. CT Scan c. Lumbar Puncture d. Surgical Biopsy e. EEG

d. Surgical Biopsy Although all of these tests are used for diagnostic evaluation, the definitive test is acquired from brain tissue during surgery

Which of the following tools is the definitive diagnosis for cystic fibrosis? a. Pulmonary function testing. b. Stool culture c. Newborn screen d. Sweat Test

d. Sweat Test A sweat chloride test is the definite diagnosis for CF. Pulmonary function testing monitors progression of illness, stool cultures will help measure fat content in the stool, and a newborn screen is used screen for the disorder.

Which statement best describes palliation? a. The use of chemotherapy and radiation when a cure is possible. b. The use of chemotherapy and/or radiation to reduce metastases. c. The used of high doses of chemotherapy as a last ditch effort to bring about a cure. d. The use of chemotherapy and/or radiation to reduce the tumor size and relieve subsequent symptoms.

d. The use of chemotherapy and/or radiation to reduce the tumor size and relieve subsequent symptoms.

The nurse is working with a mother and discussing the process of keeping the airway clear for a child diagnosed with respiratory syncytial virus​ (RSV). Which should the nurse teach the parent to do at​ home? a. Perform chest percussion b. Auscultate lung sounds c. Use a catheter to suction the airway d. Use a bulb syringe to suction the nose

d. Use a bulb syringe to suction the nose Bulb suction would be an appropriate measure for parents to take at home. The other interventions are specific to the hospital setting.

A client is scheduled for a baseline pulmonary function testing. Which action should the nurse take to prepare the client for this procedure? a. Administer oral corticosteroids 2 hours before the procedure. b. Ensure that the client has been NPO for several hours before the test. c. Give the rescue medication immediately before testing. d. Withhold bronchodilators for 6 to 12 hours before the examination.

d. Withhold bronchodilators for 6 to 12 hours before the examination. Any bronchodilator will affect the results and true lung capacities are being tested. Oral and rescue medication could also alter the results.

A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings?

decreased pH and metabolic acidosis

Tension Pneumothorax

emergency with compression of vital organs

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tell the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

encouraging the client to drink 2 to 3 L of water daily

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

increased anteroposterior diameter of the chest

PET scan

indicates metastasis throughout the body

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?

intercostal retractions

Tumor markers

oncofetal antigens that can indicate tumor growth

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

pH below 7.35

Empyema

pus in the pleural space

Tissue biopsy

removal of tissue for pathological analysis

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?

respiratory acidosis

Flail chest

rib fractures

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

the client holds his breath for 10 seconds after inhaling the medicationW

Fine needle aspiration

using a small needle to provide cells from a mass for cytologic examination

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?

white coating in the mouth (thrush!)

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

"we will give our child pancreatic enzymes with snacks and meals"

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.)

-daytime symptoms occur more than twice a week -minor limitations occur with normal activity -peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value