AH1 exam 2 practice ?
a nurse teaches a client to use a room humidifier after a laryngectomy. which statement should the nurse include in this clients teaching? a. add peppermint oil to the humidifier to relax the airway b. make sure you clean the humidifer to prevent infection c. keep the humidifier filled with water at all times d. use the humidifier when you sleep, even during daytime naps
B
a nurse teaches a client who has open vocal cord paralysis. which technique should the nurse teach the client to prevent aspiration? a. tilt the head back as far as possible when swallowing b. tuck the chin down when swallowing c. breathe slowly and deeply while swallowing d. keep the had very still and straight while swallowing
B
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
A
A nurse is demonstrating suctioning a tracheostomy during the annual skills review. what action by the student demonstrates that more teaching is needed? a. applying suction while inserting the catheter b. preoxygenating the client prior to suctioning c. suctioning for a total of three times if needed d. suctioning for only 10 to 15 seconds each time
A
An assistive personnel was feeding a client with a tracheostomy. later that evening, the UAP reports that the client had a coughing spell during the meal. what action by the nurse takes priority? a. assess the clients lung sounds b. assign a different UAP to the client c. report the UAP to the manager d. request thicker liquids for meals
A
a nurse cares for a client after radiation therapy for lung cancer. the client reports a sore throat. which action should the nurse take first? a. ask the client to gargle with mouthwash containing lidocaine b. administer prescribed intravenous pain medications c. explain that soreness is normal and will improve in a couple days d. assess the clients neck for redness and swelling
A
a nurse cares for a client who has hypertension that has not responded well to several medications. the client states compliance is not an issue. what action would the nurse take next? a. assess the client for obstructive sleep apnea b. arrange the home sleep apnea test c. encourage the client to begin exercising d. schedule a polysomnography
A
SATA a nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. which statements would the nurse include in this patient's teaching? a. you will need to cut the wires if you start vomiting b. eat six soft or liquid meals each day while recovering c. use a waterpix for dental hygiene until you can brush again d. sleep in a semi-fowler position after the surgery e. gargle with mouthwash that contains hydroxide peroxide once a day
A,B,C,D
SATA a nurse is assessing a client's hx of particulate matter exposure. what questions are consistent with the IPREPARE tool? a. investigate all hx of known exposure b. determine if breathing problems are worst at work c. ask the client what type of heating is in the home d. gather details about the geographic location of the client's home e. have client list all previous jobs and work experiences f. assess what hobbies the client and family enjoy
A,B,C,D,E,F
SATA a nurse is planning discharge teaching on tracheostomy care for an older client. what factors does the nurse need to assess before teaching this particular client? a. cognition b. dexterity c. hydration d. range of motion e. vision f. upper arm range of motion
A,B,C,D,E,F
SATA a nurse is teaching a community group about the long-term effects of untreated sleep apnea. what info does the nurse include? a. hypertension b. stroke c. weight gain d. diabetes e. cognitive deficitis f. pulmonary disease
A,B,C,D,E,F
SATA a nurse assesses a client who is at risk for neck cancer. which symptoms would the nurse assess for? a. oral mucosa is gray or dark brown b. pain when drinking grapefruit juice c. persistent weight gain over the past 2 months d. oral lesions that are over 2 weeks old e. changes in the pt voice quality
A,B,D,E
SATA while obtaining a clients health hx, the client states "i am allergic to avocados, molds, and grass." which responses by the nurse are best? a. what happens when you are exposed to those things? b. how do you treat these allergies? c. when was the last time you ate foods containing avocado d. i will document this in your record so everyone knows e. have you ever been in the hospital after allergic response f. how do you manage to avoid grass and mold
A,B,D,E
SATA a nurse is assessing clients on a rehab unit. which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? a. 24 yr old with traumatic brain injury b. 36 yr old who fractured left femur c. 58 yr old at risk for aspiration following radiation therapy d. 66 yr old who is a quadriplegic and has a sacral ulcer e. 80 yr old who is aphasic after a cerebral vascular accident
A,C,D,E
SATA a nurse is caring for a client who has a tracheostomy tube. what actions may the nurse delegate to UAP? a. applying water-soluble lip balm to the clients lips b. ensuring the humidification provided is adequate c. performing oral care with alcohol-based mouthwash d. reminding the client to cough and deep breathe often e. suctioning excess secretions through tracheostomy f. holding the new tracheostomy tube while the RN changes the ties
A,D
SATA a client is being discharged home after having a tracheostomy placed. what suggestions does the nurse offer to help the client maintain self-esteem. a. create a communication system b. dont go out in public alone c. find hobbies to enjoy at home d. try loose-fitting shirts with collars e. wear fashionable scarves
A,D,E
after teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. which statement indicates the client needs further teaching? a. i will stay away from smokers to minimize inhalation of secondhand smoke b. when i speak, i will whisper rather than use a normal tone of voice c. for the next several weeks, i will not lift more than 10 pounds d. i will drink at least three quarts of water each day to stay hydrated
B
a nurse cares for a client who is scheduled for a total laryngectomy. which action should the nurse take prior to surgery? a. assess airway patency, breathing, and circulation b. administer prescribed intravenous pain medication c. assist the client to choose a communication method d. ambulate the client in the hallway to assess gait
C
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.
B
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. administer prescribed anxiolytic medication b. ensure that informed consent is on the chart c. reinforce any teaching done previously d. start the preoperative antibiotic infusion
B
A client with a new tracheostomy is being seen in the oncology clinic. what finding by the nurse best indicates that goals for the nursing diagnosis impaired self-esteem are being met? a. the client demonstrates good understanding of stoma care b. the client has joined a book club that meets at the library c. family members take turns assisting with stoma care d. skin around the stoma is intact without signs of infections
B
A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. tilt the head back as far as possible when swallowing b. swallow twice while bearing down c. breathe slowly and deeply while swallowing d. keep the head very still and straight while swallowing
B
a nurse cares for a client who had a partial laryngectomy 10 days ago. the client states that all food tastes bland. how should the nurse respond? a. i will consult the speech therapist to ensure you are swallowing properly b. this is normal after surgery. what types of food do you like to eat? c. i will ask the dietitian to change the consistency of the food in your diet d. replacement of protein, calories, and water is very important after surgery
B
a nurse is assessing a client who is recovering from a lung biopsy. the client breath sounds are absent. while another nurse calls the rapid response team. what action by the nurse is most important? a. take full set of vitals b. obtain pulse ox reading c. ask pt about hemoptysis d. inspect biopsy site
B
SATA a nurse teaches a client who has epistaxis and recently had his nasal packing removed. which statements indicate that the client correctly understood the teaching? a. i will vigorously blow my nose multiple times each day b. nasal saline spray will help to prevent rebleeding c. i will wait at least 1 month before resuming weight lifting d. ibuprofen will decrease nasal swelling and pain e. i will apply a a small amount of petroleum jelly to my nares
B,C, E
SATA a nurse assesses a client who has developed epistaxis. which conditions in the clients history should the nurse identify as potential contributors to this problem? a. DM b. hypertension c leukemia d. cocaine use e. migraine f. elevated platelets
B,C,D
SATA a nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9 am. what actions would the nurse take? a. provide a clear liquid bfast b. verify informed consent was obtained c. document client's allergies d. review lab results e. hold clients bronchodilators f. monitor client for at least 24 hours after
B,C,D,F
SATA a nurse assesses a client who is recovering from a thoracentesis. which assessment finding would alert the nurse to a potential pneumothorax? a. bradycardia b. new onset cough c. purulent sputum d. tachypnea e. pain with respiration f. rapid, shallow respirations
B,D,E
SATA a RN cares for clients on a surgical unit. which clients should the RN delegate to a LPN? a. 32 yr old who had a radial neck dissection 6 hours ago b. 43 yr old diagnosed with cancer after a lung biopsy 2 days ago c. 55 yr old who needs discharge teaching after a laryngectomy d. 67 yr old who is awaiting preoperative teaching for laryngeal cancer e. 88 yr old with esophageal cancer who is awaiting gastric tube placement
B,E
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. client reports pain is controlled satisfactorily with analgesic regime b. client does not have foul odor to the breath or beefy red mucus membranes c. client is able to swallow own secretions without drooling d. clients vital signs are within normal parameters
C
A nurse is providing tracheostomy care. what action by the nurse requires intervention by the charge nurse? a. holding the device securely when changing ties b. suctioning the client first if secretions are present c. tying a square knot at the back of the neck d. using half-strength peroxide for cleansing
C
A nurse is assessing a client who has a tracheostomy. the nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. no other abnormal findings are noted. what action by the nurse is most appropriate? a. call the operating room to inform them of a pending emergency case b. no action is needed at this time; this is a normal finding in some clients c. remove the tracheostomy tube; ventilate the client with a bag-valve-mask d. stay with the client and have someone else call the primary health care provider immediately
D
