E4 Q's
3. A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?
"You should anticipate pain the first week during the inflow of dialysate"
9. A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 100/min, respiratory rate 40/min, and blood pressure 140/80 mmHg, HCO₃ mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention?
Administer oxygen via face mask
A nurse in the emergency department is caring for a patient who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60, a weak pulse rate of 118 and a respiratory rate of 40. Which of the following actions should the nurse take first?
Administer oxygen via nasal cannula
6. A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis. Which of the following is an expected finding for this client?
BUN 100mg/dl
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply a pulse oximeter probe to which of the following locations?
Earlobe
13. A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Keep the drainage system below the level of the client's chest at all times.
A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Movement of the ET tube into the right main bronchus
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?
Pyelonephritis increases a pregnant woman's risk for preterm labor
A nurse is caring for a client diagnosed with chronic glomerulonephritis. The nurse would expect to find a decrease in which of the following serum laboratory values?
RBC
A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Raise the head of the bed
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22PaCO2 68 mm Hg Base excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L
Respiratory Acidosis
4.A nurse is caring for a client who has acute respiratory distress syndrome and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
Suppress respiratory effort
12. A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?
The client has a 5lb weight gain since yesterday
17.A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?
administer pain medication
A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?
c
23. A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
flail chest
14. A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
performing the procedure independently
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?
"After the procedure you will be encouraged to drink plenty of fluids"
A nurse is assessing a client who is to have IV urography. Which of the following data should indicate to the nurse that this procedure is contraindicated for this client?
Allergy to shellfish
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?
Client who has diarrhea
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Continue to monitor client's respiratory status
20. A nurse is reviewing the laboratory values of a client who has respiratory acidosis. which of the following findings should the nurse expect?
PaCO2 50 mm Hg
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following interventions?
Perform Pre-oxygenation prior to suctioning
5. A nurse is planning care for a client who has acute glomerulonephritis. which of the following interventions should the nurse include in the plan?
Weight the client daily
16.A nurse is monitoring a client who has a chest tube in place connected to wall suction due to right sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
reposition the client
10. The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Fluctuation of the fluid level within the water seal chamber
11. A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Place her hands on the sides of her rib cage
15. a nurse is teaching a client who has chronic kidney failure about planning a low protein diet. the client states, why do i have to be concerned about protein? which of the following responses should the nurse make?
a low protein diet reduces the risk for uremia
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?
increasing dyspnea
21. A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
movement of the trachea toward the unaffected side
22. A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
auscultate the site for a bruit
18.A nurse is caring for a client who has a three- chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
continue to monitor the client
A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. which of the following instructions should the nurse include?
reduce intake of foods high in potassium
19. A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
respiratory acidosis
A nurse is caring for a client immediately following hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?
Headache and restlessness
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?
Potassium
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. when assessing the 3-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. action by nurse?
Verify that the suction regulator is on and check the tubing for leaks
7. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
nausea and vomiting
8. A nurse is planning care for a client who has acute respiratory distress syndrome. Which of the following interventions should the nurse include in the plan?
place in prone position
