Exam 4 semester 3
A patient has been advised to add a nasal spray (an adrenergic decongestant) to treat a cold. The nurse will include which instruction? a. "You won't see effects for at least 1 week." b. "Limit use of this spray to 3 to 5 days." c. "Continue the spray until nasal stuffiness has resolved." d. "Avoid use of this spray if a fever develops."
Correct Answer: b. "Limit use of this spray to 3 to 5 days."
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? Select one: a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
Correct Answer: d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? Select one: a. No wheezes are audible. b. O2 saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.
Correct Answer: The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? Select one: b.O2 saturation is >90%.
The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply. Select one or more: a. A client who is on complete bed rest following extensive spinal surgery. b. A client who has a large venous stasis ulcer on the right ankle area. c. A client who has recently been admitted with a broken femur and is awaiting surgery. d. A client who is receiving supplemental oxygen following shoulder surgery. e. A client who has a pleural effusion secondary to infection. f. A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy
Correct Answer: a. A client who is on complete bed rest following extensive spinal surgery. b. A client who has a large venous stasis ulcer on the right ankle area. c. A client who has recently been admitted with a broken femur and is awaiting surgery. f. A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy
The nurse is caring for a client who is in acute respiratory distress from a diagnosed pneumothorax and requires chest tube placement by the provider. Which of the following interventions should the nurse expect to perform? Select all that apply Select one or more: a. Auscultate lung sounds frequently b. Prepare for needle aspiration c. Order portable chest x-ray prior to insertion of chest tube d. Obtain a thoracotomy tray and set up chest tube drainage system e. Monitor chest tube drainage (color and amount).
Correct Answer: a. Auscultate lung sounds frequently d. Obtain a thoracotomy tray and set up chest tube drainage system e. Monitor chest tube drainage (color and amount).
After the nurse has received change-of-shift report, which patient should the nurse assess first? Select one: a. A patient with pneumonia who has crackles in the right lung base b. A patient with chronic bronchitis who has a low forced vital capacity c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
Correct Answer: c. A patient with possible lung cancer who has just returned after bronchoscopy
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? Select one or more: a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.
Correct Answer: a. Decongestants can be used to relieve swelling. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.
The nurse is caring for a client diagnosed with COPD who presents to the urgent care with dyspnea at rest, productive cough of white sputum and coarse crackles and wheezing in lungs upon auscultation. Client has oxygen in place at 2 L/NC and an Sp02 of 87%. Which of the following independent nursing actions should be implemented to improve client's respiratory status? Select all that apply Select one or more: a. Elevate the client's HOB b. Increase oxygen to 10 L/Non-re-breather mask c. Assist client with use of pursed lip breathing d. Assist client with controlled relaxation breathing to reduce anxiety e. Administer IV antibiotics as ordered f. Obtain STAT chest x-ray
Correct Answer: a. Elevate the client's HOB c. Assist client with use of pursed lip breathing d. Assist client with controlled relaxation breathing to reduce anxiety
A patient with a tracheostomy has difficulty removing excessive, thick mucus from the respiratory tract. The nurse expects that which drug will be ordered to aid in the removal of mucus? Select One: a. Guaifenesin (Humibid) b. Benzonatate (Tessalon Perles) c. Diphenhydramine (Benadryl) d. Dextromethorphan (Robitussin DM)
Correct Answer: a. Guaifenesin (Humibid)
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? Select one: a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Obtain the forced expiratory volume (FEV) flow rate.
Correct Answer: a. Listen to the patient's breath sounds.
The nurse is providing instructions to a patient who has a new prescription for a corticosteroid metered-dose inhaler. Which statement by the patient indicates that further instruction is needed? (Select all that apply.) a. "I will rinse my mouth with water after using the inhaler and then spit out the water." b. "I will gargle after using the inhaler and then swallow." c. "I will clean the plastic inhaler casing weekly by removing the canister and then washing the casing in warm soapy water. I will then let it dry before reassembling." d. "I will use this inhaler for acute asthma attacks." e. "I will continue to use this inhaler, even if I am feeling better." f. "I will use a peak flow meter to measure my response to therapy."
Correct Answer: b. "I will gargle after using the inhaler and then swallow." d. "I will use this inhaler for acute asthma attacks."
A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers will the nurse give to the patient? Select One: a. "Take the corticosteroid inhaler first." b. "Take the bronchodilator inhaler first." c. "Take these two drugs at least 2 hours apart." d. "It does not matter which inhaler you use first."
Correct Answer: b. "Take the bronchodilator inhaler first."
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? Select one: a. "Are you aware of the normal lifespan for patients with CF?" b. "Would more information regarding CF help with that decision?" c. "Many women with CF do not have difficulty conceiving children." d. "You will need to have genetic counseling before making a decision."
Correct Answer: b. "Would more information regarding CF help with that decision?"
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? Select one: a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 42 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema
Correct Answer: b. A patient with a respiratory rate of 42 breaths/min
A patient is in an urgent care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment? Select One: a. An anticholinergic such as ipratropium (Atrovent) b. A short-acting beta2 agonist such as albuterol (Proventil) c. A long-acting beta2 agonist such as salmeterol (Serevent) d. A corticosteroid such as fluticasone (Flovent)
Correct Answer: b. A short-acting beta2 agonist such as albuterol (Proventil)
The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks? (Select all that apply.) a. Salmeterol (Serevent) inhaler b. Albuterol (Proventil) nebulizer solution c. Epinephrine d. Montelukast (Singulair) e. Fluticasone (Flovent) Rotadisk inhaler
Correct Answer: b. Albuterol (Proventil) nebulizer solution c. Epinephrine
The nurse is caring for 29 y/o who had an open laparotomy and appendectomy for a ruptured appendix 2 days prior. Upon entering the room, the client is sitting in a chair at the bedside and notes "I am having a little trouble catching my breath." The client has a respiratory rate of 30 breaths per minute and an Sa02 of 88% with oxygen at 2 L per NC in place. Client has decreased breath sounds in bases, with fine crackles noted. Which of the following INTERVENTIONS should the nurse take first? Select one: a. Assist client back to bed and place HOB at 45 degrees. b. Increase the oxygen to 4 L per NC. c. Administer Furesomide 40 mg IV d. Administer the as needed Morphine IV.
Correct Answer: b. Increase the oxygen to 4 L per NC.
Which action should the nurse plan to prevent aspiration in a high-risk patient? Select one: a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.
Correct Answer: b. Place a patient with altered consciousness in a side-lying position.
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? Select one: a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.
Correct Answer: c. Arrange for a daily meal and drug administration at a community center.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? Select one: a. Restrict oral fluids during the day. b. Teach pursed-lip breathing technique. c. Assist the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.
Correct Answer: c. Assist the patient to splint the chest when coughing.
During a routine checkup, a patient states that she is unable to take the prescribed antihistamine because of one of its most common adverse effects. The nurse suspects that which adverse effect has been bothering this patient? Select One: a. Constipation b. Abdominal cramps c. Drowsiness d. Decreased libido
Correct Answer: c. Drowsiness
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? Select one: a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.
Correct Answer: c. Explain that orange discolored urine and tears are normal while taking this medication.
When giving dextromethorphan, the nurse understands that this drug suppresses the cough reflex by which mechanism of action? Select One: a. Causing depression of the central nervous system b. Anesthetizing the stretch receptors c. Having direct action on the cough center d. Decreasing the viscosity of the bronchial secretions
Correct Answer: c. Having direct action on the cough center
The prescriber has changed the patient's medication regimen to include the leukotriene receptor antagonist (LTRA) montelukast (Singulair) to treat asthma. The nurse will emphasize which point about this medication? Select One: a. The proper technique for inhalation must be followed. b. The patient needs to keep it close by at all times to treat acute asthma attacks. c. It needs to be taken every day on a continuous schedule, even if symptoms improve. d. When the asthma symptoms improve, the dosage schedule can be tapered and eventually discontinued.
Correct Answer: c. It needs to be taken every day on a continuous schedule, even if symptoms improve.
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? Select one: a. Patient's chest x-ray indicates clear lung fields. b. Heart rate is between 60 and 100 beats/minute. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.
Correct Answer: c. Patient reports a decrease in exertional dyspnea.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? Select one: a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.
Correct Answer: c. Require the use of protective equipment.
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? Select one: a. Use of long-acting oral b-adrenergic medications b. Side effects of sustained-release theophylline c. Self-administration of inhaled corticosteroids d. Complications associated with O2 therapy
Correct Answer: c. Self-administration of inhaled corticosteroids
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? Select one: a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.
Correct Answer: c. Teach the patient about administration of insulin.
The nurse is monitoring drug levels for a patient who is receiving theophylline. The most recent theophylline level was 22 mcg/mL, and the nurse evaluates this level to be: Select One: a. below the therapeutic level. b. at a therapeutic level. c. above the therapeutic level. d. at a toxic level.
Correct Answer: c. above the therapeutic level.
After change-of-shift report, which patient should the nurse assess first? Select one: a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain d. A 64-yr-old with lung cancer and tracheal deviation after chest tube insertion
Correct Answer: d. A 64-yr-old with lung cancer and tracheal deviation after chest tube insertion
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which ACTION should the nurse take first? Select one: a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.
Correct Answer: d. Elevate the head of the bed to a semi-Fowler's position.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? Select one: a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Emergency Thoracentesis
Correct Answer: d. Emergency Thoracentesis
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? Select one: a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion
Correct Answer: d. Impaired gas exchange related to respiratory congestion
A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response? Select One: a. Increased sputum production b. Increased heart rate c. Increased respiratory rate d. Increased ease of breathing
Correct Answer: d. Increased ease of breathing
The nurse is providing instructions about the Advair inhaler (fluticasone propionate and salmeterol). Which statement about this inhaler is accurate? Select One: a. It is indicated for the treatment of acute bronchospasms. b. It needs to be used with a spacer for best results. c. Patients need to avoid drinking water for 1 hour after taking this drug. d. It is used for the prevention of bronchospasms
Correct Answer: d. It is used for the prevention of bronchospasms
When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects? Select One: a. Fatigue and depression b. Anxiety and palpitations c. Headache and rapid heart rate d. Oral candidiasis and dry mouth
Correct Answer: d. Oral candidiasis and dry mouth
The nurse will instruct patients about a possible systemic effect that may occur if excessive amounts of topically applied adrenergic nasal decongestants are used. Which systemic effect may occur? Select One: a. Heartburn b. Bradycardia c. Drowsiness d. Palpitations
Correct Answer: d. Palpitations
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? Select one: a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.
Correct Answer: d. Perform chest physiotherapy every 4 hours.
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? Select one: a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.
Correct Answer: d. Sputum smears for acid-fast bacilli are negative.
Which intervention will the nurse include in the discharge plan of care for a patient who is diagnosed with a lung abscess? Select one: a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital
Correct Answer: d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? Select one: a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 94%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 55 mm Hg.
Correct Answer: d. The partial pressure of oxygen in arterial blood (PaO2) is 55 mm Hg.
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? Select one: a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
Correct Answer: d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? Select one: a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
Correct Answer: d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? Select one: a. A patient who is complaining of a sore throat and has a muffled voice b. A patient who has a "scratchy throat" and a positive rapid strep antigen test c. A patient who is receiving radiation for throat cancer and has severe fatigue d. A patient with a history of a total laryngectomy whose stoma is red and inflamed
Correct Answer: a. A patient who is complaining of a sore throat and has a muffled voice
A patient is taking guaifenesin (Humibid) as part of treatment for a sinus infection. Which instruction will the nurse include during patient teaching? Select One: a. Force fluids to help loosen and liquefy secretions b. Report clear-colored sputum to the prescriber. c. Avoid driving a car or operating heavy machinery because of the sedating effects. d. Report symptoms that last longer than 2 days.
Correct Answer: a. Force fluids to help loosen and liquefy secretions
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? Select one: a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes
Correct Answer: a. Inspiratory crackles at the bases
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? Select one: a. Paradoxical chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest
Correct Answer: a. Paradoxical chest movement
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action(s) should the nurse take? Select one or more: a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.
Correct Answer: b. Administer the prescribed morphine.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Select one: a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository
Correct Answer: b. Blood cultures from two sites
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? Select one: a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.
Correct Answer: b. Briefly ask specific questions about this episode of respiratory distress.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? Select one: a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.
Correct Answer: b. Continue to monitor the collection device.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select one: a. Listen to a patient's lung sounds for wheezes or crackles. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.
Correct Answer: b. Label specimens obtained during percutaneous lung biopsy.
A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for which adverse effects associated with the use of xanthine derivatives? Select One: a. Diarrhea b. Palpitations c. Bradycardia d. Drowsiness
Correct Answer: b. Palpitations
A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? Select one: a. Change the O2 flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.
Correct Answer: b. Teach the patient to use the Flutter airway clearance device.
A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? Select one: a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the scheduled follow-up appointment.
Correct Answer: c. Administer a bronchodilator and recheck the peak flow.
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? Select one: a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.
Correct Answer: c. Ask the patient whether medications have been taken as directed.
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? Select one: a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy.
Correct Answer: c. Keep the patient in semi-Fowler's position.
When evaluating a patient's use of a metered-dose inhaler (MDI), the nurse notes that the patient is unable to coordinate the activation of the inhaler with her breathing. What intervention is most appropriate at this time? a. Notify the doctor that the patient is unable to use the MDI. b. Obtain an order for a peak flow meter. c. Obtain an order for a spacer device. d. Ask the prescriber if the medication can be given orally.
Correct Answer: c. Obtain an order for a spacer device.
The nurse is making a home visit to a middle-aged client who was recently hospitalized with a right leg DVT and a pulmonary embolism. The client only current prescription is enoxaparin subcutaneously. Which of the following should be reported to the provider immediately? Select one: a. The client states that her right leg aches most of the time. b. The client's right calf measures 1.2 cm larger than the left calf. c. The client is unable to remember their date of birth. d. There are multiple ecchymotic areas on the client's arms and abdomen.
Correct Answer: c. The client is unable to remember their date of birth.
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? Select one: a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.
Correct Answer: c. The patient takes propranolol (Inderal) for hypertension.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? Select one: a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.
Correct Answer: c. The patient's white blood cell (WBC) count is 9000/µL.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? Select one: a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)
Correct Answer: d. Piperacillin/tazobactam (Zosyn)
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? Select one: a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.
Correct Answer: d. Tape a nonporous dressing on three sides over the wound.
The nurse is caring for a client who is receiving mechanical ventilation via endotracheal intubation. Which of the following nursing interventions are essential in reducing the client's risk for ventilator-associated pneumonia? Select all that Apply Select one or more: a. Maintain elevation of the HOB at 30 degrees b. Assess the client's readiness for extubation at least daily. c. Administer pneumococcal vaccine to client. d. Provide an kinetic bed to continually reposition client. e. Provide oral care with chlorhexidine at least daily
Correct Answers: a. Maintain elevation of the HOB at 30 degrees b. Assess the client's readiness for extubation at least daily. e. Provide oral care with chlorhexidine at least daily
After receiving a nebulizer treatment with a beta agonist, the patient complains of feeling slightly nervous and wonders if her asthma is getting worse. What is the nurse's best response? Select One: a. "This is an expected adverse effect. Let me take your pulse." b. "The next scheduled nebulizer treatment will be skipped." c. "I will notify the physician about this adverse effect." d. "We will hold the treatment for 24 hours."
Correct Question: a. "This is an expected adverse effect. Let me take your pulse."
