FINAL EXAM

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

check capillary refill at least every 4 hr

A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect?

flashes of bright light

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions?

"I should call my doctor if my vision gets worse."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

"I should expect that this medication can cause me to be drowsy."

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

"I should remove the old twill ties after the new ties are in place." R: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

a nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching?

"I will avoid going to the store when it is crowded."

A nurse is providing teaching to a client who has chronic asthma and a new prescription of montelukast. Which of the following client statements indicates an understanding of the teaching?

"I will take this medication every night even if I don't have symptoms." R: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect?

-Crepitus with joint movement -decreased range of motion of the affected joint -joint pain that resolves with rest

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?

A client who has epistaxis R: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?

Blood-tinged sputum R: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority?

Administer heparin via continuous IV infusion R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?

Container of Sterile Water R: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

Continuous bubbling in the water seal chamber R: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

A nurse is assessing a client who is 4 he postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?

Decreased oxygen saturation R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?

Elevated temperature R: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?

Intercostal Retractions R: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?

Nonrebreather mask R: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2. - nasal cannula= 1-6L - simple face mask 40-60% - Partial rebreather mask 60-70%

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?

PaO2 58 mm Hg R: The nurse should expect the client to have lower partial pressures of oxygen.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?

Persistent cough R: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?

Tachycardia R: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

A nurse is planning to teaching a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include?

Take medication at a consistent time each day to maintain therapeutic blood levels

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?

Temperature 38.8C (101.8F)

A nurse is working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax?

Tracheal deviation to the unaffected side R: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suction. Which of the following actions should the nurse take?

Use a rotating motion when removing the suction catheter. R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

check the position of the weights and ropes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

clear drainage from nose

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain?

client's report of pain on a pain scale

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?

elevated the head of the client's bed

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?

ensure that the client lies flat for up to 12 hr

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

impulsive behavior

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

intention tremors

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

ulnar deviation

A nurse is assisting The provider who is performing a thoracentesis at the bedside of a client. Which of the following action should the nurse take? (Select all that apply.)

•Wear goggles and mask during the procedure •Cleanse the procedure area with an anti-septic solution • Apply pressure to the site after the procedure

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?

"Expect your urine and other secretions to be orange while taking this medication." R: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider.

Productive cough with green sputum R: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. Expected findings: -increased anterior posterior chest - clubbing of fingers - pursed lip breathing w/ exertion

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

Artificial airway cuff leak R: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound. R: Kinks in the tubing & excess of secretions & biting on the endotracheal tube can cause an obstruction, which causes the high-pressure alarm to sound.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?

A client who is 48 hr postoperative following a total hip arthroplasty R: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?

Presence of gag reflex R: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

Provide a diet that is high in calories and protein R: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

maintain a PaCO2 of approximately 35 mmHg

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

monitor pulse oximetry findings

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

osmotic diuretics via IV bolus

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place an abductor pillow between the client's legs when turning the client

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

establish IV access

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?

Albuterol R: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?

Apply Supplemental oxygen R: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?

tissue plasminogen activator

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

remind the client to look consciously at both sides of their meal tray

A nurse a caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

request a prescription for gabapentin for the client.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure?

restlessness

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

several pieces

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement?

Airborne R: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?

High-Fowler's position with the arms support on the over-bed table. R: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching?

"Remain upright for 30 minutes after taking this medication."

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?

Arterial blood gases R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

feet flat on the floor

A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

stroke the client's inner thigh